PRACTICE APPLICATIONS Emerging Science and Translational Applications
Clinical Nutrition Staffing Benchmarks for Acute Care Hospitals
D
UE TO BUDGET CONSTRAINTS and increasing pressure in hospitals to manage and evaluate staff resources effectively, nutrition managers need standards against which to compare their staffing for registered dietitian nutritionists (RDNs). The Academy of Nutrition and Dietetics addressed the issue of RDN staffing in the hospital setting in a comprehensive book published in 2004 discussing factors that should be included in a clinical staffing analysis.1 At that time, a staffing ratio of one RDN for every 65 to 75 patients (average census) for a medical/surgical acute care floor and a ratio of 1:30 to 1:60 for an intensive care unit was suggested, but not widely adopted, in the hospital industry.1 There has not been a universally accepted number of RDNs that are employed based on average daily census or any other metrics.2 Nutrition managers, therefore, have a limited ability to assess whether their clinical nutrition staff is meeting productivity goals or to advocate for adequate staffing. The Dietetics Practice-Based Research Network is currently evaluating RDN staffing and productivity in acute care hospitals.3 The amount of time spent in patient care activities such as obtaining diet histories, performing nutrition-focused physical exams, and providing patient education can vary by clinician and by patient. The amount of detail written in notes, the speed and efficiency of using the patient care records, and the amount of time spent in medical
This article was written by Wendy Phillips, MS, RD, FAND, regional clinical nutrition manager, Morrison Healthcare, Charlottesville, VA; director, nutrition systems, University of Virginia Health System, Charlottesville; and a certified lactation educator and a certified nutrition support clinician, Crozet, VA. http://dx.doi.org/10.1016/j.jand.2015.03.020 Available online 20 April 2015
1054
rounds or committees can also affect the overall number of patients seen per day. In addition, each facility serves different patient populations, and the expectations required of staff may vary according to each hospital administrator. Separate staffing benchmarks should be set for medical-surgical floors vs critical care beds, but there is variation within those care settings as well. For example, critical care units that treat transplant patients are likely to have a higher acuity level than critical care units that do not treat such patients. Emerging health care trends also affect RDN activities and would likely change the suggested staffing ratios from 2004 even if they had been accepted as industry standard.4 As more attention is focused on employee health and wellness in hospitals, many RDNs are being asked to participate in these initiatives. This may include designing hospital cafeteria menus, providing wellness education displays, and overseeing other wellness-related items. Because health care accrediting agencies such as the Joint Commission have an increased focus on patient safety and provision of quality care, RDNs are even more involved in quality improvement initiatives in today’s health care environment.5 These responsibilities are often added to the existing patient care load, but RDN staff is not increased. Although these activities add value and are worthy of RDN time and involvement, an RDN’s time dedicated toward direct patient care activities can be reduced.
ESTABLISHING PRODUCTIVITY BENCHMARKS Understanding the current workload assigned to RDNs in the hospital setting is the first step toward establishing a standardized staffing ratio that accounts for all activities the RDN is responsible for, including direct and indirect care activities. Using a standardized productivity monitoring tool,
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
baseline data collection to establish these benchmarks was done over an 11-month period at hospitals contracted with Morrison Healthcare (MHC) for clinical nutrition services. Although policies and procedures for nutrition care provided by MHC are standardized, the large number of participating hospitals in various geographic locations with different patient populations and levels of acuity make the benchmarks established by this study applicable to hospitals that are not contracted to MHC. Hospitals were classified as either: 1) academic/ tertiary care, or 2) community hospitals. Hospitals that are part of a university or other teaching setting were considered in the first category, as well as hospitals with a level 1 trauma unit. Although most MHC hospitals collected data, hospitals were excluded from this current analysis if the population included an extended care facility or other noneacute care hospital setting. Only data recorded by RDNs was included in this final analysis because the patient care duties performed by nutrition and dietetics technicians, registered (NDTRs), are usually substantially different than those performed by RDNs in the acute care setting. Hospitals with a single RDN who spent a lot of time completing foodservice activities instead of clinical responsibilities were excluded from this current analysis. Clinical nutrition managers (CNMs) were not required to complete the form unless a substantial portion of their day was dedicated to direct patient care activities. The Figure lists the categories of data collected for direct and indirect care activities. To ensure consistency in documentation, education sessions were provided in a variety of formats for RDNs who would be using the tool. Sessions were offered via webinar and as individual in-person training or small-group teleconferences; questions were answered via e-mail and telephone; and step-by-step instruction ª 2015 by the Academy of Nutrition and Dietetics.
PRACTICE APPLICATIONS
Figure. Categories used to document the productivity of registered dietitian nutritionists (RDNs) working in 420 hospitals. One monthly summary report for each hospital, including information from each RDN, was sent to the researcher over an 11-month period. A total of 1,311 monthly summary reports were analyzed. Comprehensive and limited assessments/reassessments and patient education were tracked in total numbers of patients seen. All other categories were documented in 15-minute increments. Total hours worked was also tracked. aQAPI¼Quality Assurance and Performance Improvement. sheets were provided. Most CNMs took part in more than one type of education session. The researcher was available to answer questions at any point during the data collection time via telephone or e-mail. The CNM at each hospital sent one summary form per hospital to the researcher at the end of the month; the form included the documentation from each RDN, and the CNM was responsible for ensuring accuracy of the data. If data appeared flawed in the final version after being submitted to the researcher, follow-up contact was made to verify the accuracy of the results. If needed, corrections were made by the RDNs and CNMs at the facility prior to the final version being accepted. This study did not distinguish between initial or follow-up visits, but rather RDNs tracked the number of patients seen per complexity of the care provided (comprehensive or limited). An assessment/reassessment was defined as comprehensive or limited by the activities performed, not in assumed increments of time. RDNs were instructed to document an encounter as comprehensive if they completed multiple activities with the patient, such as reviewing laboratory test results and medications, obtaining and reviewing diet and medical history, and documenting the patient encounter in the medical record. Limited assessments were defined as brief encounters for follow-up on adequacy of intake, tolerance or acceptance of supplements provided, or similar issues. If the RDN was approached by another health care team member to discuss the patient but did not document this in the medical record, the patient was still to be July 2015 Volume 115 Number 7
counted as a limited assessment due to the time required to discuss the patient. Direct care activities are defined as any activities that directly influence patients, whereas indirect care activities are those activities required to provide services in that facility, but are not directly linked to individuals or groups of patients. For example, many RDNs spend time in patient care committees, such as the Patient Satisfaction Committee or the Provision of Care Committee. Additional indirect care activities commonly performed by RDNs include completing productivity monitoring forms; helping with foodservice audits; participating in performance improvement and quality assurance projects, development of care guidelines and policies, and research; serving as a preceptor for dietetic interns; and teaching nutrition to other health care staff. RDNs were not asked to track nonproductive time, such as lunch breaks, because this is nonpaid time. Institutional Review Board approval was not needed as this was a quality assurance project and no patient identifying information was documented or sent to the researcher. Descriptive statistics were run using Microsoft Excel (version 2010, Microsoft Corp). Benchmarks were determined for percent of time spent in direct care and indirect care activities, number of patients seen per hour spent in direct care, number of patients seen per hour worked, and number of patients seen per full-time equivalent employee (see the Table).
Sample Analyzed Total sample size was 1,311 summary reports analyzed from 420 different
hospitals, which reflected each hospital reporting for multiple months over the 11-month data collection period. Of the 1,311 summary reports, 439 were from hospitals classified as tertiary care hospitals, and 872 were from hospitals classified as community hospitals. There were no statistically or clinically significant differences in data collected from tertiary vs community hospitals, so the data were aggregated and one benchmark was established for all hospitals.
RESULTS On average, RDNs saw 2.42 patients per hour spent in direct patient care (see the Table). Since not all time was spent in direct patient care activities, the number of patients seen per total hours worked was smaller, at an average of 1.43 patients seen per hour worked. RDNs spent 77% of their time on direct care activities and 23% of time on indirect care activities. No trends were consistently seen between hospitals for the indirect care activities on which RDNs focused their time, since division of responsibilities among RDNs and other management staff varied substantially depending on the hospital. An average of 2.42 patients seen per hour spent in direct care translates to the RDN spending about 25 minutes on each patient. Since RDNs spent 77% of their time in direct care activities, and 2.42 patients were seen per hour spent in direct care, about 15 patients were seen per 8-hour work day (8 hours0.77¼6.16 hours spent in direct care activities; 6.16 hours2.42¼14.9). Some RDNs will spend more time with each patient than others, and some
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1055
PRACTICE APPLICATIONS Table. Average productivity data for registered dietitian nutritionists (n¼1,311) working in 420 different hospitalsa
Meanstandard deviation
Average patients seen per hour spent in direct care
Average patients seen per hour worked
% Direct care
% Indirect care
2.420.022
1.430.014
770.004
230.004
a
Each hospital reported for multiple months over the 11-month data collection period. Every registered dietitian nutritionist working in the hospital reported data each month.
patients will require more time than others. The numbers reported here are averages over time.
IMPLICATIONS FOR PRACTICE This work establishes metrics against which RDN productivity can be compared, but it does have limitations. Data were self-reported by RDNs and summarized by CNMs at hospitals remotely located from the researcher. This creates the same limitation as any self-reported data would have, and is similar to other productivity monitoring research that has been completed or is currently being completed. In addition, exclusions of hospitals using NDTRs limits the application of results to hospitals that do employ NDTRs. The simple descriptive statistics utilized in the data analysis make it impossible to control for factors such as acuity level or patient population. However, a strength of this work is the large heterogeneous sample size of hospitals in every geographic region of the country, which helps to ensure the results are applicable in almost every acute care setting to use for benchmarking comparisons.
In addition to using the numbers reported here for external benchmarking, CNMs can monitor the effectiveness of the care provided by RDNs in the hospital and the efficiency with which that care is provided. Using the calculations obtained from this productivity monitoring tool, CNMs can objectively compare productivity statistics between the RDNs in one hospital, keeping in mind the intricacies inherent in the patient care floors assigned to each of the RDNs and the characteristics of the hospital population. For example, the CNM can evaluate whether RDNs are spending the expected percentage of time in direct care vs indirect care activities, or seeing a comparable number of patients per month as other RDNs at that hospital or compared to an average from a comparable population, as reported in the Table. It is essential to note that the metrics reported in this article set benchmarks for comparing select aspects of RDN staffing in acute care hospitals. Since patient outcomes related to RDN staffing were not tracked as part of this study, this does not reflect the staffing
ratio that is needed to ensure safe and quality care, optimize patient outcomes, or contribute to professional job satisfaction for the RDN. Research is still needed to help determine a standardized staffing ratio for optimal patient care in multiple care settings.
References 1.
Biesemeier C. Achieving Excellence: Clinical Staffing for Today and Tomorrow. Chicago, IL: American Dietetic Association; 2004.
2.
Marcason W. What is ADA’s staffing ratio for clinical dietitians? J Am Diet Assoc. 2006;106(11):1916.
3.
Dietetics Practice-Based Research Network. Academy of Nutrition and Dietetics website. http://www.eatrightpro.org/resources/res earch/evidence-based-resources/dpbrn. Accessed March 12, 2015.
4.
Rhea M, Bettles C. Future changes driving dietetics workforce supply and demand: Future scan 2012-2022. J Acad Nutr Diet. 2012;112(3 suppl):S10-S24.
5.
Accreditation Council for Education in Nutrition and Dietetics. Rationale for future education preparation of nutrition and dietetics practitioners. http://www. eatrightacend.org/ACEND/content.aspx?id¼ 6442485290. Updated February 18, 2015. Accessed March 12, 2015.
DISCLOSURES STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the author.
FUNDING/SUPPORT There is no funding source or any other disclosures to report.
ACKNOWLEDGEMENTS The author would like to acknowledge the following people for their significant guidance and support for this project: Jennifer Reiner, MS, RD, LD, corporate director, Nutrition & Wellness, Morrison Healthcare; Gisele LeBlanc, MS, RD, LDN, FAND, corporate director, Nutrition & Wellness, Morrison Healthcare; Peggy O’Neill, MS, RDN, CSG, LDN, vice president, Nutrition and Wellness, Morrison Healthcare; and all of the Morrison Healthcare RDNs and CNMs who contributed data to this project.
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JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
July 2015 Volume 115 Number 7
Clinical Nutrition Staffing Benchmarks for Acute Care Hospitals
D
UE TO BUDGET CONSTRAINTS and increasing pressure in hospitals to manage and evaluate staff resources effectively, nutrition managers need standards against which to compare their staffing for registered dietitian nutritionists (RDNs). The Academy of Nutrition and Dietetics addressed the issue of RDN staffing in the hospital setting in a comprehensive book published in 2004 discussing factors that should be included in a clinical staffing analysis.1 At that time, a staffing ratio of one RDN for every 65 to 75 patients (average census) for a medical/surgical acute care floor and a ratio of 1:30 to 1:60 for an intensive care unit was suggested, but not widely adopted, in the hospital industry.1 There has not been a universally accepted number of RDNs that are employed based on average daily census or any other metrics.2 Nutrition managers, therefore, have a limited ability to assess whether their clinical nutrition staff is meeting productivity goals or to advocate for adequate staffing. The Dietetics Practice-Based Research Network is currently evaluating RDN staffing and productivity in acute care hospitals.3 The amount of time spent in patient care activities such as obtaining diet histories, performing nutrition-focused physical exams, and providing patient education can vary by clinician and by patient. The amount of detail written in notes, the speed and efficiency of using the patient care records, and the amount of time spent in medical
This article was written by Wendy Phillips, MS, RD, FAND, regional clinical nutrition manager, Morrison Healthcare, Charlottesville, VA; director, nutrition systems, University of Virginia Health System, Charlottesville; and a certified lactation educator and a certified nutrition support clinician, Crozet, VA. http://dx.doi.org/10.1016/j.jand.2015.03.020 Available online 20 April 2015
1054
rounds or committees can also affect the overall number of patients seen per day. In addition, each facility serves different patient populations, and the expectations required of staff may vary according to each hospital administrator. Separate staffing benchmarks should be set for medical-surgical floors vs critical care beds, but there is variation within those care settings as well. For example, critical care units that treat transplant patients are likely to have a higher acuity level than critical care units that do not treat such patients. Emerging health care trends also affect RDN activities and would likely change the suggested staffing ratios from 2004 even if they had been accepted as industry standard.4 As more attention is focused on employee health and wellness in hospitals, many RDNs are being asked to participate in these initiatives. This may include designing hospital cafeteria menus, providing wellness education displays, and overseeing other wellness-related items. Because health care accrediting agencies such as the Joint Commission have an increased focus on patient safety and provision of quality care, RDNs are even more involved in quality improvement initiatives in today’s health care environment.5 These responsibilities are often added to the existing patient care load, but RDN staff is not increased. Although these activities add value and are worthy of RDN time and involvement, an RDN’s time dedicated toward direct patient care activities can be reduced.
ESTABLISHING PRODUCTIVITY BENCHMARKS Understanding the current workload assigned to RDNs in the hospital setting is the first step toward establishing a standardized staffing ratio that accounts for all activities the RDN is responsible for, including direct and indirect care activities. Using a standardized productivity monitoring tool,
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
baseline data collection to establish these benchmarks was done over an 11-month period at hospitals contracted with Morrison Healthcare (MHC) for clinical nutrition services. Although policies and procedures for nutrition care provided by MHC are standardized, the large number of participating hospitals in various geographic locations with different patient populations and levels of acuity make the benchmarks established by this study applicable to hospitals that are not contracted to MHC. Hospitals were classified as either: 1) academic/ tertiary care, or 2) community hospitals. Hospitals that are part of a university or other teaching setting were considered in the first category, as well as hospitals with a level 1 trauma unit. Although most MHC hospitals collected data, hospitals were excluded from this current analysis if the population included an extended care facility or other noneacute care hospital setting. Only data recorded by RDNs was included in this final analysis because the patient care duties performed by nutrition and dietetics technicians, registered (NDTRs), are usually substantially different than those performed by RDNs in the acute care setting. Hospitals with a single RDN who spent a lot of time completing foodservice activities instead of clinical responsibilities were excluded from this current analysis. Clinical nutrition managers (CNMs) were not required to complete the form unless a substantial portion of their day was dedicated to direct patient care activities. The Figure lists the categories of data collected for direct and indirect care activities. To ensure consistency in documentation, education sessions were provided in a variety of formats for RDNs who would be using the tool. Sessions were offered via webinar and as individual in-person training or small-group teleconferences; questions were answered via e-mail and telephone; and step-by-step instruction ª 2015 by the Academy of Nutrition and Dietetics.
PRACTICE APPLICATIONS
Figure. Categories used to document the productivity of registered dietitian nutritionists (RDNs) working in 420 hospitals. One monthly summary report for each hospital, including information from each RDN, was sent to the researcher over an 11-month period. A total of 1,311 monthly summary reports were analyzed. Comprehensive and limited assessments/reassessments and patient education were tracked in total numbers of patients seen. All other categories were documented in 15-minute increments. Total hours worked was also tracked. aQAPI¼Quality Assurance and Performance Improvement. sheets were provided. Most CNMs took part in more than one type of education session. The researcher was available to answer questions at any point during the data collection time via telephone or e-mail. The CNM at each hospital sent one summary form per hospital to the researcher at the end of the month; the form included the documentation from each RDN, and the CNM was responsible for ensuring accuracy of the data. If data appeared flawed in the final version after being submitted to the researcher, follow-up contact was made to verify the accuracy of the results. If needed, corrections were made by the RDNs and CNMs at the facility prior to the final version being accepted. This study did not distinguish between initial or follow-up visits, but rather RDNs tracked the number of patients seen per complexity of the care provided (comprehensive or limited). An assessment/reassessment was defined as comprehensive or limited by the activities performed, not in assumed increments of time. RDNs were instructed to document an encounter as comprehensive if they completed multiple activities with the patient, such as reviewing laboratory test results and medications, obtaining and reviewing diet and medical history, and documenting the patient encounter in the medical record. Limited assessments were defined as brief encounters for follow-up on adequacy of intake, tolerance or acceptance of supplements provided, or similar issues. If the RDN was approached by another health care team member to discuss the patient but did not document this in the medical record, the patient was still to be July 2015 Volume 115 Number 7
counted as a limited assessment due to the time required to discuss the patient. Direct care activities are defined as any activities that directly influence patients, whereas indirect care activities are those activities required to provide services in that facility, but are not directly linked to individuals or groups of patients. For example, many RDNs spend time in patient care committees, such as the Patient Satisfaction Committee or the Provision of Care Committee. Additional indirect care activities commonly performed by RDNs include completing productivity monitoring forms; helping with foodservice audits; participating in performance improvement and quality assurance projects, development of care guidelines and policies, and research; serving as a preceptor for dietetic interns; and teaching nutrition to other health care staff. RDNs were not asked to track nonproductive time, such as lunch breaks, because this is nonpaid time. Institutional Review Board approval was not needed as this was a quality assurance project and no patient identifying information was documented or sent to the researcher. Descriptive statistics were run using Microsoft Excel (version 2010, Microsoft Corp). Benchmarks were determined for percent of time spent in direct care and indirect care activities, number of patients seen per hour spent in direct care, number of patients seen per hour worked, and number of patients seen per full-time equivalent employee (see the Table).
Sample Analyzed Total sample size was 1,311 summary reports analyzed from 420 different
hospitals, which reflected each hospital reporting for multiple months over the 11-month data collection period. Of the 1,311 summary reports, 439 were from hospitals classified as tertiary care hospitals, and 872 were from hospitals classified as community hospitals. There were no statistically or clinically significant differences in data collected from tertiary vs community hospitals, so the data were aggregated and one benchmark was established for all hospitals.
RESULTS On average, RDNs saw 2.42 patients per hour spent in direct patient care (see the Table). Since not all time was spent in direct patient care activities, the number of patients seen per total hours worked was smaller, at an average of 1.43 patients seen per hour worked. RDNs spent 77% of their time on direct care activities and 23% of time on indirect care activities. No trends were consistently seen between hospitals for the indirect care activities on which RDNs focused their time, since division of responsibilities among RDNs and other management staff varied substantially depending on the hospital. An average of 2.42 patients seen per hour spent in direct care translates to the RDN spending about 25 minutes on each patient. Since RDNs spent 77% of their time in direct care activities, and 2.42 patients were seen per hour spent in direct care, about 15 patients were seen per 8-hour work day (8 hours0.77¼6.16 hours spent in direct care activities; 6.16 hours2.42¼14.9). Some RDNs will spend more time with each patient than others, and some
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1055
PRACTICE APPLICATIONS Table. Average productivity data for registered dietitian nutritionists (n¼1,311) working in 420 different hospitalsa
Meanstandard deviation
Average patients seen per hour spent in direct care
Average patients seen per hour worked
% Direct care
% Indirect care
2.420.022
1.430.014
770.004
230.004
a
Each hospital reported for multiple months over the 11-month data collection period. Every registered dietitian nutritionist working in the hospital reported data each month.
patients will require more time than others. The numbers reported here are averages over time.
IMPLICATIONS FOR PRACTICE This work establishes metrics against which RDN productivity can be compared, but it does have limitations. Data were self-reported by RDNs and summarized by CNMs at hospitals remotely located from the researcher. This creates the same limitation as any self-reported data would have, and is similar to other productivity monitoring research that has been completed or is currently being completed. In addition, exclusions of hospitals using NDTRs limits the application of results to hospitals that do employ NDTRs. The simple descriptive statistics utilized in the data analysis make it impossible to control for factors such as acuity level or patient population. However, a strength of this work is the large heterogeneous sample size of hospitals in every geographic region of the country, which helps to ensure the results are applicable in almost every acute care setting to use for benchmarking comparisons.
In addition to using the numbers reported here for external benchmarking, CNMs can monitor the effectiveness of the care provided by RDNs in the hospital and the efficiency with which that care is provided. Using the calculations obtained from this productivity monitoring tool, CNMs can objectively compare productivity statistics between the RDNs in one hospital, keeping in mind the intricacies inherent in the patient care floors assigned to each of the RDNs and the characteristics of the hospital population. For example, the CNM can evaluate whether RDNs are spending the expected percentage of time in direct care vs indirect care activities, or seeing a comparable number of patients per month as other RDNs at that hospital or compared to an average from a comparable population, as reported in the Table. It is essential to note that the metrics reported in this article set benchmarks for comparing select aspects of RDN staffing in acute care hospitals. Since patient outcomes related to RDN staffing were not tracked as part of this study, this does not reflect the staffing
ratio that is needed to ensure safe and quality care, optimize patient outcomes, or contribute to professional job satisfaction for the RDN. Research is still needed to help determine a standardized staffing ratio for optimal patient care in multiple care settings.
References 1.
Biesemeier C. Achieving Excellence: Clinical Staffing for Today and Tomorrow. Chicago, IL: American Dietetic Association; 2004.
2.
Marcason W. What is ADA’s staffing ratio for clinical dietitians? J Am Diet Assoc. 2006;106(11):1916.
3.
Dietetics Practice-Based Research Network. Academy of Nutrition and Dietetics website. http://www.eatrightpro.org/resources/res earch/evidence-based-resources/dpbrn. Accessed March 12, 2015.
4.
Rhea M, Bettles C. Future changes driving dietetics workforce supply and demand: Future scan 2012-2022. J Acad Nutr Diet. 2012;112(3 suppl):S10-S24.
5.
Accreditation Council for Education in Nutrition and Dietetics. Rationale for future education preparation of nutrition and dietetics practitioners. http://www. eatrightacend.org/ACEND/content.aspx?id¼ 6442485290. Updated February 18, 2015. Accessed March 12, 2015.
DISCLOSURES STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the author.
FUNDING/SUPPORT There is no funding source or any other disclosures to report.
ACKNOWLEDGEMENTS The author would like to acknowledge the following people for their significant guidance and support for this project: Jennifer Reiner, MS, RD, LD, corporate director, Nutrition & Wellness, Morrison Healthcare; Gisele LeBlanc, MS, RD, LDN, FAND, corporate director, Nutrition & Wellness, Morrison Healthcare; Peggy O’Neill, MS, RDN, CSG, LDN, vice president, Nutrition and Wellness, Morrison Healthcare; and all of the Morrison Healthcare RDNs and CNMs who contributed data to this project.
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JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
July 2015 Volume 115 Number 7
