Mounting evidence provided by Institute of Medicine (IOM) reports, regulatory and legislative mandates, and the aligning of financial resources through these regulations have created the tipping point for radical change in healthcare.1–6 This "radical change" requires us to rethink how we provide care and to understand the interconnectedness and the structure of healthcare by looking at it as a whole vs. the sum of its parts.7 As leaders we need to view the evidence in its entirety and bring it to the executive table, staff, and community as we rethink healthcare together. We also need to critically evaluate the various models that have been tested, determine if they meet the needs of our communities, and/or shape them into a more appropriate measure. Finally, we need to translate the evidence and engage in a dialogue with our staff, managers, and the patients we serve.
In 2000, the first report To Err Is Human: Building a Safer Health System was released. The report concluded that many patients die each year from errors that could be prevented in a redesigned healthcare system. This report created the urgent need for change. Although there was a greater focus on quality improvement initiatives, the changes were incremental and selectively targeted key disease management issues, such as core measures, and didn't fundamentally change systems.8 It did, however, serve as a wakeup call for the healthcare industry.
It was clear from this report that revolutionary changes needed to be made. Yet 10 years later, there's controversy over how to measure the change that has occurred as a result of this report. One expert graded the progress made in safety efforts at the 5- and 10-year anniversary of this report, respectively. Five criteria were graded in 2004: standards and regulation, process for reporting errors, use of information technology as it relates to safety, accountability among healthcare providers, and work training for healthcare providers.9 In 2009, the expert added research, patient involvement, leadership engagement, national and international organizational initiatives, and the use of the payment system to drive safety in measuring the progress of healthcare organizations.10 In 2004 he graded the overall safety efforts in hospitals at a C+, and in 2009, he raised it to a B, which shows modest improvement overall, with leadership engagement specifically making significant progress.9,10
In the Interdisciplinary Nursing Quality Research Initiative report published by the Robert Wood Johnson Foundation (December 2009) expert opinion leaders, responses included: "nurses have a central and essential role to play on the team but that recognition is just now coming and it hasn't really had much of an impact;" "the issue is who is involved in actually designing the way care is delivered;" "[the] healthcare delivery system is in need of a major overhaul."8 In a recent study of adverse events, researchers identified that adverse events in hospitals may be 10 times greater than previously measured because of the tools utilized to measure them.11 Although the jury is out on the amount of progress made, what's abundantly clear is that organizations over the past 10 years have recognized the complexity of delivering and measuring quality and safety outcomes and then sustaining the efforts once achieved.
The IOM's To Err Is Human report was followed by Crossing the Quality Chasm, which helped set a strategic direction for redesigning healthcare delivery. In this report, the committee categorized the issues identified in the healthcare system: (1) lack of continuity and coordination of care, (2) miscommunication among care providers, (3) wasteful process and excess costs, (4) slow adoption of information technology, (5) workforce shortages, (6) lack of patient-centeredness, and (7) service-education gaps.2 Again, there have been incremental changes over time as a result of requirements and criteria set by organizations, such as The Joint Commission and the Leapfrog Group, to address these concerns. Programs such as TeamSTEPPS developed by the Agency for Healthcare Research and Quality have been incorporated into hospital settings to improve patient safety through interprofessional teamwork and communication to address these issues. Nursing has also engaged in addressing these issues through programs such as Transforming Care at the Bedside, which was funded by the Robert Wood Johnson Foundation working with the Institute for Healthcare Improvement and the American Organization of Nurse Executives (AONE) to improve staff vitality, patient-centeredness, and reduce nonvalue added time spent by nurses.13 The Technology Drill Down work by the American Academy of Nursing is another example of how nursing has taken the lead in looking at how technology can impede or promote care and then developing strategies for seamless integration.14 Although all of these contribute to improvements in patient-care delivery, there's much more work that needs to be done to radically change healthcare delivery for the future.
Finally, in 2011, the seminal IOM report, The Future of Nursing: Leading Change, Advancing Health, described how nurses could help meet the demands for safe, high-quality, patient-centered, and equitable healthcare in the United States.6 The four key messages included: (1) nurses should practice to the full extent of their education and training, (2) nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression, (3) nurses should be full partners with physicians and others in redesigning U.S. healthcare, and (4) effective workforce planning and policy-making requires better data collection and an information infrastructure.6 Embedded within these four key messages were eight recommendations made by the interdisciplinary committee. (See Table 1.) With each of these recommendations there was a blueprint created for action at a national, state, and local level. The key difference with this IOM report as compared with the other reports previously described is that there was an action-oriented structure added to the roll-out that's helping to continue to move these recommendations forward. Sponsored by the Robert Wood Johnson Foundation and the American Association of Retired Persons, a plan for implementation was unveiled: the "Coalition for Action." Regional Action Coalitions (RACs) were formed in 5 states and quickly rolled out to 10 other states to begin the process of implementation and evaluation of these recommendations at a state level. All states are anticipated to be engaged by 2012. This was done recognizing that sustained change comes from the grassroots efforts of states and local leaders. At a national level, the recommendations that require federal engagement are also being addressed. Nursing and non-nursing leaders are coordinating these efforts in these states, with the help of a diverse group of constituents. For further information on the ongoing work of the RACs, visit http://thefutureofnursing.org. Additionally, many professional nursing organizations have also joined in to help move these recommendations forward.
Table 1: IOM report ...Image Tools
Recognizing that the leveraging of technology was a key component in changing the healthcare system, lawmakers enacted the American Recovery and Reinvestment Act (ARRA) in 2009.15 In 2010, the Office of the National Coordinator and the Centers for Medicare and Medicaid released the rules for certification criteria, meaningful use, and the incentive programs for electronic healthcare regulations.15 There are three stages of development. Stage 1 utilizes coded information to track key clinical conditions for coordination, quality, and public health purposes. Stage 2 focuses on disease management, clinical decision support, and medication management, and will build upon Stage 1. Stage 3 focuses on quality, efficiency, and safety to help improve population health outcomes.15 These regulations, which apply to eligible providers and hospitals that meet specific requirements, begin to address the IOM's findings of slow adoption of information technology. Hospitals and healthcare providers will either be incentivized to implement or penalized if they don't implement electronic healthcare records.
The regulations begin to address quality, safety, and patient-care systems by providing information in a more effective and efficient manner.16 This is a prime area for nursing leaders to become involved with, as it impacts workflow for nurses and other care providers. Quality of care and patient safety are key outcomes of these regulations. Nurse leaders need to be engaged from the planning through the implementation and evaluation process when implementing an integrated computerized system. Guidelines exist to support this process. They include: Guiding Principles for Defining the Role of the Nurse Executive in Technology Acquisition and Implementation and Guiding Principles for the Nurse Executive to Enhance Clinical Outcomes by Leveraging Technology.17,18 These tools provide important aspects that the nurse executive should consider in technology purchase, implementation, and evaluation. Equally important is for staff nurses to be engaged in this process, along with other caregivers. Those closest to the bedside can help provide insight on how systems will impact patient-care delivery/flow. Working in an interprofessional manner requires us to rethink how we document and communicate using technology.
The most significant law recently introduced is the Patient Protection and Affordable Care Act (PPACA), which was signed into law on March 23, 2010 by President Obama. The PPACA provides the impetus and resource allocations to provide new consumer protections, improve quality and lower cost, hold insurance companies accountable, and increase access to affordable care. Although some may argue it won't accomplish the changes outlined in the act, it's the first substantive attempt to reform the healthcare system by the U.S. government since the introduction of Medicare and Medicaid. Part of the PPACA is the establishment of the Center for Medicare and Medicaid Innovation, which has been funded to support several key goals: (1) provide better care for individuals, (2) coordinate care to improve health outcomes for patients, and (3) develop community care models. This Center will provide the resources to test new models of care delivery.19
By 2014, everyone is required to have healthcare insurance. Medicaid will expand to reach more Americans, and health insurance exchanges will help to create a marketplace for insurance. These changes will add over 30 million more Americans to the current health system. This therefore requires the healthcare system to look at new models of care delivery, capacity management strategies, and strategic planning. Additionally, the competencies needed to work in this new world need to be incorporated into the planning of these changes.
Care delivery across the continuum
Various models have been or are in the process of being tested at a national, state, regional, or local level. These models include accountable care organizations (ACOs), health/medical homes, nurse managed models, and transitional care models. These models have unique requirements.
* The first model is the ACO, which is an organization of healthcare providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries enrolled in the traditional fee-for-service program and are assigned to the ACO.20,21 ACOs may include professional group arrangements, networks of individual practices, joint ventures between physicians and hospitals already in existence, and hospitals that employ physicians. They must serve 5,000 Medicare beneficiaries at a minimum, have a legal structure in place, use evidence to support practice, and be patient-centered. The shared saving program will begin to test a bundled payment structure.20,21 This model will shift the volume of patients coming to a hospital for care and require the hospital and the physicians to manage patient care so that they keep patients healthy and out of the hospital environment.21 ACOs require clinical integration across the continuum of services. Technology will play a key role in keeping the care providers informed. One of the major areas that need to be addressed in these proposed regulations is the role of nurse practitioners (NPs). Currently, the regulations address primary care physicians as the only gatekeepers. Savings will be shared to encourage collaboration and shared responsibility. As the regulations don't address NPs, reimbursement issues will be impacted, as well as scope-of-practice issues. If this model is to be successful as measured by value, the right level of caregiver must provide and manage the care. There aren't enough primary care physicians to manage the influx of patients anticipated, and, therefore, this gap needs to be addressed by leaders across the country by removing the barriers to scope of practice for NPs.
* The second model is the medical home model, which includes adoptions of health information technology and a decision support system, modification of practice patterns, and assurance of continuity of care.22 The National Committee for Quality Assurance (NCQA) has been adopted as the measuring stick for allowing practices to call themselves medical homes. Again, this has been primarily a physician-oriented model. In 2011, the American Academy of Nursing announced that eight nurse-managed health centers sites were designated as medical homes by NCQA.23 This is a first step, however small. Further advocacy efforts need to be undertaken to ensure appropriate and sustained funding for nurse-managed clinics that are in essence medical homes for patients, particularly the underserved population.
* The third model is the transitional care model, which focuses on transitioning older adults with two or more risk factors, multiple-chronic conditions, and poor self-health ratings between healthcare levels and across care settings.24 This model has been tested and refined, with several randomized controlled trials completed.25,26 APNs play a lead role in coordinating the care for this population. There's an interdisciplinary approach with collaboration across settings and communication between the patients, caregivers, and healthcare providers. The results show an improvement in health outcomes, patient satisfaction, and a reduction in total healthcare costs.25,26 The IOM Future of Nursing Report recommends the use of transitional care models utilizing APNS to address the fragmentation of care delivery across settings.6 Regulatory and reimbursement issues are key to implementing more of these models. Handoffs of patients between levels and settings are critical and are a key area where nurses can excel. Leaders in organizations need to replicate these models across settings and levels of care, and advocate for funding to support these models.
Additionally, models are being tested and evaluated in acute care hospitals such as the 12-bed hospital, self-organized agile teams, and patient-centered care models. In 2007, the Robert Wood Johnson Foundation funded research on innovative care delivery models.27 The criteria focused on interdisciplinary teams, use of technology, patient-centeredness, sustainability, improved patient safety and quality, improved patient and provider satisfaction, reduced cost, and reduced demand for acute care nurses.11 Twenty-four innovative delivery models were identified. The common themes included (1) elevation of the roles for nurses, (2) an interdisciplinary approach to care, (3) the bridging of the continuum of care, (4) boundaries being pushed, (5) high uses of care being targeted, (6) patient- and family-centeredness, (7) technology being leveraged, and (8) models that were result-driven. In addition, it looked at models that could be replicated. Again, these models are in various development stages and evaluation.27 As these different models are explored, they need to be measured against the criteria of access, quality outcomes, and cost reduction that's contained in the six aims originally identified by the IOM in the Crossing the Quality Chasm report.2
All of these reports, regulations, and models need to be synthesized and evaluated by leaders to determine fit in the communities they serve. Leadership across the continuum, staff, patients, and their families need to be engaged in the planning, implementation, and evaluation of these models. Healthcare leaders need to collaborate with partners that previously may have been considered competitors to ensure that healthcare is revolutionized to meet the demand. The question is how and where to begin.
Redesigning healthcare requires organizations to create the time, the resources, and the methodology to move forward. Envisioning what the future should look like without barriers helps create the path for creative solutions. A clear methodology needs to be identified to take on this challenge. Components should include governance, strategic planning/thinking, assessing workforce capability and capacity, integrating safety, performance improvement methodologies, leveraging technology, and evidence to support the changes, but most importantly, incorporating the stakeholders—inclusive of patient, family, and the community served. Each one of these components will be explored.
No longer can we ignore the evidence or be resistant to change. We need to create the time and structure to begin this process. Through interprofessional dialogue, executive teams need to address what this means to their organization and what it means for their community. In a time of uncertainty, it's critical that leaders lead and not try to manage the situation. The employees in the organization are counting on leadership to help guide the change with their input. Leaders need to earn the trust and commitment in their organization to guide success in a highly competitive and global marketplace.28
Governance plays a pivotal role in creating the future vision. Governance includes the board and senior-level executives. Effective governance was defined by a blue ribbon panel, the Health Research and Educational Trust.29 It identified five areas considered essential for governance: (1) accountability-earning and maintaining the public's trust, (2) being proactive and interactive, (3) creating a foundation for effective decision making, (4) focusing on key governance priorities, and (5) clarifying authority and responsibility.29
There needs to be a clear vision that provides guidance for the actions taken by the organization. It needs to be inspirational and sustainable, with enough flexibility to evolve as the new healthcare system matures. Governance requires organizations and the community to come together to look at the services provided, identify the challenges and opportunities in providing those services, and determine if they'll contribute to the community's health in the future. Having patients and their families sit on various board committees, for example, can help frame the direction of the organization for the future. It also means forging new relationships with other levels of care or other providers across the continuum that may not have been considered before. Board makeup should be redesigned to include other levels of care providers to begin seamless integration. Additionally, as we begin to look at medical homes or ACOs, who will be in the network of providers and resources? Nursing leaders need to look at how nurses can play a key role in providing care in these new models.
Strategic planning should be used as a tool to help focus the organization and cascade the agreed upon direction to the operations level of the organization. A SWOT (Strengths, Weaknesses, Opportunities, and Threats) Analysis should be conducted to help inform the organizational leaders. This includes an environmental scan with the immediate community and the broader environment in which the organization operates. As services are evaluated, they should be reviewed through the lens of the future. Do they meet the six aims outlined in the IOM report? Is the service ensuring that the patient/client is getting the right level of care, at the right time, by the right level of care provider, at the right cost with consistent evidence-based interventions and outcomes? A facilitator who doesn't have a vested interest in the outcome may be needed to ensure that all of the issues and concerns are raised by all constituents inclusive of patients and their families.
Based on the trends identified in strategic planning, various scenarios or "what ifs" need to considered, including their probabilities and the initiatives that will have benefits over all of the scenarios and what investments will need to be made.30 For example, what if mandatory insurance is considered unconstitutional? How will that impact the marketplace? Organizations need to be agile enough to make corrections quickly and effectively.
Capacity management is our Achilles' heel in healthcare. Once the vision is clear and the strategic goals are set, then we can address this issue. Looking at inefficient work process and workflow is key to dealing with capacity, especially in hospitals. This requires interprofessional dialogue, planning, and leadership. Within the healthcare system we need to look at elements that cause inefficiencies and create bottlenecks. This may require leadership to step in to address these issues. For example, if scheduling-specific services are Monday through Friday because of physician availability during normal business hours, this will need to be addressed, or if there are gaps in scheduling because of office hours, this will also have to be addressed to ensure access at various times for patients and their families. Simulation models that predict information about capacity need to be utilized in the new health system to ensure an even distribution of patients, where appropriate.30
Assessing the workforce capability is another area that needs to be explored. Do staff and leaders have the competencies needed to move into the future state? If we're creating new models of care delivery in acute care, what are the competencies needed, what's the skill mix, and are there new types of caregivers that must be developed or retooled? For example, if more primary care providers such as NPs are needed, how does the current scope of practice regulations and reimbursement structures impede their use? Nurse executives need to be political advocates for this issue in their state. Through the state RACs, this issue is a key area of focus across the country. Academia needs to be involved, as well, by ensuring that the APN can transition into the practice arena through working collaboratively with service organizations in the development of residency programs for this level of provider as well as the new graduate.
Experts project the demand for nursing over the next 10 years to increase based on societal needs, especially as it relates to the aging population, increasing technology, and population growth.31 They continue to describe that the skill mix will be determined based on the following factors: "organizations' objective function, budget, quality standards and the ways that other healthcare personnel, capital, and technology can be productively combined."31 Based on these factors, we'll need to focus on nurse competencies for home care, long-term care, and preventive health, which is in concert with the PPACA and the most recent IOM report. Nursing leaders and faculty need to collaborate to develop models that help retool nurses for new areas of practice as hospital volume decreases.
The IOM report, Health Professions Education: A Bridge to Quality, identified five interrelated core competencies that all professionals require. These competencies include: (1) providing patient-centered care, (2) employing evidence-based practice, (3) applying quality improvement, (4) working in interdisciplinary teams, and (5) utilizing informatics to leverage practice.3 Although this isn't an exhaustive list of competencies, it does provide a framework to ensure our workforce has the capability to function in the new healthcare future. One way to address these competencies is by creating interprofessional educational courses between nursing universities and other healthcare disciplines. Nursing leaders also must ensure that organizations support this type of work so that new graduates aren't disillusioned when they begin to practice and that those in practice have ongoing education to help develop these competencies.
Evidence-based leadership also needs to be incorporated into the plan when we look at capability. The IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses, identified five essential practices for evidence-based management: (1) balancing the inherent tension between efficiency and reliability, (2) creating and sustaining trust in the organization, (3) actively managing the process of change, (4) involving workers in work design and workflow decisions, and (5) creating a learning organization.32 Researchers further defined evidence-based leadership as a "transformational relationship involving organizational stewardship, decision-making and vision translation through reasoned application of empirical evidence from management, leadership and patient care research."33 The leaders of today may not be the leaders of tomorrow. We may need education to retool ourselves for the future.
Experts have also identified eight essential nurse leadership competencies for the future. They included: (1) a global mindset so that the nurse leader can identify and respond to global trends that could impact on national and local healthcare, (2) technology integration, (3) expert decision-making skills utilizing the best evidence and tools available, (4) quality and safety as the number one priority, (5) political skill, (6) collaborative and team building skills, (7) balancing authenticity and organizational performance expectations, and (8) coping effectively with change.34
All of the competencies for both staff and leaders require the joint collaboration between nursing education and healthcare organization. These competencies need to be incorporated in formalized and ongoing learning for staff and leaders across the continuum. Many of the new DNP programs in leadership are currently incorporating these competencies into the curriculum. These programs are designed to translate evidence into practice across settings. Most recently, the AONE issued the revised guiding principles for Future Care Delivery. These guidelines integrate the future challenge and the role that nurse executives play in leading change.35
Employing evidence in practice as leaders is important to minimize variation in expected outcomes and reduce costs. Currently it takes 17 years for evidence to be translated into practice. This is entirely too long and requires us to rethink how decision support can be accelerated. Every strategy developed should have evidence to support it. For nursing professionals, it also includes integrating the recommendations from the recent Future of Nursing report.6 Nurses should be working to the full capacity of their education and experience, and there needs to be a plan for lifelong learning. Nurse executives have the ability to move this forward in their organizations. Strategies include only hiring BSN nurses or creating a contract that requires progression over a predetermined period, offering incentives, flexibility in time, and partnerships between academia and service to create models that provide an infrastructure for this progression for both formal and lifelong learning opportunities. One example is onsite programs for staff and leaders to continue their formal education, through the use of long-distance technology that can support education and ongoing professional dialogue.
Integrating safety and performance improvement methods will be needed as work is redesigned. All caregivers need to be educated on the methods/tools used to redesign work. This is a competency that organizations need to make a mandatory requirement and an ongoing learning opportunity. This isn't a skill set for a select few, but needs to be widely distributed. As teams work together, they need to have a common language that can be applied. This should be offered in an interprofessional forum to teach across disciplines as teams are formed. Examples of educational programs that should be considered include TeamSTEPPS, crew resource management, process mapping, rapid cycle change, measurement techniques, and action planning and evaluation. These skills need to be evident from boardroom to bedside.
Integrating technology requires both competence and a clear identification of what data should be shared across the continuum. ARRA has provided the impetus for hospitals and providers to create an electronic healthcare record. What's needed is to identify the data points that are to be transferred across the continuum. It's not too early to bring together providers from various levels of care to begin to define a common lexicon of data points. This has already begun in small pockets across the country though health information exchanges. To create continuity we have to share data. This has begun but shouldn't be lost in the rush to develop and implement electronic healthcare records in organizations.
Leveraging technology also means involving staff to determine how it integrates into their workflow. For example, creating a forum within your organization to complete the Technology Drill Down developed by the American Academy of Nursing could help engage staff and leaders from across the disciplines to illuminate the issues that staff have in providing care and can help provide a roadmap for the future.14 Without their input, we'll continue to have fragmentation.
Most importantly, we need to have patients and families included in the redesign from the beginning. This includes incorporating them as members on all committees and boards. Massachusetts has been the leader in this area. Unfortunately, it required legislation to move this forward. All states need to learn from Massachusetts in this area. Although we talk about being patient-family centered, few of us have fully integrated them as partners into our organizations. We shouldn't need to be regulated to make this a reality. New regulations (105 CMR 130.1800-.1801) required hospitals to set up Patient and Family Advisory Councils by October 2010.36 Strategies that can be used to integrate patients and their families at various system levels can be found in Table 2. Engaging patients and families in the redesign can help us remove barriers to becoming more patient-centered and impact on quality and safety.
Table 2: Patient-cen...Image Tools
Nurse executives need to help translate this information to boards and care providers inclusive of staff at all levels and the community. Therefore, the nurse executive needs to be knowledgeable and able to translate these changes to various audiences. He or she needs to have the skills/competencies required to be a leader at the executive table. One simple action is to present the IOM report, The Future of Nursing: Leading Change, Advancing Health, to the board of trustees for discussion and application to the organization.
Creating a vision of how nurses can fill the gaps in the new healthcare system is imperative to moving forward. The nursing vision should align with the organization's vision. Testing the vision requires assessing that it's clear, actionable, inspirational, and sustainable for the future healthcare system. The IOM's six aims can be used as a method of measuring whether it's comprehensive enough to meet the future state.
Translating the vision of the organization to the nursing leaders and staff is a critical function. Change creates uncertainty and resistance that needs to be addressed early on. Nursing needs to speak with one voice. Developing the blueprint for action requires the nurse executive consider the forces that will impede and promote success in his or her culture. Incorporating the staff and leaders into the creation of the blueprint helps to limit resistance. Conducting a retreat using the IOM blueprint may be one way to begin the dialogue with staff and other nursing leaders in the organization.
As the blueprint is developed, identifying whether the infrastructure is in place and that the appropriate talent is being recruited and retained should be considered. Working collaboratively with the leaders in human resources and the medical staff department to begin to develop a recruitment priority is important. Engaging key members both internally and externally who will need to support or be a part of the change is important. Those constituents that will be part of this change should be brought in early on in the process. Identifying key metrics to determine success needs to be defined upfront. An action plan and clear timeline for implementation need to be announced. Finally, there can never be too much communication and opportunities for questions and dialogue. Creating forums or an electronic means of communication for questions and feedback is important.
Nursing is the most trusted profession and, therefore, nurse leaders should assume the role of engaging the community in dialogue about the future healthcare system. Former patients and their families can identify the issues they observed in the system to help improve quality and safety. The Institute for Patient- and Family-Centered Care provides resources to help guide the development of Patient and Family Advisory Councils within an organization.37 There's also a tremendous opportunity for academia and service to partner on many of the recommendations identified in the IOM report. For example, partnerships could be formed for the development of curricula and competencies needed for the new care delivery models, using technology for competency testing and lifelong learning, and residency program development, implementation, and evaluation.
Nursing leaders from across the continuum need to be familiar with the areas being addressed in their state through their Coalitions for Action. They should also be engaged in the initiatives. Learning how other states have addressed the recommendations can help move the state and profession forward. Nurse leaders need to become engaged outside of their institution in the dialogue around reimbursement, scope of practice issues, healthcare models, and funding sources to support new initiatives. This can be accomplished through various mechanisms, with the simplest being engagement in professional organizations and associations that monitor activities at a national and state level.
One need, many paths
Each organization needs to reflect on how best to approach the challenges ahead of us. There's not one path for success. What's clear is that the time for action is now.
© 2011 by Lippincott Williams & Wilkins, Inc.