Fostering a healthcare sector quality and safety culture

Ricardo Santa Universidad Icesi, Valle, Colombia

Silvio Borrero Universidad Icesi, Cali, Colombia

Mario Ferrer Alfaisal University College of Business, Riyadh, Saudi Arabia, and

Daniela Gherissi Alfaisal University College of Medicine, Riyadh, Saudi Arabia

Abstract Purpose – Quality issues, increasing patient expectations and unsatisfactory media reports are driving patient safety concerns. Developing a quality and safety culture (QSC) is, therefore, crucial for patient and staff welfare, and should be a priority for service providers and policy makers. The purpose of this paper is to identify the most important QSC drivers, and thus propose appropriate operational actions for Saudi Arabian hospital managers and for managers in healthcare institutions worldwide. Design/methodology/approach – Quantitative data from 417 questionnaires were analyzed using structural equation modeling. Respondents were selected from various hospitals and managerial positions at a national level. Findings – Findings suggest that error feedback (FAE) and communication quality (QC) have a strong role fostering or enhancing QSC. Findings also show that fearing potential punitive responses to mistakes made on the job, hospital staff are reluctant to report errors. Practical implications – To achieve a healthcare QSC, managers need to implement preemptive or corrective actions aimed at ensuring prompt and relevant feedback about errors, ensure clear and open communication and focus on continuously improving systems and processes rather than on failures related to individual performance. Originality/value – This paper adds value to national healthcare, as Saudi study results are probably generalizable to other healthcare systems throughout the world. Keywords Communication, Quality assurance, Safety culture, Accreditation, Error feedback Paper type Research paper

Introduction Understanding the factors that drive a quality and safety culture (QSC) is an ethical and social priority for healthcare providers (Huotari et al., 2016; Richter et al., 2016; Withrow, 2006). In response to poor quality, increasing patient expectations and unsatisfactory media reports, healthcare providers in developed and developing countries are increasingly concerned about patient safety and how it can be assured (Øvretveit, 2003). Hospital staff around the world are increasingly committed to developing a QSC, as it is crucial for patient and staff welfare. Consequently, policy makers are promoting patient safety culture as a critical healthcare quality component, and a necessary requisite for effective safety management systems (Huotari et al., 2016).

Healthcare accreditation initiatives, either voluntary or mandatory, are a strategy implemented in national health systems to ensure safe, quality care (Øvretveit, 2003). The Joint Commission, a US independent nonprofit organization, is known for promoting patient safety through voluntary accreditation standards and safety culture initiatives.

International Journal of Health Care Quality Assurance Vol. 31 No. 7, 2018 pp. 796-809 © Emerald Publishing Limited 0952-6862 DOI 10.1108/IJHCQA-06-2017-0108

Received 22 December 2016 Revised 12 January 2018 Accepted 16 January 2018

The current issue and full text archive of this journal is available on Emerald Insight at: www.emeraldinsight.com/0952-6862.htm

This research was funded by Strategic Research Project No. SRG2015 – 118191502151 Smart City, granted by Alfaisal University.

796

IJHCQA 31,7

The literature suggests that voluntary accreditation is an effective way to stimulate healthcare quality improvements and safety cultures (Wagner et al., 2012).

In Saudi Arabian healthcare, a national system in which the government provides various services through several agencies, patient safety has become a major healthcare priority for providers (Alolayyan et al., 2013; Zakari, 2011). However, there are relatively few Saudi Arabian safety culture studies (Mwachofi et al., 2011). One compared Riyadh’s public and private hospitals, exploring healthcare provider patient safety and error reporting perceptions using the Hospital Survey on Patient Safety Culture (Al-Ahmadi, 2009). The Saudi Arabian kingdom provides significant resources to achieve better performance and was among the first Arab countries to implement healthcare accreditation initiatives. In 2005, based on the Saudi Council of Health Service recommendation, the Central Board of Accreditation for Healthcare Institutions was formed to ensure that health services across the country are safe and error free. Despite the positive steps that the Saudi Arabian Government officers took to improve healthcare, they still face challenges (Sweis et al., 2013). Insufficient Saudi medical professionals, an unqualified health workforce and employee turnover are among the most critical challenges currently facing the Kingdom. Our study contributes to the QSC theory and practice by answering the following research question:

RQ1. What are the hospitals’ main QSC drivers generally and in the Saudi Arabia Kingdom particularly?

We also explore how a QSC in Middle Eastern hospitals, and in healthcare generally, is affected by healthcare quality accreditation.

Materials and methods Theoretical antecedents Most researchers agree that quality drives operational effectiveness, competitive advantage, performance excellence, sustained profitability and innovative, value-adding practices (Santa et al., 2014; Zineldin, 2006), and that healthcarers should commit to providing good quality services as an ethical and operational obligation. Achieving a precise consensual quality definition is, however, much harder. Quality is a fuzzy construct owing to multiple dimensions that can be used to operationalize quality and its good or bad perceptions (Grönroos, 2007). For healthcare institutions, quality can be defined as doing the right thing, at the right time, in the right way, for the right person, while at the same time achieving the best possible results (Zineldin, 2006). Also, as in service industries (Grönroos, 2007), healthcare quality can be operationalized using two distinct dimensions: technical and functional. Technical quality, understood as compliance with specifications and standards, can be assessed and monitored using clinical performance measures, such as illness prevention and treatment, or medical effectiveness (Zineldin, 2006). Functional quality, on the other hand, is concerned with service delivery and its impact on patients, which can be assessed using consumer satisfaction surveys that record patient perceptions. Both quality dimensions are affected by avoidable patient injuries and inappropriate practices in hospitals, which increase adverse outcome risks, operational inefficiencies and healthcare costs (Øvretveit, 2003). As poor, health-service quality wastes resources, which could be used to treat more patients, the public increasingly criticize healthcare quality and demands improvements in hospital quality and safety. By determining Middle Eastern hospital QSC drivers, we aim to provide useful, generalizable insights for healthcare practitioners. However, decision makers should recognize situational specificity. Attempting to replicate any given strategy in different settings or cultures may yield varying results (Hofstede, 1983). Many successful strategies reported in the literature occur in Western cultures (Øvretveit, 2003) and likely obey Western specifics about rational management,

797

Healthcare sector QSC

authority and employee participation that do not necessarily apply to other countries. Therefore, attention needs to be given to financial, cultural and other conditions when implementing a quality strategy.

Healthcare quality accreditation Healthcare accreditation, either voluntary or mandatory, is a strategy implemented by national health system managers to ensure safe, high-quality care (Øvretveit, 2003). The quality literature indicates that voluntary accreditation, following the US Joint Commission model, can stimulate quality improvement and foster a safety culture (Wagner et al., 2012). There is no consensus, however, on how accreditation should be implemented (Øvretveit, 2003). Some argue that poor-quality providers are least likely to participate in public assessment or, if they do participate, then they can be tempted to falsify data. It is the national government’s duty to ensure minimum standards to protect people from inferior quality or unsafe practices, which can be achieved using mandatory inspection or accreditation, contingent sanctions for staff that do not comply and rewards for those that improve their performance. An opposing perspective states that such punish and reward approach is detrimental to sustained quality improvement. Opponents to the coercive approach argue that healthcare quality is best improved by openly discussing gaps between current and acceptable practices and that hospital staff who achieve the best improvements over time should be rewarded (i.e. an inspire and develop approach). Healthcare staff benefit from this method through implementing best practices that consistently improve performance.

Healthcare safety culture Safety culture was conceptualized by the International Nuclear Safety Advisory Group as a response to the defective processes that contributed to the 1986 Chernobyl disaster (Boughaba et al., 2014). Safety is embedded in organizational culture, which is defined as the norms, practices, values, guiding beliefs or thinking that are shared among an organization’s associates (Murphy et al., 2006). Healthcare providers have traditionally been taught – through incident reporting procedures and modeling other staff members’ behavior – that when things go wrong, they should find out who made the mistake, focusing on individual failures. A culture based on quality and safety principles, what happened and how can they be improved, looking at the system, environment, knowledge, workflow, tools, information flow and other stressors that may have affected provider behavior and caused the failure.

Singer et al. (2003) explored the fundamental attitudes and essential components needed to develop an American hospital safety culture. They showed that commitment to safety must be articulated at the highest organizational levels, to be subsequently conveyed into shared values, beliefs and behavioral norms at all other levels. In turn, staff will be able to positively influence and improve overall performance – a view shared by Boughaba et al. (2014), who showed that a safety culture influences performance through manager commitment, training, incentives, communication and employee involvement. Singer et al. (2003) also argued that a safety culture is driven by effectively deploying resources and incentives. In such a safety culture, communication between workers and across hierarchical levels is valued, frequent and sincere, error and problem reporting when they occur, encourages continuous improvement and organizational learning.

The independent variables related to safety culture were operationalized in a hospital survey on patient safety culture developed at the American Agency for Healthcare Research and Quality (AHRQ). Variables have been subsequently measured in several studies (Al-Ahmadi, 2009; Alahmadi, 2010; Bodur and Filiz, 2009; El-Jardali et al., 2010). Aboul-Fotouh et al. (2012) used this survey in Egypt’s Ain Shams University Hospital to

798

IJHCQA 31,7

determine which factors improved patient safety culture. Respondents awarded organizational learning and teamwork (OLT) the highest score, whereas non-punitive response to error (NPRE) was given the lowest score.

Wagner et al. (2012) applied the nursing home survey on patient safety (also developed by AHRQ researchers) to compare differences between accredited and non-accredited nursing homes. Respondents from accredited nursing homes scored higher on NPRE, feedback and communication about incidents. Higher scores were related to reporting adverse events, which enabled staff in certified organizations to focus on systems and processes rather than on individual failures. We infer that accreditation supports a favorable safety culture by setting a framework for care processes and continuous quality improvement.

Mardon et al. (2010) found that a positive patient safety culture is associated with reduced adverse events in hospitals. However, they also observed that there has been limited research linking hospital staff patient safety culture perceptions with adverse clinical events. The QSC phenomena, therefore, should be studied in more detail to help healthcare staff minimize errors by promoting QSC. As Sammer et al. (2010) observe, there is a need to prioritize safety within the organization, integrating safety practices and awareness into daily operations, ensuring senior manager engagement and commitment to safety issues and leadership, and allocating organizational resources to promote safety.

QSC drivers QSC depends on numerous factors and acts as a guide to determine and predict employee behavior. A strong and proactive safety culture motivates people to: discuss and learn from errors; document and improve patient safety; encourage teamwork and open communication; spot potential hazards; use systems for reporting and analyzing adverse events; and celebrate workers as heroes if they improve safety rather than as villains if they commit errors (Aboul-Fotouh et al., 2012). Hospital staff, aiming at implementing a safety culture, need to consider these drivers and how they interrelate to influence safety culture. El-Jardali et al. (2011) and Fracica et al. (2006) found that a non-punitive environment encourages staff to better report medical errors, which, in turn, results in more reliable systems. Longenecker and Fink (2001) found that practitioners who do not include and document feedback about errors (FAE) in their development programs tend to experience lower performance. Likewise, Wagner et al. (2012), on the relationship between communication feedback and NPRE, observed that establishing communication channels for problem-solving and quality improvement maintained a positive working relationship.

Non-punitive response to errors (NPRE) One important safety cultural aspect is a non-punitive approach when incidents are investigated (Alahmadi, 2010; Bodur and Filiz, 2009). An open, non-punitive reporting environment supports and motivates healthcare staff to discuss and report errors. In a non-punitive environment, staff are encouraged to acknowledge errors as a legitimate means to develop and maintain professional accountability. According to Leape (2004), having a safety culture does not exclude punishment for willful misconduct, reckless behavior and unjustified, deliberately violating rules. Individuals in a blame culture are held accountable for all errors regarding patients under their care, regardless of source (Sandars and Cook, 2009). When staff make mistakes, the response in a blame culture is to discipline and re-educate employees. Such practices promote a work atmosphere in which staff are afraid to admit their mistakes, resulting in demoralization, high disciplinary processes, employee turnover, and higher costs, stifling creativity and quality improvement. Sadly, most healthcare managers exhibit this culture (Alahmadi, 2010; Bodur and Filiz, 2009). Healthcare managers are encouraged to create an atmosphere that promotes trust and

799

Healthcare sector QSC

fairness, where it is safe for staff to discuss weaknesses and failures without fearing retaliation. One important quality and safe healthcare driver is a blame-free work environment in which punitive behavior is mitigated with programs such as safety briefings about potential safety problems and informal conversations with frontline staff about safety issues (Wagner et al., 2012). In a non-punitive work environment, responding to adverse events is not synonymous with punishment, and people who report an error can be confident that they will not be penalized, which, in turn, encourages them to share more information about its cause. Managers using this approach acknowledge that human error is possible even acceptable underadequate circumstances. Investigating a medical error should focus more on what and why rather than who (Twerski, 2007). Moreover, parties involved should remain anonymous and unknown to expert investigators who analyze information to identify root causes. NPRE more accurately identifies adverse event causes, which, in turn, improves patient safety and operational quality, thus developing a safety culture within the organization.

Communication quality (QC) An adequate healthcare safety culture is characterized by communication based on mutual trust, shared perceptions and confidence in preventive measures. Consequently, most accidents could be avoided by implementing communication channels based on quality principles (AHRQ, 2007). Excellent communication between personnel at different organizational levels is likely to yield successful healthcare outcomes (Nembhard et al., 2015; Richter et al., 2016). Mazzei (2010) presented a model that describes how successful managers tend to promote active communication between employees. Likewise, Matthews and Thomas (2007) investigated poor communication, documentation and information exchange between healthcare professionals and stakeholders. They found that poor communication was responsible for many undesired occurrences and for omissions in the feedback given to stakeholders. Similarly, Lenz and Reichert (2007) described complicated healthcare organization information networks and how they affect good communication. Reader et al. (2007) also showed that interdisciplinary communication is asymmetrical, with nurses revealing closed communication compared to senior doctors, resulting in poor communication and potentially serious incidents in intensive care units. Leadership and open communication helped team members to understand patient care plans. Physician–patient communication also has a positive influence on healthcare service quality. The physician–patient relationship influences patient satisfaction, a crucial indicator for measuring healthcare quality (Lin et al., 2010; Mercer et al., 2008; Moret et al., 2008). Majeed Alhashem et al. (2011) identified Kuwaiti primary care patient satisfaction determinants. Based on patient responses, relationships and formal interfaces between nursing and medical staff, they found that the time allotted for communication between physician and patient was short and that the command chain was lengthy and cumbersome. There is, therefore, an imperative to implement immediate and effective solutions for patient safety and welfare problems. There is no need for a traditional command chain that requires a nurse to contact two or more people, before appropriate action can be taken. Unfortunately, questions about care or urgent interventions are not addressed properly and, at the right time, owing to ineffective communication processes (Murphy et al., 2006).

Feedback about errors Laidoune and Gharbi (2016) argue that healthcare is an open sociotechnical system in which reliability, information, safety and service quality are enhanced by sociocultural factors such as feedback about experience. Reporting events and providing feedback when errors occur are important safety culture determinants ( Jha, 2008). Reporting incidents is essential to achieving a learning culture, which can only happen in a non-punitive environment where

800

IJHCQA 31,7

events are reported without people being blamed. However, actual error rates are probably much higher than reported, as many errors might lead to public humiliation or punitive consequences, or a belief that reporting will not result in effective change (VanGeest and Cummins, 2003).

Encouraging health professionals to report events in a non-punitive environment is crucial for improving patient safety. Operating rooms errors are commonplace, which can be catastrophic (Makary et al., 2006). Creating a surgical patient safety culture by improving communication and reporting events is therefore a staff priority but it is often difficult to achieve. Employees who do not deal directly with patients are usually more willing to report errors. Jones et al. (2008) felt that laboratory work is considered more organized since it is controlled by professional standards and because errors are investigated as a group, and everyone in the group shares responsibility. In contrast, when a health professional makes a mistake, responsibility is an individual issue. El-Jardali et al. (2011) conducted a patient safety study that revealed two interesting facts: experience and tenure has an impact on error reporting, i.e. as people’s years within the organization increase, they report more events; and that staff patient safety perception decreases as their experience in the hospital increases. According to El-Jardali et al. (2011), patient safety perception is usually defined as the extent to which people feel that procedures and systems are good at preventing errors and problems. As people become more experienced, they become more aware and criticize the safety practices in their institutions. Consequently, more experienced staff are more likely to demand patient safety practices, systems and procedures that effectively limit errors and problems. Bodur and Filiz (2009) found that patient safety culture decreases as seniority increases because staff elect not to report the error to avoid additional reporting required when errors are detected. Another plausible explanation is that senior staff, influenced by a culture that does not enforce patient safety, become, in time, less strict in ensuring appropriate safety practices.

Finally, continuous error reporting – a widespread practice in accredited institutions – is a favorable tool to improve patient safety. After an adverse event report is completed, staff can conduct root cause analyses and develop action plans to reduce future risks. Moreover, accredited institutions are expected to focus such analyses on systems and processes, rather than on failures related to individual performance, thus creating an atmosphere that promotes trust and fairness where it is safe for staff to discuss vulnerabilities and failures without reprisal (Wagner et al., 2012).

Research hypotheses Based on the literature, we contend that FAE, NPRE and QC foster or enhance QSC in healthcare organizations, i.e.:

H1. There is a predictive relationship between FAE and QSC.

H2. There is a predictive relationship between NPRE and QSC.

H3. There is a predictive relationship between QC and QSC.

The conceptual model summarizing these hypotheses is shown in Figure 1.

Data collection To test our hypotheses, a survey instrument, measurement constructs and best fit model were developed using Hair et al.’s (2010) guidelines. A self-administered, customized questionnaire was designed to collect responses in Saudi Arabian hospitals. A model was conceptualized and tested using both descriptive and inferential statistics. A five-point Likert scale (from strongly agree to strongly disagree) was used to rate statements related to the model’s operationalization. The questionnaire was based on Wagner et al. (2012) and

801

Healthcare sector QSC

Withrow (2006), partially adapting Churchill’s (1979) work. The statements’ mean ratings were used to build variables making up the structural equation model (SEM). We used Analysis of Moment Structures (AMOS) software to confirm the model to estimate its predictive relationship, fit indices and to determine confidence levels. Independent variables included FAE, NPRE and QC. The dependent variable was QSC. Among 600 questionnaires distributed to different hospitals across the Saudi Arabia Kingdom, 465 returns were usable. Each questionnaire was reviewed for completeness and 48 were considered unusable owing to inconsistencies and missing data, resulting in a 69.5 percent response rate. Therefore, 417 respondents affiliated with Saudi Arabia hospitals were used to calculate mean ratings, to build variables that made up the SEM. Figures 2 and 3, respectively, show sample demographics by current employment and respondents’ role. As shown in Figures 2, 40.3 percent were medical doctors and 16.8 percent were nurses and midwives. Figure 3 shows that 57.1 percent were staff members with no managerial responsibility, whereas the remaining 42.9 percent had managerial positions (e.g. directors and supervisors).

FAE

NPRE

QC

QSC

H1

H2

H3Figure 1. Research model with hypothesis

0.7% 2.6% 2.6%

5.0% 5.5%

10.1% 16.3%

16.8% 40.3%

0% 10% 20% 30% 40% 50%

Ambulance/Paramedic Intern

Scientific/Research Allied health: Diagnostic Technical

Pharmacy Allied Health: Therapy

Other health worker Nursing and Midwifery

Medical

Figure 2. Respondents

Team Leader/Supervisor

Line Manager

Senior Manager Middle Manager

Staff member

Executive

9.6%

70%60%50%40%30%20%10%0%

57.1%

2.4% 6.2% 7.7%

17.0%

Figure 3. Respondent’s role

802

IJHCQA 31,7

Data analysis Both SPSS V21 (SSPS Inc and IBM Company, Chicago, Illinois, USA) and AMOS (version 21.0.0, AMOS Development Corporation, Spring House, Pennsylvania, USA) were used for our multivariate analysis. Software applications confirmed the conceptualized model shown in Figure 1 by estimating the variable’s predictive relationship and model fit indexes, and to determine the confidence level. Confirmatory factor analysis (CFA) was used to study the relationships between observed and continuous latent variables, and to determine the measurement model’s overall fit (Cooksey, 2007; Hair et al., 2010). Factor loadings were estimated, items loaded on only one construct (i.e. no cross loading) and latent constructs were correlated (equivalent to oblique rotation in exploratory factor analysis). Internal consistency was assessed using Cronbach’s α coefficient and items-to-total correlation. Table I summarizes construct coefficients. All constructs have values greater than the 0.7 cut-off level set for basic research (Nunally and Bernstein, 1978). CFA was used to test construct validity (Table II). The model included 37 variables: 16 observed, 21 unobserved, 20 exogenous and 17 endogenous.

The model had 136 distinct sample moments and 38 distinct parameters. χ2 was equal to 298.9 (98 degrees of freedom), with a 3.049 CMIN/DF and a 0.000 probability level. Wheaton et al. (1977) suggested a 5:1 CMIN/DF ratio or less as a reasonable criterion, Marsh and Hocevar (1985) recommended using ratios as low as 2 or as high as 5, and Carmines and McIver (1981) suggested ratios between 2:1 or 3:1, indicating an acceptable fit between the hypothetical model and the sample data. Construct reliability in the model was evaluated using several fit statistics: A goodness-of-fit index was considered acceptable if above the recommended 0.9 value; a comparative fit index was considered acceptable at 0.9 or more (Bentler, 1990); the adjusted goodness-of-fit was considered acceptable at 0.9; and the root mean square error of approximation was acceptable at a maximum 0.08 value (Bentler, 1990; Jöreskog and Sörbom, 1982). The baseline comparisons fit indices suggest that the hypothesized model fits the observed variance-covariance matrix well, relative to the null or independence model (Table II).

Results The SEM findings (Table III and Figure 4) show a strong and significant relationship between FAE and QSC (b¼ 0.48, po0.001), which supports H1. Although only 17.7 percent of the surveyed population were native English speakers, the main communication channel in Saudi Arabian hospitals was English. Overall, it seems that language is not a barrier to effective feedback. Nembhard et al. (2015) and by Richter et al. (2016) felt that staff who

Variable Alpha (α)

Quality safety culture (QSC) 0.754 Quality of communication (QC) 0.863 Non-punitive response to errors (NPRE) 0.896 Feedback about error (FAE) 0.725

Table I. Cronbach’s α

Model NFI Delta1 RFI rho1 IFI Delta2 TLI rho2 CFI

Default model 0.882 0.855 0.917 0.898 0.917 Saturated model 1.000 1.000 1.000 Independence model 0.000 0.000 0.000 0.000 0.000

Table II. Baseline comparisons

803

Healthcare sector QSC

ensure excellent communication between personnel are more likely to ensure successful healthcare handoffs.

Regarding H2, analysis showed a low, non-significant relationship between NPRE and QSC (b¼ 0.03, non-significant), which indicate deficiencies in: policy and procedure; and staff communication channels between managers and medical staff, about the actions taken after errors are found. Also, there could be cultural characteristics that account for people not being able to accurately judge that an NPRE environment exists, i.e. if punitive, contingent consequences are generally accepted and assumed to be the norm throughout the country, it could be harder for respondents to judge whether managers in their organization foster a non-punitive culture, which indicates that health professionals need encouraging to report events in a non-punitive environment – crucial for improving patient safety and that creating a patient safety culture in any healthcare environment could be influenced positively by improving communication and reporting events (Makary et al., 2006).

Finally, the strong, significant relationship between QC and QSC (b¼ 0.48, po0.001) supports H3, suggesting that communication in English is not a QSC barrier in Saudi Arabia. Additionally, this result indicates that overall communication among policy makers and staff is clear and therefore fosters QS

Our website has a team of professional writers who can help you write any of your homework. They will write your papers from scratch. We also have a team of editors just to make sure all papers are of HIGH QUALITY & PLAGIARISM FREE. To make an Order you only need to click Ask A Question and we will direct you to our Order Page at WriteDemy. Then fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.

Fill in all the assignment paper details that are required in the order form with the standard information being the page count, deadline, academic level and type of paper. It is advisable to have this information at hand so that you can quickly fill in the necessary information needed in the form for the essay writer to be immediately assigned to your writing project. Make payment for the custom essay order to enable us to assign a suitable writer to your order. Payments are made through Paypal on a secured billing page. Finally, sit back and relax.

Do you need an answer to this or any other questions?

Order Plagiarism Free Answer Here

About Wridemy

We are a professional paper writing website. If you have searched a question and bumped into our website just know you are in the right place to get help in your coursework. We offer HIGH QUALITY & PLAGIARISM FREE Papers.

How It Works

To make an Order you only need to click on “Order Now” and we will direct you to our Order Page. Fill Our Order Form with all your assignment instructions. Select your deadline and pay for your paper. You will get it few hours before your set deadline.

Are there Discounts?

All new clients are eligible for 20% off in their first Order. Our payment method is safe and secure.

Hire a tutor today CLICK HERE to make your first order

Related Tags

Academic APA Writing College Course Discussion Management English Finance General Graduate History Information Justify Literature MLA