Identify any publicly available data about the organization and the quality of care and services.

Succinctly describe the quality gap and the evidence that supports the existence of a quality gap. This may include:
o Presenting statistics/data that demonstrate performance below a desired quality benchmark.
o Drawing a process flow diagram that demonstrates where variation in the process may result in errors, delays, wasted steps and/or opportunities for improvement.

o Identify any publicly available data about the organization and the quality of care and services. (For example, data from public websites, HCAHPS, CMS, Leapfrog, Dartmouth Atlas, Hospital Compare or Nursing Home Compare).

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