Tag: patient and public involvement

Regional neonatal units celebrate highest delayed cord clamping rates in England

Maternity and neonatal (MatNeo) units across the South West are celebrating achieving the highest delayed cord clamping rates in 2020 in England, as measured by the National Neonatal Audit Programme (NNAP). On average, units across the South West also achieved the third lowest rates of mortality to discharge, the second lowest rates of necrotising enterocolitis, alongside the fourth highest administration levels of magnesium sulphate (MgSO4) across England.

The NNAP assesses whether babies admitted to neonatal units in England, Scotland and Wales receive consistent high-quality care, and identify areas for quality improvement. The NNAP’s most recent audit shows delayed cord clamping was at its highest level in units in the South West. More than a 20% difference was illustrated between South West units (at 60.6%) and the second highest performing region (39%). Evidence shows that avoiding immediate cord clamping reduces death in preterm babies by nearly a third.

These results follow intensive activity across the region to drive adoption and spread of a range of neonatal interventions, including delayed cord clamping and MgSO4, through a unique care bundle known as PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth).

Implementing PERIPrem

Launched in April 2020, PERIPrem is a perinatal bundle designed to improve the outcomes for babies born before 34 weeks. The West of England Academic Health Science Network (AHSN) is delivering PERIPrem in partnership with South West AHSN and South West Neonatal Network. The bundle consists of eleven interventions that demonstrate a significant impact on brain injury and mortality rates amongst babies born prematurely.

The bundle was the first of its kind, and co-created by clinicians, MatNeo teams and parents. Since April 2021 PERIPrem has continued to be delivered across the region as part of the NHS Improvement Maternal and Neonatal Safety Improvement Programme. A number of NHS Trusts across England are now implementing care bundles based on the PERIPrem model.

Achieving results

By providing frequent share and learns, 360 simulation videos, toolkits and quality improvement coaching to facilitate the spread of knowledge and best practice, PERIPrem increased confidence in delayed cord clamping. This incudes when babies are extremely premature, require resuscitation at delivery or are part of a twin delivery. Free cord clamping resources can be accessed on the PERIPrem webpages.

The NNAP explains that necrotising enterocolitis (NEC) “is a devastating illness which can follow preterm birth. Bowel inflammation prevents milk feeding and surgery may be needed. Babies who develop NEC typically stay in hospital for a long time. Rates of mortality in babies with NEC are high, at over 20%. Babies who survive NEC can have developmental as well as long-term feeding and bowel problems”. Units in the South West achieved the second lowest levels of NEC (at 4.7%) in England. Rates of NEC are directly influenced by two PERIPrem bundle elements: probiotics and early breast milk.

Learning from PReCePT

Building on the progress made nationally through the AHSN Network PReCePT programme (which was developed in the West of England region), the administration of MgSO4 remained a core intervention of the PERIPrem care bundle.  The administration of MgSO4 to all eligible women in England during preterm labour (less than 30 weeks) reduces the incidence of cerebral palsy. Magnesium sulphate costs from just £1 per dose. Free MgSO4 resources can be accessed on the PERIPrem website.

The focus across a broad range of interventions known to reduce mortality led to the region achieving the third lowest rate of pre-term mortality to discharge home in England (at 5.6%).

Natasha Swinscoe, Chief Executive of the West of England AHSN and Patient Safety Lead for the AHSN Network said:

“To December 2021 over 1090 babies have benefited from the PERIPrem bundle. It is a testament to the hard work of all South West MatNeo staff, and everyone who contributed to our PERIPrem project, that the South West region has the highest levels of delayed cord clamping alongside multiple other positive results which crucially include the third lowest level of pre-term mortality in England.

Launching PERIPrem during a pandemic, and at a time of extreme pressure on the NHS, wasn’t easy but these results illustrate the dedication and enthusiasm to improve the safety and life chances of the most vulnerable babies and their mothers”.

Sarah Bates, Consultant Paediatrician & Neonatologist at Great Western Hospitals NHS Foundation Trust and PERIPrem Neonatal Operational Clinical Lead said:

“Working as part of the PERIPrem team has been an inspiring experience. The results of the NNAP illustrate the impact the bundle is having – it’s particularly striking to see average delayed cord clamping rates in our units at least 21% higher than in other regions. In all my years looking at similar data I don’t think I’ve ever seen such a wide range.

Knowing that PERIPrem has longevity locally and is now being adopted in other parts of England, illustrates the potential it has to change the lives of pre-term babies – that is something everyone who contributed to the project can be very proud of”.

At the 2021 HSJ Patient Safety Awards, PERIPrem was highly commended in the category of Patient Safety Pilot of the Year. PERIPrem was also shortlisted for Provider Collaboration of the Year at the HSJ Awards in 2021.

Read more in our PERIPrem case study.

The full NNAP report and data can be accessed here.

Working with the learning disability community to produce our new annual health check videos

Posted on by Vanesther Hamer

The West of England Learning Disabilities Collaborative puts people with a learning disability at the centre of everything we do.

The Misfits Theatre Company, based in Bristol, have previously worked with the AHSN to create videos on topics such as the flu vaccine. In our latest video series, commissioned by NHS South West, we have worked with the Misfits to produce a range of videos that encourage greater uptake of annual health checks for those with a learning disability. The videos cover a range of audiences including health professionals working in primary care, with a second playlist focusing on people with a learning disability and those that care for them.

In this joint blog from members of the Misfits Theatre Company and Rosy Copping, Project Support Officer for the West of England Learning Disabilities Collaborative, we talk about how the video project came to fruition and what it was like to get involved in the filming.

The AHSN perspective from Rosy

Co-creation is the most important factor in our work at the West of England Learning Disabilities Collaborative. It is essential that we gain an insight into the lives of people with a learning disability and their carers, so that we can ensure the needs, concerns and views of the community is reflected through our work.

The video series was created to educate health professionals, carers and people living with learning disabilities on the importance of annual health checks. Annual health checks are so important for people living with learning disabilities as it can help alert them, their carers and their doctors to any underlying medical conditions, and to help manage any current medical conditions that the individual may also be living with, such as epilepsy or diabetes.

We have worked with many experts by experience to produce these videos, namely, the Misfits Theatre Company, Andrew Bright, Head of Development at Thera Trust and Ian Harper, Service Quality Director at Aspire Living. Without their help, the videos may not have spoken to people with learning disabilities in the same way and we might not have been communicating effectively how important it is to get an annual health check. We think it’s vital that when we produce resources, we ensure people from the community who will be using them, get to shape their creation and be directly involved.

We worked with Ian and Andrew on the development of the scripts, and they helped us to ensure that the wording was appropriate for people with learning disabilities to understand, and that the style and tone was friendly and informative. For example, Ian suggested that we change the phrasing of epilepsy to read “seizures”. We then worked with Misfits Theatre Company to film the videos. The Misfits added their own flair to the videos, and we hope they will inspire many others living with learning disabilities to get their annual health checks.

We very much enjoyed working with the Misfits, Andrew and Ian for this piece of work, and we hope that their depictions of why annual health checks are so important, resonate with viewers as much as they did with us.  We certainly could not have achieved this work without their help, so we’d like to say a big thank you!

The Misfits Theatre Company Perspective from Sara Melton

It was fantastic to be part of this very important project.  It is so vital that people with learning disabilities are aware of the importance of having their annual health check and what’s involved in the process.

We asked the actors working on the project to tell us what it meant to them. Here’s what they said:

Rob “I always enjoy helping create different accessible information about the importance of health care.  The fact that the people are willing to get the information out there is wonderful.  I felt the filming went smoothly.  I always have fun doing filming”. 

Beth “It was nice to be involved in the project and feel like I can make a difference by getting the important messages across.  The day was exciting.  I loved using my skills and abilities to educate and inform others”.

Bill “It was brilliant to be involved and I loved being on location filming.  It is so important for people like me to get an annual health check.  The filming went smoothly, and I really enjoyed myself.  The people we worked with were really friendly, which always helps”. 

Penny “The annual health check film went really well.  It helps people with learning disabilities to get their health check.  I really enjoyed being involved in the project.  The film is informative for people like me.  It is rewarding to know I have made a difference for other people with learning disabilities.  I always have fun being involved in films!”

As you can tell from our actors’ comments they really enjoyed being involved in the project.  It is of utmost importance for them to be able to educate others who also have learning disabilities, as well as health care professionals.  Their first-hand experience really enables them to connect and relate with their audience.  The filming also gives them a platform to educate professionals who will be working with people with learning disabilities like them.

We look forward to the next film project!

To find out more about the West of England Learning Disabilities Collaborative, including signing-up to receive newsletters, please visit the collaborative’s webpage.

PPI in practice

Hosted by the West of England AHSN as part of our innovation for quality improvement work, the second PPI (public and patient involvement) in Practice event took place last month.

Drawing on the expertise of People in Health West of England, the network aims to strengthen and build good practice in PPI throughout the region. It brings together PPI professionals (in service improvement as well as research) and lay reps from clinical commissioning groups (CCGs), trusts and health service providers from around the West of England region.

The format of the event follows the ‘Dilemma Café’ approach where topics are proposed by individuals looking for advice and ideas. After a short presentation of the dilemma, the group then break into smaller groups to discuss the topic of their choice.

Dilemmas brought to the group so far include:

  • How to involve the public in co-commissioning?
  • How to influence the Sustainability and Transformation Plans?
  • What does good look like?
  • How can we improve our PPI engagement forums?

Those who attended have been enthusiastic about having the space to benchmark their own performance and share good practice. “It’s nice to hear what other people are doing and know that we aren’t doing too badly,” said one person leading on PPI for their CCG.

There is also the opportunity to learn techniques and ideas from others and have a safe space in which to discuss any difficulties people might be having. “I like the mixture of non-professionals and professionals coming together,” said a lay rep. “It makes it really interesting.”

At the moment the group is limiting its scope to those with a responsibility for PPI, either as a lay rep on a board or in a professional capacity, in order to ensure the meetings meet the need for peer support and learning that might otherwise be missing for lay reps and PPI professionals.

For further information contact Hildegard Dumper, Patient and Public Involvement Manager, at hildegard.dumper@weahsn.net.

Stephen’s story

In partnership with Sirona Care & Health and North Bristol NHS Trust, our Human Factors programme offers tailored training to support staff working in community health settings. A toolkit has been developed, supported by face-to-face train-the-trainer sessions and collaborative events for shared learning and problem solving.

Stephen Early is a service user and volunteer with Sirona who has been actively involved in the development of this training programme, from designing scenarios to reflect realistic situations that staff might encounter to giving talks at staff inductions.

This is Stephen’s story, introduced by Karen Gleave, Project Lead for Sirona Care & Health.

Stephen is a service user living in one of our Extra Care Services, and currently is a volunteer with Sirona Care & Health and sits on the service user panel/forum.

I met Stephen just over a year ago when I approached members of the panel about working with me to provide a service user’s perspective for the Sirona support worker induction on what it is like to receive a service.

Once Stephen started it became quickly apparent that he was a “natural” talking with people and able to get his message across about how important communication and human factors are when supporting people. Stephen is able to bring the scenarios alive for the audience, has made people laugh and at times brought people to tears.

Stephen is a very inspirational person and has touched the lives of many. The feedback we receive after each induction is really very positive…

quotes

It really shows the great value that service users can make to organisations and how they can help to shape future services.

Stephen’s story

Unfortunately I’ve caught pneumonia about six or seven times, and on about four or five occasions I’ve been took into hospital…

… because I was living by myself I’ve had problems with eating for about six years.

… one of the things they do here is try and make me eat and drink so they make me a sandwich now and then, or every time they come in, no matter what they’re going to do they always make me a cup of tea and put it in front of me, and I feel if they’ve made me a cup of tea, then I should drink it, even thought I don’t feel thirsty if that makes sense, and when I go up to Karen’s they the same, everyone does the same. “Tea Steve!” and it’s great.

So one day the doorbell went and the lady came in and she was a support worker. I think she was, I’m not sure now. She came in and said [grunting] “Alright.”

Well, straight away you know that you were not going to have a conversation with this lady about anything and the worst thing is that these sort of five, ten minutes ones which you might get spread out between the day, maybe three times, maybe four, not sure, all depends on what your needs are, are very important to everyone because it’s communication. It’s talking to someone.

And loneliness in these sort of places is quite bad actually because you know it has an effect on them and on their health as well. Because if you’re feeling down, you’re more likely I feel to get things wrong with you and depressed and things like that, so it’s quite important when people come in that they’re a bit… and say things. So when she came in I knew straight away I wasn’t going to have a conversation with her.

Now if I was feeling a bit unwell or anything like that, or had troubles or things, I wouldn’t have talked to her about it because I knew she wasn’t in the right mood to receive any sort of information. And then she came and said, “Got to make you a drink.” Now “got to”, so that hit me home that “got to” is not “Oh, I’m going to make you a…”, “Got to make you a drink. Can’t understand why you can’t do it yourself.” That was a little whisper underneath the voice.

And then the sandwiches… “What do you want in your sandwiches?” I said, “Well anything please” and then again I heard her say, “Can’t understand why you can’t do it yourself” and then she left. And as soon as she left I got up and I chucked the tea down the sink, and I put her sandwiches in the bin because I wasn’t going to eat or drink anything from someone who didn’t’ want to do anything for me and it made me feel really bad.

So that went on for about six or seven weeks. I stopped taking food, and when they did make me food I just tipped in the bin, and the drinks, because I felt like no one wanted to do it and they didn’t understand me. They didn’t’ understand my problems. They just thought I was lazy. So it didn’t matter if they came in happy or joyful, I would still do it. That was quite a bad experience.

And then a good experience was one lady come to see me, well lots of them. And they come in and ring the bell [brightly] “Hi Steve!” Straight away you know you’re going to have a positive talk to that person and positive reaction. And you’re going to say to that person if there is something troubling you, you’re going to mention it to them, you know, “Oh I don’t feel too good today… Oh I’ve got this problem” or whatever.

And the other thing is they come in and say, “What have you been up to today? What’s been going on? What are you going to do this afternoon?” All them little things, you know, it helps the conversation to go through and it is brilliant. “Oh,” she said, “Is it two sugars, Steve, innit? It’s two innit?” Them little things, it’s not like “Oh, I gotta make you a cup of tea” or anything like that. It’s “I’m going to put in two sugars.” Some don’t even talk about it they just do it and bring it out and put on the table which is brilliant so it’s them sort of things…

…unfortunately the people, some of the residents we have here, I call them my family because they are they’re all my family, and I tell them that. Anyway, they’ve got problems some of them and some of them suffer with memory loss, Alzheimer’s, so they’re not able and some of them can’t speak properly and they cannot relay to the support workers what it means, what they mean to us and they mean everything.

I call all of my support workers “my ladies” because that’s what they are. They’re my ladies. And they’re here… if it wasn’t for them I wouldn’t be here, they mean so much. Doesn’t matter if they come in and make me a cup of tea or just the simplest of things like help me taking off my shoes. My legs swell up around about half past two in the afternoon. They come in and take my shoes off and they always make me a cup of tea when they do it, and they have a little chat whilst they do it, and it means so much.

And I’m able when I go on my induction days to translate to them what they actually mean to people like me and the rest of the residents what they’re doing. Their job’s just as much important as a doctor or anyone like that because they’re doing something to help and they’re not only helping in the sense of doing something like giving someone tablets at the right time or doing some domestic or whatever or making sure someone eats. They’re actually talking to that person, which is fantastic, which makes them feel good.

… if I can hit that one person at induction day and she stays doing caring for maybe ten years? So she might see thousands and thousands of people on her journey through her career. If she carries that through, with all of them, what a magnificent difference that’s going to make! So that’s how I think of it.

Stephen was the winner of Sirona Volunteer of the Year 2015 for his work on the project:

Patient voice at the heart of new Genomic Medicine Centre

In January members of the public joined clinicians and other healthcare professionals to find out more about the new West of England Genomic Medicine Centre, which was announced in December.

The centre forms  part of the three-year national 100,000 Genomes programme to transform diagnosis and treatment for patients with cancer and rare diseases.

The event started with an introduction to the ambitions of the West of England Genomic Medicine Centre by Clinical Director, Dr Andrew Mumford from University Hospitals Bristol. Our aim is to complete whole genome sequencing of 4,650 samples from patients and their families in the region, and to integrate whole genome sequencing into standard clinical care pathways. You can see Andrew’s presentation here.

There was then a lively discussion about how we can best engage people in getting involved with the work of the Genomic Medicine Centre, raise public awareness and support, and gather feedback from service users about their experience so we can improve and develop how we do things.

Adele Webb from Gloucestershire was one of the public contributors who attended the event. Adele said, “It was so good to be involved – I thought there was an excellent atmosphere, particularly one without barriers.

“There was broad and open dialogue between professionals, patients and public contributors, although we could have done with a few more members of the public. I really hope it’s possible to get all those people back together not too far down the line, along with the others who weren’t able to attend. There was tremendous potential there.”

Hildegard Dumper, Patient & Public Involvement Manager for the West of England AHSN, added, “I was thrilled to be part of what I hope will be the beginnings of a dialogue between the Genomic Medicine Centre and patients and the public.

“The discussion we had was open and honest and it was generally agreed that it was important that the experiences of patients and the public help to shape the project as it gets rolled out. We are still working some of this out, so anyone who would like to be involved should get in touch.”

Find out more about the West of England Genomic Medicine Centre here or email ubh-tr.wegmc@nhs.net.

 

Patients set to benefit from new Genomic Medicine Centre in the West of England

Patients in the West of England are set to benefit from a new NHS Genomic Medicine Centre based in Bristol.

A partnership made up of NHS provider organisations in Bristol, Bath, Cheltenham and Gloucestershire, universities, the West of England AHSN, NHS commissioners and Health Education South West has been designated the West of England NHS Genomic Medicine Centre (WEGMC).

The centre will be part of the three-year project launched by the Prime Minister launched by the Prime Minister, to transform diagnosis and treatment for patients with cancer and rare diseases.

This involves collecting and decoding 100,000 human genomes – complete sets of people’s genes – that will enable scientists and doctors to understand more about specific conditions. It could allow personalisation of drugs and other treatments to specific genetic variants.

Clinicians from the hospitals involved will recruit potentially eligible patients. Then patients choosing to be involved will take part in a test which will then be processed in a lab at Southmead Hospital, before being sent nationally for sequencing.

Some of the patients involved could benefit from a quicker conclusive diagnosis for a rare and inherited disease or cancer because treatment may be targeted at a particular genetic change.

Patients at the heart of the project

Life Sciences Minister George Freeman MP said, “The opening of this centre, as part of our revolutionary 100,000 Genomes Project to sequence the genomes of NHS patients with cancer and rare diseases, underlines the UK’s position as a world leader in 21st century medicine.

“Patients are at the heart of the project. That’s why we have chosen NHS sites like this to sequence DNA on an unprecedented scale, which will bring better treatments to people with rare diseases and cancer in the West of England.”

Transformative possibilities

Tony Gallagher, Chair of WEGMC, said “This is an important step forward for patients and the development of future treatments in the West of England. Working together we have teams of dedicated and experienced doctors, nurses, counsellors, scientists, managers, commissioners and academics who are committed to realising the transformative possibilities that genomic medicine offers to patients in our area.”

Creating ground-breaking discoveries

Caroline Gamlin, NHS England South West Medical Director, said: “This is a huge tribute to the quality of our medical science in the west. Our local doctors will help to create ground-breaking discoveries about diseases, predict who is susceptible and design personalised treatments to tackle them.”

The national project to sequence 100,000 genomes was announced by the Prime Minister in 2012 in a bid to transform diagnosis and treatment for patients with cancer and rare diseases in the fast-emerging field of genomic medicine. NHS England established 11 NHS Genomic Medicine Centres (GMCs) in 2014. A year on, two more GMCs have been announced – one for the West of England and the second in Yorkshire and Humber.

An individualised approach to patient care

Professor Ruth Newbury-Ecob is a leading member of the West of England partnership. She works in the Clinical Genetics Service at University Hospitals Bristol which provides genetic services for Bristol, Bath Gloucestershire and Somerset. Specialising in rare diseases including inherited cardiac conditions, she works with colleagues  at the Bristol Royal Hospital for Children and the Bristol Heart Institute to provide specialist multidisciplinary care She works closely with the Regional Genetics Laboratory at North Bristol NHS Trust to develop new genetic testing, translating research findings into NHS services for patients across the UK.

She said, “Genomics has the potential to transform healthcare by developing a more tailored individualised approach to patient care and through better screening and targeting treatments to prevent development of diseases such as cancer and heart disease. The West of England partnership has brought together multiple interested parties for the first time to bring about this wonderful transformation in healthcare.”

Humbling and inspiring

Patients are involved in planning the new service. Deborah Evans, Managing Director of the West of England AHSN, said, “In recent weeks I’ve been involved in interviews with people locally who have experienced rare diseases or cancer and their carers, and we have gathered very rich and useful insights that will help us plan our new services.

“It has been humbling and inspiring to hear first-hand these stories from people who, when faced with cancer or a rare familial disease, have not only coped with extraordinary life-changing challenges for themselves or their families, but still have the commitment to contribute more for other people through this research which will play such an important role in the future of medicine and treatment.”

Tara Mistry from Bristol said: “As someone with personal experience of cancer, with a diagnosis before the age of 40 and with two young daughters having grown up under the shadow of their mother’s surgery and subsequent treatments, this news of the Genomic Medicine Centre for the West of England is just fantastic.

“I’m so pleased that I and other patients have been involved in helping design aspects of this new service from a patient perspective because we have enormous interest in making this work for the prevention of illness in our children and communities. It’s so good to feel that this service can help target treatments to individuals and so make us less sick while being treated and hopefully eliminate the disease altogether – so my daughters and others may not have to go through this in their lives. I look forward to being more involved as this project unfolds.”

Vital research

Adele Webb has also been involved in the patient and carer interviews. She said: “I am delighted that the West of England has been successful in its application to join the 100,000 Genome Project. This is our chance to contribute to an initiative that has the potential to impact not only on the health of people across the world, but also for future generations of our families.  Since I have personal experience of a rare disorder within my family, I  am particularly heartened to know that we can contribute towards the research that is so vital.”

Professor Aniko Varadi from the University of the West of England in Bristol will lead the work in education and training. She said, “It is critical that the workforce in the NHS is educated and trained to ensure the effective delivery of genomic technologies. The education and training programme supports the delivery of the 100,000 Genomes Project but it goes well beyond that. The ultimate aim is that the next generation of clinicians, scientists and multi-disciplinary healthcare teams have the awareness, knowledge and capacity to apply genomics to clinical practice.”

 

Putting patients at the heart of Quality Improvement

How can we work collaboratively with patients and carers to co-produce and transform clinical services? This was the focus of our latest West of England Academy masterclass, hosted by our colleagues at Royal United Hospitals Bath.

The 41 participants from our member organisations were joined by three inspirational speakers for a stimulating and interactive workshop in which they got to practice using some of the resources from the Kings Fund’s Experience-based Co-design toolkit.

Our three speakers were:

Annie Laverty, Director of Patient Experience at Northumbria Healthcare NHS Trust

Annie discussed how her organisation has put patient experience at the core of their approach to improving care, with positive results in patient satisfaction and staff morale. Attendees were particularly interested in how patient feedback is collected in the morning and delivered to staff directly that afternoon, in a way that encourages staff members to actively use the feedback to improve the way they and their team mates deliver care.

Suzie Bailey, Head of Development at Monitor

Suzie was able to explain how Quality Improvement approaches are being used by the regulator to increase the range of support they are able to provide to front line care providers. In a previous job, Suzie played an important role in the development of the Sheffield Microsystems Coaching Academy at Sheffield Health and Social Care NHS Foundation Trust, and Sheffield Children’s NHS Foundation Trust, in partnership with the Dartmouth Institute Microsystem Academy from the USA, and was able to offer some practical anecdotes from her work there.

Anna Burhouse, Director of Quality at the West of England AHSN

As well as working for the AHSN, Anna still practices clinically as a Child and Adolescent Psychotherapist.  She also works on a voluntary basis to help develop the Severn & Wye Recovery College in Gloucestershire, which was set up by the 2gether Trust in 2013 to provide a new way to support people living with mental health problems. Anna shared personal stories about some of the people they had helped, including  video clips to emphasise the success of the approach.

In the afternoon, delegates were introduced to the Experience-based Co-design toolkit, working in large groups to consider what observations they might make about their working environment if they were a patient, carer or visitor, with a view to making the environment more attractive for guests. They then worked in small groups to practice interviewing patients in a way that would support their involvement in co-design meetings between clinicians and patients.

Throughout the day there was an extremely positive vibe within the room. The post-event feedback reflected this, with comments on the “inspirational speakers” and being surprised at “how real” the exercises were, as well  “how well organised” the event was.

For more information, contact:

David Evans, QI Programme Manager
0117 900 2249
david.evans@weahsn.net

For details of forthcoming events, check out our Events section. Read the evaluation report here.