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Increasing ED and Hospital Capacity Top Initiatives for Dramatic Results in 6 Months Presented by Michael B. Hill, MD, FACEP January 10, 2003 “On Our Watch”

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Presentation on theme: "Increasing ED and Hospital Capacity Top Initiatives for Dramatic Results in 6 Months Presented by Michael B. Hill, MD, FACEP January 10, 2003 “On Our Watch”"— Presentation transcript:

1 Increasing ED and Hospital Capacity Top Initiatives for Dramatic Results in 6 Months Presented by Michael B. Hill, MD, FACEP January 10, 2003 “On Our Watch” Illinois College of Emergency Physicians

2  2003 Confidential and Proprietary Page 2 of 78 Overview of Presentation Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Tactical Inpatient Capacity Solution Tactical Inpatient Capacity Solution Healthcare Change – How to Design Change Healthcare Change – How to Design Change

3  2003 Confidential and Proprietary Page 3 of 78 Why Don’t Hospitals and EDs Work?

4  2003 Confidential and Proprietary Page 4 of 78 Barriers to Top ED Performance Caregivers have unclear vision on how to meet conflicting needs of emergency and unscheduled medical care Caregivers have unclear vision on how to meet conflicting needs of emergency and unscheduled medical care Most EDs are not set up to deal with predictably unpredictable arrival times of ED patients. Most EDs are not set up to deal with predictably unpredictable arrival times of ED patients. Organizational culture is one in which we do not ask for help: Organizational culture is one in which we do not ask for help:  Unclear when to do it  Unsure who to ask  Variable response to request

5  2003 Confidential and Proprietary Page 5 of 78 Barriers to Top ED Performance Variable integration of ED operation with inpatient delivery systems Variable integration of ED operation with inpatient delivery systems Varying degrees of sophistication in defining operational metrics Varying degrees of sophistication in defining operational metrics ED as significant revenue driver is not articulated/understood by key constituencies. ED as significant revenue driver is not articulated/understood by key constituencies.

6  2003 Confidential and Proprietary Page 6 of 78 Key Finding Confirms Central Challenge to Hospital Capacity Issues Bottom quartile performance for key operational tasks that affect inpatient intake/discharge and ED performance: Bottom quartile performance for key operational tasks that affect inpatient intake/discharge and ED performance:  Explains heavy resource utilization  Indicates unclear ownership, accountability, lack of operational metrics, significant process and unit variability, and lack of backup systems

7  2003 Confidential and Proprietary Page 7 of 78 Overview of Presentation Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Tactical Inpatient Capacity Solution Tactical Inpatient Capacity Solution Healthcare Change – How to Design Change Healthcare Change – How to Design Change

8  2003 Confidential and Proprietary Page 8 of 78 Traditional Approach for Improvement We’ll fix the ED if you give us more: We’ll fix the ED if you give us more:  Space  Staff  Information technology We can’t fix our ED due to: We can’t fix our ED due to:  Demographics of our population  Unpredictable volume surges

9  2003 Confidential and Proprietary Page 9 of 78 Traditional Change Process Initiation Based on Tactical Initiatives Testimonial Testimonial Anecdote Anecdote Manager has an idea Manager has an idea Strategic initiative – rare Strategic initiative – rare

10  2003 Confidential and Proprietary Page 10 of 78 Why ED Physicians Think of Solutions as Tactical Initiatives Primary tool we use for CQI Primary tool we use for CQI Does not require hospital leadership buy-in or approval. Does not require hospital leadership buy-in or approval. Minimal budgeting impact. Minimal budgeting impact. Few resources to identify desired behavior. Few resources to identify desired behavior.

11  2003 Confidential and Proprietary Page 11 of 78 Major Problems with Tactical Initiatives Leadership not brought into process prior to implementation Leadership not brought into process prior to implementation Not enough resources to: Not enough resources to:  Develop solution  Communicate solution  Inspect to ensure proposed change is actually completed Staff not brought into development process Staff not brought into development process No measurement systems No measurement systems No inspection for desired behaviors No inspection for desired behaviors

12  2003 Confidential and Proprietary Page 12 of 78 Overview of Presentation Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Tactical Inpatient Capacity Solution Tactical Inpatient Capacity Solution Healthcare Change – How to Design Change Healthcare Change – How to Design Change

13  2003 Confidential and Proprietary Page 13 of 78 Team Based Care Assign hospital and unit ownership and accountability Assign hospital and unit ownership and accountability Give tool sets and skills to owner for success Give tool sets and skills to owner for success Use multiple processing units Use multiple processing units Reduce set up / start time Reduce set up / start time Deliver staff consistently Deliver staff consistently Set up real time communication system Set up real time communication system

14  2003 Confidential and Proprietary Page 14 of 78 Metrics Driven Management Develop operational definitions and goals Develop operational definitions and goals Reach agreement on expectations. Then hold managers and staff accountable Reach agreement on expectations. Then hold managers and staff accountable Monitor data on a weekly basis – database management Monitor data on a weekly basis – database management Give people access to the data Give people access to the data Hard wire specific next step activities based on results Hard wire specific next step activities based on results

15  2003 Confidential and Proprietary Page 15 of 78 Major Problems with Metrics Key performance indicator identification Key performance indicator identification No defined targets No defined targets Acuity selection Acuity selection Removing outlier data Removing outlier data Start / stop points Start / stop points Sample size Sample size Ownership not identified Ownership not identified

16  2003 Confidential and Proprietary Page 16 of 78 ED KPIs and Owners KPIOwner Overall LOS – Admit, Discharge, Overall Charge Nurse Arrival to Bed Placement Charge Nurse Bed Placement to MD Exam ED MD/CN Lab TAT – Blood/Urine CN/Lab Superv Radiology TAT – Plain/Specialized CN/Rad Superv Bed Request to Patient Departure CN/House Mgr

17  2003 Confidential and Proprietary Page 17 of 78 Inpatient KPIs and Owners KPIOwner Direct Admission – Arrival to Departure Admit Superv/ House Mgr Bed Control – Request to Pt Departure BC/House Mgr Pt Intake – Bed Assigned to Pt Arrival CN/House Mgr Pt Discharge – MD Discharge Order to Written to Bed Ready CN/House Mgr Housekeeping – Pt Departure to Clean Initiation CN/HK Superv/ House Mgr

18  2003 Confidential and Proprietary Page 18 of 78 Reduce Cycle Time Achieving target goals by: Moving from push to pull systems Moving from push to pull systems Being absolutely ruthless in eliminating variation Being absolutely ruthless in eliminating variation Defining clear transition steps from each provider to the next Defining clear transition steps from each provider to the next Delivering work consistently Delivering work consistently Defining time expectations for common task completion Defining time expectations for common task completion Hard wiring triggers and backup systems Hard wiring triggers and backup systems

19  2003 Confidential and Proprietary Page 19 of 78 Push Systems – Scope of the Problem Current process owner responsible to get patient to next step Current process owner responsible to get patient to next step Individual ownership encourages innovation, negotiating skills and rewards variability Individual ownership encourages innovation, negotiating skills and rewards variability Variability in task accomplishment means that most tasks are sequential Variability in task accomplishment means that most tasks are sequential High utilization of resources required to complete tasks High utilization of resources required to complete tasks Predictably breaks down when busy due to lack of defined back up system Predictably breaks down when busy due to lack of defined back up system Almost all hospital intake and discharge systems are “push” systems Almost all hospital intake and discharge systems are “push” systems

20  2003 Confidential and Proprietary Page 20 of 78 Pull Systems – Why We Want Them! Next Step process owner responsible to ensure patient receives next step Next Step process owner responsible to ensure patient receives next step Defined expectations of other staff decreases variability and encourages consistency (“hand off”) Defined expectations of other staff decreases variability and encourages consistency (“hand off”) Decreased variability allows parallel processes to stabilize Decreased variability allows parallel processes to stabilize Processes keyed to Key Performance Indicators ensure consistent work effort regardless of census Processes keyed to Key Performance Indicators ensure consistent work effort regardless of census Well defined backup systems can tolerate volume surges Well defined backup systems can tolerate volume surges Top performing hospitals use “pull” systems Top performing hospitals use “pull” systems

21  2003 Confidential and Proprietary Page 21 of 78 Learning Organization Explicit training and orientation program Explicit training and orientation program Performance evaluation explicitly link constituency specific behavior to key performance indicators Performance evaluation explicitly link constituency specific behavior to key performance indicators

22  2003 Confidential and Proprietary Page 22 of 78 Stakeholder Loyalty Passionate, single mindedness to customer outcomes Passionate, single mindedness to customer outcomes Achieve target goals Achieve target goals

23  2003 Confidential and Proprietary Page 23 of 78 Overview of Presentation Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Healthcare Change – How to Design Change Healthcare Change – How to Design Change

24  2003 Confidential and Proprietary Page 24 of 78 We’ve Tried to Fix the ED Before And … Bad News: Tactical initiatives rarely create signifi- cant overall length of stay improvement. Tactical initiatives rarely create signifi- cant overall length of stay improvement.

25  2003 Confidential and Proprietary Page 25 of 78 Even Successful Tactical Initiatives Do Not Have Great Success – The ED Perspective Ease of SuccessImplementation Ease of SuccessImplementation Charge Nurse runs the ED AD Team Based Care A-D Inpatient Admission Ownership B+D- Scribes BC Fast Track BC Physician Compensation System B-D Match Capacity to Demand B-D Bedside Registration B-D Observation Unit C-D

26  2003 Confidential and Proprietary Page 26 of 78 Tactical Initiatives That Require Evaluation ED Mini Lab ED Mini Lab Dedicated Lab Phlebotomist Dedicated Lab Phlebotomist Dedicated Radiology Technician Dedicated Radiology Technician Patient Tracking Systems Patient Tracking Systems Additional Staff Additional Staff Additional Space Additional Space

27  2003 Confidential and Proprietary Page 27 of 78 Problems with Traditional Approach to ED Overcrowding Most ED efforts traditionally focus on tactical initiatives that ED has traditionally acknowledged control over Most ED efforts traditionally focus on tactical initiatives that ED has traditionally acknowledged control over No single tactical initiative appears to create significant ED LOS improvement on its own No single tactical initiative appears to create significant ED LOS improvement on its own Success in reducing ED LOS or ambulance diversion appears to be related to multiple, simultaneous initiatives that focus on defined backup systems for common processes Success in reducing ED LOS or ambulance diversion appears to be related to multiple, simultaneous initiatives that focus on defined backup systems for common processes

28  2003 Confidential and Proprietary Page 28 of 78 Overview of Presentation Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Tactical Inpatient Capacity Solution Tactical Inpatient Capacity Solution Healthcare Change – How to Design Change Healthcare Change – How to Design Change

29  2003 Confidential and Proprietary Page 29 of 78 Is the ED the Actual Problem? ED Overcrowding ED Overcrowding Direct Admission Process Direct Admission Process Critical Care Intake and Transfer to Floor Critical Care Intake and Transfer to Floor PACU Transfer to Floor PACU Transfer to Floor Surgery Scheduling Surgery Scheduling ED crowding is actually one of several symptoms of hospital inpatient capacity issues.

30  2003 Confidential and Proprietary Page 30 of 78 Overview of Presentation Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Tactical Inpatient Capacity Solution Tactical Inpatient Capacity Solution Healthcare Change – How to Design Change Healthcare Change – How to Design Change

31  2003 Confidential and Proprietary Page 31 of 78 Why Is It Hard to Fix the Inpatient Admission Process? – The Bad News Inpatient admissions are inexorably linked to both: Inpatient admissions are inexorably linked to both:  Inpatient discharge process  Movement of patients from floor to floor No clear ownership of any of these sub- processes No clear ownership of any of these sub- processes No clear organized operations knowledge base to start from No clear organized operations knowledge base to start from

32  2003 Confidential and Proprietary Page 32 of 78 Tactical Initiatives for Hospital Admission Ease of Efficacy Implementation Roles & Responsibility Hospital Change Nurse AC- Unit Charge Nurse AC- 3 Bed Ahead SystemA C+ Key Bed Process Automation A- B- High Census Bed Protocol B+D Constrain Inpatient Bed Demand B-D Change of Shift Overrides C+D EDMD Admit Privileges D+ D- Bed Control in EDD-B

33  2003 Confidential and Proprietary Page 33 of 78 Key Opportunities to Increase Inpatient Capacity–Moving From “Push” to “Pull” Increase Inpatient Capacity Increase Inpatient Capacity Augment bed control/admission process Augment bed control/admission process Intake and Discharge Process Redesign Intake and Discharge Process Redesign Develop Metrics system to measure operational performance and provide feedback to staff and leadership for intake and discharge process Develop Metrics system to measure operational performance and provide feedback to staff and leadership for intake and discharge process Integration of IT for key processes Integration of IT for key processes

34  2003 Confidential and Proprietary Page 34 of 78 Increase Capacity of Inpatient Beds by Constraining Demand Create dedicated outpatient area for short-stay patients and outpatient procedures, rather than utilizing inpatient beds Create dedicated outpatient area for short-stay patients and outpatient procedures, rather than utilizing inpatient beds Discharge patients earlier in the day in a more consistent fashion to decrease discharge/ admission mismatch Discharge patients earlier in the day in a more consistent fashion to decrease discharge/ admission mismatch Formal multidisciplinary rounds to evaluate any patient in hospital greater than 15 days. Formal multidisciplinary rounds to evaluate any patient in hospital greater than 15 days.

35  2003 Confidential and Proprietary Page 35 of 78 Aligning Bed Identification Process - Moving from “Push” to “Pull” System Formalize hospital ownership of all intake/ Formalize hospital ownership of all intake/ discharge activities  “Hospital Administrative Supervisor” Formalize unit responsibility for pre-planning “bed ahead” system Formalize unit responsibility for pre-planning “bed ahead” system Automation of key processes Automation of key processes  Bed request/notification system  Hospital bed activity status with intake/discharge activity, KPIs, and staffing  Capacity simulation modeling to predict bed/staffing needs using information from intake/discharge data to predict bottlenecks

36  2003 Confidential and Proprietary Page 36 of 78 Communication Systems: Real Time Notification of Work Effort and Capacity Bed Tracking – implement a bed tracking system that allows bed availability status to be monitored by Bed Control and Charge Nurse with the following notification capabilities:  Pending/actual  Discharge cleans  Open beds  Pending discharge/transfer activity  Occupied beds  Staffing  Key performance indicator

37  2003 Confidential and Proprietary Page 37 of 78 Aligning Bed Identification Process - Moving from “Push” to “Pull” System Obtain ETA on new patients Obtain ETA on new patients Monitor time to arrival with Bed Control notification if receiving unit observes delay Monitor time to arrival with Bed Control notification if receiving unit observes delay Develop bed cancellation policies Develop bed cancellation policies Formal inpatient diversion notification system Formal inpatient diversion notification system Bed control meeting with hard wired action plan Bed control meeting with hard wired action plan Pre-plan critical care and step-down transfers to floor and telemetry removals 12 hours prior to transfer Pre-plan critical care and step-down transfers to floor and telemetry removals 12 hours prior to transfer Formalize high census protocol with defined electronic hospital and medical staff notification of desired work effort Formalize high census protocol with defined electronic hospital and medical staff notification of desired work effort

38  2003 Confidential and Proprietary Page 38 of 78 Align Intake Process- Moving from “Push” to “Pull” System Bed Control gives bed assignment and ETA to receiving unit Bed Control gives bed assignment and ETA to receiving unit Sending unit gives ETA with report Sending unit gives ETA with report Formal pre-planning prior to patient arrival Formal pre-planning prior to patient arrival Formal greeting, order placement and order initiation Formal greeting, order placement and order initiation Formal monitoring and communication of new workload Formal monitoring and communication of new workload

39  2003 Confidential and Proprietary Page 39 of 78 Aligning Discharge Process- Moving from “Push” to “Pull” System Formal assignment of discharge process ownership for all patients Formal assignment of discharge process ownership for all patients Formal pre-planning 2 days prior to discharge of key nurse and care coordinator discharge activities Formal pre-planning 2 days prior to discharge of key nurse and care coordinator discharge activities Formalize evening pre-planning of discharge review Formalize evening pre-planning of discharge review Formalize time of discharge for patients and pre-plan for estimated time of discharge Formalize time of discharge for patients and pre-plan for estimated time of discharge Formalize patient/family communication about method and time of discharge Formalize patient/family communication about method and time of discharge

40  2003 Confidential and Proprietary Page 40 of 78 Aligning Ancillary Service Process Adjust housekeeping hours to match discharge demand Adjust housekeeping hours to match discharge demand Formal pre-planning of discharge activities with Charge Nurse for each shift Formal pre-planning of discharge activities with Charge Nurse for each shift Preplan at least 50% of transportation needs Preplan at least 50% of transportation needs Prioritize category of “potential discharge” for lab and radiology Prioritize category of “potential discharge” for lab and radiology

41  2003 Confidential and Proprietary Page 41 of 78 Aligning Medical Staff Work Process Constrain Demand Constrain Demand  Utilize alternative hospital source for short stay/outpatient procedures  Discharge patients earlier in the day in a maximum consistency fashion to decrease discharge/admission mismatch Intake Intake  Utilize primary contact for all incoming patients to either Admitting or to ED  Time/date orders legibly  Provide ETA on new patients  Orders accompany patient prior to arrival on floor

42  2003 Confidential and Proprietary Page 42 of 78 Aligning Medical Staff - Discharge Process Standardize predischarge planning procedures and tools Standardize predischarge planning procedures and tools Pre-plan discharges 2 days out Pre-plan discharges 2 days out Formal communication on evening prior to discharge Formal communication on evening prior to discharge  Use of “potential discharge” category for lab/radiology tests needs by 0730 Round by 0745 on potential discharges Round by 0745 on potential discharges  Lab/radiology test results on chart  Review potential discharges as first step of morning rounds Initiate timed discharge orders prior to 0900 with conditional orders Initiate timed discharge orders prior to 0900 with conditional orders

43  2003 Confidential and Proprietary Page 43 of 78 Overview of Presentation Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Tactical Inpatient Capacity Solution Tactical Inpatient Capacity Solution Healthcare Change – How to Design Change Healthcare Change – How to Design Change

44  2003 Confidential and Proprietary Page 44 of 78 How to Organize a Plan to Decrease Length of Stay No magic bullet. No magic bullet. Focus on key multiple key sub-processes. Focus on key multiple key sub-processes. Develop organized plan which includes: Develop organized plan which includes:  Resources to perform analysis, recommend changes and then implement changes  Communication plan  Assessment methodology  Measurement system

45  2003 Confidential and Proprietary Page 45 of 78 Key Reference: Diffusion of Innovations, Everett Rogers (1962, 1983, 1995) Diffusion : the process by which an innovation is communicated through certain channels over time, among the members of a social system. Includes both spontaneous and planned spread. Innovation : an idea, practice, or object that is perceived as new by an individual or other unit of adoption.

46  2003 Confidential and Proprietary Page 46 of 78 Hospital Clones Diffusion Process PhaseActivityTarget Communication Strategies Rapid Cycle Testing Testing Early Adopters One-to-One Watching Tests Mentoring Testing and Implementation Early Majority One-to-Several Promotion and Visibility Next Grouping Mentoring Implementation and Spread Early/Late Majority Traditionalists Many-to-Many

47 The “Diffusion Curve” “tipping” point”

48  2003 Confidential and Proprietary Page 48 of 78 The “Tipping Point” “The name given to that one dramatic moment in an epidemic when everything can change all at once.” - M. Gladwell “The part of the diffusion curve from about 10 percent to 20 percent adoption is the heart of the diffusion process. After that point, it is often impossible to stop the further diffusion of a new idea, even if one wished to do so.” - E. Rogers

49  2003 Confidential and Proprietary Page 49 of 78 Adopter Categorization: Speed of Adoption 2%13% 35% 15% Resistors (Traditionalists) Late Majority Early Majority Early Adopters PAT Members Mentors

50  2003 Confidential and Proprietary Page 50 of 78 Successful Spread – How to Manage It Attributes of the change Attributes of the change Type of decision Type of decision Communication channels Communication channels The social system The social system Promotional efforts Promotional efforts Change attributes that affect adoption Change attributes that affect adoption  Relative advantage (evidence from testing)  Compatibility with current system (structure, values, practices)  Simplicity of the change and transition  Testability of the change  Ability to observe the change and its impact Variables affecting the rate of adoption

51  2003 Confidential and Proprietary Page 51 of 78 Lessons Learned Organization leadership needs to initiate and lead the change process to achieve dramatic results Organization leadership needs to initiate and lead the change process to achieve dramatic results ED has capability to decrease LOS by 30 to 40% ED has capability to decrease LOS by 30 to 40% Inpatient cycle times can decrease up to 70%, which can reliably increase bed capacity by 10% Inpatient cycle times can decrease up to 70%, which can reliably increase bed capacity by 10% Customer satisfaction can predictably achieve 90 th percentile performance Customer satisfaction can predictably achieve 90 th percentile performance The ED can be defined as a significant revenue driver for the hospital The ED can be defined as a significant revenue driver for the hospital

52  2003 Confidential and Proprietary Page 52 of 78 Hospital Capacity Change Initiatives Critical to Organizational Success… …A Noble Fight Lies Ahead. “It is not the critic who counts, not the man who points out the strong man stumbled or where the doer of deeds could have done better. The credit belongs to the man who is actually in the arena; whose face is marred by dust and blood; who strives valiantly; who errs and comes up short again and again; who knows the great devotions and spends himself in a worthy cause; who, at the best, knows in the end the triumph of high achievement; and who, at the worst, if he fails, at least fails while daring greatly so that his place shall never be with the timid souls who know neither victory nor defeat.” - Theodore Roosevelt

53  2003 Confidential and Proprietary Page 53 of 78 Opportunity for Discussion Scope of the Problem Scope of the Problem Traditional Approach to ED Crowding Traditional Approach to ED Crowding Key Concepts in Capacity Redesign Key Concepts in Capacity Redesign Tactical ED Capacity Solution Tactical ED Capacity Solution Relationship of ED Overcrowding to Inpatient Capacity Relationship of ED Overcrowding to Inpatient Capacity Tactical Inpatient Capacity Solution Tactical Inpatient Capacity Solution Healthcare Change – How to Design Change Healthcare Change – How to Design Change


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