Baluja LabsPROJECT REPORTONA RECOMMENDATION ON REDUCING WAITINGTIME IN THE OUT-PATIENT DEPARTMENT INTAIBA HOSPITALSubmitted in partial fulfillment of the requirements for qualifyingMASTER OF BUSINESS ADMINISTRATIONSUBMITTED BYNAME :ROLL NO. :CENTER COD E:Submi!" i# $%&i%' (u'(i''m!# )( *! &!+ui&!m!#, ()& +u%'i(-i#.M%,!& )( Bu,i#!,, A"mi#i,&%i)# /MBA01 Baluja LabsBaluja LabsA RECOMMENDATION ON REDUCING WAITINGTIME IN THE OUT-PATIENT DEPARTMENT INTAIBA HOSPITALU#"!& Su$!&1i,i)# )(:Submi!" B-:Name:Programme Code: MBAEnrollment No. :Study Centre Code : Baluja LabsBaluja LabsCERTIFICATE OF ORIGINALITY!his is to "ertify that the proje"t titled A RECOMMENDATION ON REDUCINGWAITINGTIMEINTHEOUT-PATIENTDEPARTMENT INTAIBAHOSPITALisanoriginal#or$oftheStudentandisbeingsubmittedinpartialfulfillmentforthea#ardoftheMBA/OPERATION0 . !hisreporthasnotbeensubmitted earlier either to this %ni&ersity or to any other %ni&ersity'(nstitution for thefulfillment of the requirement of a "ourse of study.Si.#%u&! )( Su"!#Si.#%u&! )( Su$!&1i,)&) Baluja LabsAC2NOWLEDGEMENTBaluja Labs*ithCandorandPleasure(ta$eopportunitytoe+pressmysin"erethan$sandobligation tomy esteemed guide,,,,,,,.,,. (tisbe"ause ofhisableandmature guidan"e and "o-operation #ithout #hi"h it#ould not ha&ebeen possible forme to "omplete my proje"t.(t is my pleasant duty to than$ all the staff member of the "omputer "enter #ho ne&erhesitated me from time during the proje"t..inally/(gratefullya"$no#ledgethesupport/en"ouragement0patien"eofmyfamily/ and as al#ays/ nothing in my life #ould be possible #ithout 1od/ !han$ 2ou3NAMEROLL NO4 Baluja LabsDECLARATIONBaluja Labs( herebyde"larethat this proje"t#or$titled A RECOMMENDATIONONREDUCINGWAITINGTIMEINTHEOUT-PATIENTDEPARTMENTINTAIBAHOSPITALismyoriginal#or$andnopartofithasbeensubmittedforany other degree purpose or published in any other from till date.NAMEROLL NO5 Baluja LabsBaluja LabsTA BL E O F CO NT EN TTOPIC PAGE NO1.!itle of the Proje"t 6. (ntrodu"tion 7).8ospital 9&er&ie# 154. :e&ie# of literature 55. 9bje"ti&e and s"ope of Study)7;. :esear"h nalysis 0 (nterpretation 47. .indings and suggestion ;5?.Con"lusion ;71=. Bibliography 6=11.@uestionnaire 6); Baluja LabsBaluja LabsA RECOMMENDATION ON REDUCING WAITINGTIME IN THE OUT-PATIENT DEPARTMENT INTAIBA HOSPITAL6 Baluja LabsC*%$!& 3 4INTRODUCTIONBaluja Labs>n outpatient is another hugely important area for the majority of patient path#ays. (t isusuallythestepinthepatientAspath#ay#herethemajorityofdifferentpath#aysinterse"t/ diagnosti"tests arere&ie#edandthede"isiontotreatBorrequestadditionaltestingC is made.""esstheba"$ground reading materials a&ailable for impro&ement and proje"tmanagement.Lin$tothe N8S(mpro&ementSystem toseeiftherearesimilar"hangeideas/related do"uments and impro&ement stories that "an be used for your #or$.Pro"essmaps theser&i"einordertounderstandthepatientflo#dynami"andpotential bottlene"$s.%nderstand the demand and "apa"ity of the ser&i"e.%nderstand the baseline le&els of a"ti&ity of the ser&i"e.:e&ie# the boo$ing pro"ess in order to understand the administrati&e pro"essesin&ol&ed #ith these "lini"s.:e&ie# the "lini" templates and s"hedules for all staff that hold these "lini"s.%nderstand the baseline #aits that patients e+perien"e and the o&erall &ariation.? Baluja LabsBaluja Labs%nderstand the did not attend BEN>C rates/ ne# to follo#-up ratios and hospital"lini""an"ellationratesforea"h"lini"andmemberofstaff#hoholdthese"lini"s.:e&ie#thereferral"riteriaandguidelinesforthe"lini"inordertounderstand#hat patients are "urrently referred to the ser&i"e.Eis"uss the ser&i"e #ith all related staff D get a feel for ho# the ser&i"e is &ie#edand used and also establish the "urrent issues and "hallenges of the ser&i"e..urther Considerations B.irst 9utpatient >ppointmentC!hereareoftenahighproportionofnon-"ardia"referralsmadetothe"ardiologydepartment.(mpro&eds"reeningofpatientsin primary"are isrequiredFpossiblythrough diagnosti"s prior to #hen the de"ision to refer is made.>ll referrals should be generi"ally addressed unless the referral is for a sub-spe"ialistopinion that only spe"ifi" "onsultants "an pro&ide.>highproportionofpatients"anbereferredforageneral"ardiologyoutpatientappointment#hentheirreferralmeetsthe"riteriafor :apid>""essChestPainClini"B:>CPCC.(mpro&ed"ommuni"ationto1Psonthe"riteriaisrequiredinorder to maintain the referral pro"ess along agreed path#ays of "are.(t is "lear that a Grapid a""essA model of "are for outpatients has a signifi"ant impa"tono&erallpath#aytimes.!rustsneedto"onsiderdupli"atingsimilarmodelsforother high &olume spe"ialty "onditions su"h as heart failure and arrhythmias.>re&ie#of diagnosti" a""essforoutrea"h"lini"sshouldbemadeBifrele&antCtopre&ent the post-outpatient appointment B9P>C diagnosti" s"enario. !he benefits of a1= Baluja LabsBaluja Labslo"allya""essibleser&i"e&ersuso&erallser&i"eeffi"ien"yandthepotentialforredu"ed #aits #ill need to be balan"ed. (t may be possible to "ontinue these ser&i"esbased on tighter s"reening of patients requiring little diagnosti" inter&ention.!he times bet#een referral letter re"eipt/ letter grading and appointment are often toolong.*hilethe ChooseandBoo$ initiati&e#illalle&iatesomeoftheseproblems/trusts #ill need to "onsiderthe full impli"ationsof Chooseand Boo$ forthepurposes of 17 #ee$s.!he&astmajorityof"lini"sare"urrentlymanagedbymedi"alstaffandsome"ardiologistsparti"ipateonthegeneralmedi"alrota.!rustsneedto"onsiderthe#or$for"eimpli"ationsofthisde"isionandallo#for ne##aysof#or$ing#hi"hin"ludethede&elopmentofnurseand 1eneralPra"titioners#ithaSpe"ial(nterestB1P#S(C led"lini"sinprimary andse"ondary "areinordertoin"reaseo&erall "apa"ity. Some follo#-up "lini"s su"h aspost myo"ardial infar"tion Bsystem toidentify and redu"e ba"$log #ill need to be introdu"ed that enables sustainability asopposed to a Gqui"$ fi+A.!hereisoften&erylittletodistinguishthedifferen"eina&erage#aitingtimesforurgent and routine outpatient appointments. rate is the traditional method of performan"e measurement andredu"ing EN>rates remainsasa$ey obje"ti&e.EN>ratesnormally in"rease#ithlengthof#aitduetopatientsmo&ing/"hangein"onditionet".E&iden"esuggeststhat greater sophisti"ation in measuring EN> rates is required as high le&el analysis"an disguise problems #ith indi&idual patient groups.(t is "ommonly a""eptedthat #hen "lini"s are "an"elled or redu"ed by the hospital/patients #ith "lini"al priorities retain priority a""ess. >n analysis of the "lini" rules isessential.!hisshouldbe"oupled#ithananalysisby#aitingtimeforurgentandsoontobeseenpatients.!here&ie#of"lini"rulesshouldensuretheyrefle"tthepriority mi+ of the referrals.!hemajorityofoutpatientser&i"esuseatraditionalfi+edappointmentsystem/#here patients are gi&en appointments on re"eipt of a referral letter. !his system hasmany#ea$nesses.Patientsareappointed#ellinad&an"esoany"hangestothe"lini" s"hedule or frequen"y of "lini"s #ill affe"t the appointments of all the patients#aiting. ChooseandBoo$ #illaddresssomeoftheseissuesbut"losemonitoring#ill still be required.>lthough patients are originallyappointed in "hronologi"al order/ "hanges toappointments Be.g. as a result of "lini" "an"ellationsC lead to #idely different #aitingtimes for indi&idual patients #hen attending "lini". meri"an Bilingual S"hool B>.B.S.C(nHhaitanarea/#heretheyperformedanumberofmedi"alteststostudentsto"he"$ontheirhealth/#hi"h#ould helpinenhan"ing studentsK performan"e andin"rease thele&eloftheir edu"ational a"hie&ement L1ood hearts to donate bloodL "ampaign:!aiba 8ospital hosted a t#o-days "ampaign under the title of Lgood hearts todonate bloodL#hi"hemphasiIesontheso"ialandhumanitarianroleplayedbythehospitaltothe"ommunity/ and in order to support this humanitarian proje"t #hi"h aims to help patients andemergen"y "ases that need a blood transfusion.So"ial Care EarEuringthemonthof8olly:amadan/!aiba8ospitalparti"ipatedinthe"elebrationofL1urgaianL#hi"htoo$pla"eattheSo"ialCareEarBdepartmentofthemeri"an %ni&ersity of Hu#aitBaluja Labs%nderthesponsorshipof!aiba8ospital/!he>meri"an%ni&ersity ofHu#aitorganiIeda"ampaign under the title of BPin$ *ee$C #hi"h aims to spread the a#areness of breast "an"er/"onsidering breast"an"erasthese"ondmost"ausesofdeathinthe#orld.!aiba8ospitaldistributed edu"ational bro"hures that enhan"e the studentsK $no#ledge and a#areness of thedisease.Campaign for breast "an"er disease:M9nthee&entoftheinternationalmonthofbreast"an"er/#hi"h"oin"ided#iththeperiodfrom9"tober4toNo&ember 5/==?/!aibahospitalorganiIeda#ee$ly "ampaignone&ery Saturday and*ednesday of the same period/ #here "lini"ale+amination of the breastare done for agroup of #omen todete"t the disease. !his ser&i"e is pro&ided free of "hargeat !aiba Spe"ialiIed "enters at .ar#aniya and .intas. !aiba 8ospital also granted a dis"ountof5Nforallthose#ho#ishtousethemammogram forearly dete"tionofbreasttumorsand also for +-"olor "hannels in the breast mil$.Hu#ait Eisable Sport Club!aiba8ospitalhassigneda"ooperationproto"ol#ithn outpatient "lini" is $no#n as apri&ateor publi"health"are fa"ility#hi"his de&otedto diagnosesandtreatmentsofoutpatients M1R. !he types and fun"tions of outpatient "lini"s "o&er different spe"ialties and&aryfrom"ountryto"ountryMR.Studyinthispaperisfo"usedonoutpatient"lini"sinSingapore/#hi"his$no#nasspe"ialistoutpatient"lini"sBS9CC.S9CinSingaporeare"lini"s asso"iated #ith hospitals and medi"al "enters. Ea"h S9C is spe"ialiIed on one typeof diseases/ e.g./ orthopedi" "lini"/ ear/ nose and throat "lini"/ eye "lini"/ et". >n S9C mainlya""eptspatientsreferredby&arioussour"es#ithappointments.S9Cstaffsarrangeanappointment forea"happointment request by pi"$ing upafreeslotofa spe"ifi"spe"ialistthrough the appointment management system.:e"ent years S9Cs are fa"ing in"reasing pressure to handle more appointment requests thanbefore due to the aging andgro#ing population M)R. !he lead time bet#een an appointmentrequestandthea"tual&isittendstobelongerbe"ausethegro#thofS9C"apa"ity"annot"at"hup#iththein"reasingdemand.(nordertomitigatethein"reasingappointmentleadtime/moreslotsarearrangedinea"hoperating session tomaintaina"onstantappointmentlead time. 8o#e&er/ therising #or$load per session "auses other problems. !he o&erloaded"lini" be"omes more "ongested and patients ha&e to #ait longer for their "onsultations. !hereis also higher "han"e of o&errunning session time. !he in"reasing #aiting time and o&ertimeha&e negati&e impa"t on patient satisfa"tion and staff morale.)1 Baluja LabsBaluja Labs!he 9ut Patient Eepartment B9PEC pro&ides "lini"al ser&i"es to patients #ithout the need tostay o&ernight.Patients#honeedmedi"alorsurgi"al"arebutarenotina"uteemergen"ygenerally attend the 9PE. (n "omparison to indoor "are the outpatient "are is relati&ely more"on&enient to patients and is less e+pensi&e. !he "han"es of hospital-a"quired infe"tions areless.Shortageofhospitalbedsinthe"ountryalsoen"ouragesoutpatientser&i"estobeutiliIed optimally.>mong alldepartments inahospital/ the9PE "aterstoma+imum number ofpatients.(tisgenerally thefirstpointof"onta"tofpatientsandtheirattendants #ithahospital/andthus"reatesfirstimpressionaboutthehospitalser&i"es.!herefore/ithas#iderimpli"ationsonthe reputation and brand image of the hospital. >lthough 9PE is not a major profit "enter ofhospitals/ it generates re&enues indire"tly through diagnosti" ser&i"es and admissions.S7)$! )( ,!&1i7!,Clini"al"onsultationsarepro&idedtopatientsin9PE.!he"onsultationsin"ludehistoryta$ing/"lini"ale+amination/ diagnosing andpro&iding pres"ription topatients. !hesupportofdiagnosti"ser&i"esli$elaboratories/radiologyand"ardia"labet"mightberequiredto"onfirm the diagnosis. prospe"ti&eauditofplasti"surgery outpatient "lini"s #as "ondu"ted during the si+ months from January to June 1??6/ todetermine the "lini"al and demographi" profile of non attainders. 9f ;=?5 appointments 1;N#ere not $ept. %sing the demographi" information/ #e "hanged our follo#-up guidelines torefle"tris$fa"torsformultiplenon-attendan"es/ andaself-referral"lini"#asintrodu"edtorepla"e routine follo#-up for high ris$ non-attainders. >fter these "hanges/ a se"ond audit inthesamesi+monthsof1??7re&ealedanon-attendan"e rateof11N--i.e.)=Nlo#erthanbefore.dministratorsregardingthepun"tuality ofstaffs.9utof5B1==NCadministrators/B4=NCofthemrespondedthatpun"tuality of the staffs is satisfa"tory. 1B=NC says that it is good/ 1B=NC responded to it asa&erage and the rest 1B=NC says that pun"tuality of the staffs need impro&ement.K44. C))&"i#%i)# %m)#. *! 1%&i)u, "!$%&m!#, )( *! OPD.T%b'! 4.44: Di,&ibui)# )( )$i#i)#, )( *! %"mi#i,&%i)# &!.%&"i#. *! C))&"i#%i)#%m)#. *! 1%&i)u, "!$%&m!#, )( OPD.C&i!&i% N). )( R!,$)#"!#/A"mi#0P!&7!#%.!1ood 4=NSatisfa"tory4=N>&erage1 =NNeed (mpro&ement ==NG&%$* 4.44: Di,&ibui)# )( )$i#i)#, )( *! %"mi#i,&%i)# &!.%&"i#. *! C))&"i#%i)#%m)#. *! 1%&i)u, "!$%&m!#, )( OPD.5? Baluja LabsBaluja Labs>s persho#nin theabo&e graphthe responsesof the >dministratorsregardingtheCoordinationamongthe&ariousdepartmentsof9PE.9utof5B1==NCadministrators/B4=NCofthemrespondedthatCoordinationamongthedepartmentsof9PEisgood.B4=NC says that it is satisfa"tory.K45. D) -)u $&)1i"! %#- &%i#i#. ()& *! (&)# )((i7! ,%(( i# *! OPDLT%b'! 4.45: Di,&ibui)# )( &!,$)#,!, )( *! %"mi#i,&%i)# &!.%&"i#. %#- &%i#i#.b!i#. $&)1i"!" ) *! (&)# )((i7! ,%((.C&i!&i% N). )( R!,$)#"!#/A"mi#0P!&7!#%.!2es 1 =NNo4 7=NG&%$* 4.45: Di,&ibui)# )( &!,$)#,!, )( *! %"mi#i,&%i)# &!.%&"i#. %#- &%i#i#.b!i#. $&)1i"!" ) *! (&)# )((i7! ,%((.;= Baluja LabsBaluja Labs;1;1Baluja LabsSho#s the responses of the >dministrators regarding any training being pro&ided to the frontoffi"e staff. 9ut of 5B1==NC administrators/ 4B7=NC disagreed #hile 1B=NC agreed to this.;;Baluja LabsBaluja LabsK4>.A&! *! ()'')=i#. !7*#i+u!,Im!*)", ()'')=!" ()& &!"u7i#. *! =%i'i#. im! i#OPDLT%b'!4.4>:Di,&ibui)#)()$i#i)#)(*!%"mi#i,&%i)#&!.%&"i#.%#- !7*#i+u!,Im!*)", ()'')=!" ()& &!"u7i#. *! =%i'i#. im! i# OPD.C&i!&i% N). )( R!,$)#"!#/A"mi#0P!&7!#%.!@ueuing method 4 7=NComputer simulation 1 =NSi+ sigma==NG&%$*4.4>: Di,&ibui)# )( )$i#i)# )( *! %"mi#i,&%i)# &!.%&"i#. %#-!7*#i+u!,Im!*)", ()'')=!" ()& &!"u7i#. *! =%i'i#. im! i# OPD>spersho#nintheabo&egraphtheresponsesofthe>dministratorsregardinganyte"hniques'methodsfollo#edforredu"ingthe#ailingtimein9PE.9utof5B1==NCadministrators/ 4B7=NCofthemrespondedthat@ueuingmethodisfollo#ed#hile1B=NCsays that Computer simulation is follo#ed.Baluja LabsK4@. D)!, *! OPD ,%& )# im!LT%b'! 4.4@: Di,&ibui)# )( S%(( 1i!= )# ,%&i#. )( *! OPD i# im!.C&i!&i% N). )( ,%((, P!&7!#%.!2es 1= 1==NNo = =NG&%$*4.4@: Di,&ibui)# )( S%(( 1i!= )# ,%&i#. )( *! OPD i# im!.!able1.14andgraph1.14sho#sthedistributionofStaff&ie#onstartingofthe9PEin time. 9ut of 1=B1==NC staff/ all 1=B1==NC of them responded that 9PE starts on time.Baluja LabsK4J. D) *! ")7)&, 7)m! '%!LT%b'! 4.4J: Di,&ibui)# )( S%(( 1i!= )# ")7)&, 7)mi#. '%! ) OPD.C&i!&i% N). )( ,%((, P!&7!#%.!2es 7 7=NSometimes=NTery 9ften = =NG&%$* 4.4J: Di,&ibui)# )( S%(( 1i!= )# ")7)&, 7)mi#. '%! ) OPD.>s per sho#n in the abo&e graph the distribution of the staff &ie# on do"tors "oming late to9PE.9utof1=B1==NCstaff/7B7=NCofthemsaysthatdo"torsdonot"omelateto9PE.*hile B=NC staffs responded that sometimes the do"tors do "ome late.Baluja LabsK4A. D) *! $%i!#, 7)m! )# ,7*!"u'!" %$$)i#m!# im!LT%b'! 4.4A: Di,&ibui)# )( S%(( 1i!= )# P%i!#, C)mi#. )# S7*!"u'!" %$$)i#m!#Tim! ) OPD.C&i!&i% N). )( ,%((,P!&7!#%.!2es 6 6=NNo1 1=NSometimes delayed =N>l#ays delayed==NG&%$* 4.4A: Di,&ibui)# )( S%(( 1i!= )# P%i!#, C)mi#. )# S7*!"u'!" %$$)i#m!#Tim! ) OPD.Sho#n in the abo&e graph and table the distribution of the staff &ie# on patients "oming on s"heduled appointment time to 9PE.9ut of 1=B1==NC staff/6B6=NC of them says patients do"ome on s"heduled time. B=NC responded that sometimes the patients get delayed and the rest 1B1=NC says that patient do not "ome on s"heduled appointment time.Baluja LabsK4;. W*) i, .i1!# *! $&!(!&!#7!, ()& 7)#,u'%i)#Ii#1!,i.%i)#LT%b'! 4.4;: Di,&ibui)# )( S%(( 1i!= )# P&!(!&!#7! .i1!# ) $%i!# ()& 7)#,u'%i)#.C&i!&i% N). )( ,%((,P!&7!#%.!>ppointments 7 7=N*al$-in =NG&%$* 4.4;: Di,&ibui)# )( S%(( 1i!= )# P&!(!&!#7! .i1!# ) $%i!# ()& 7)#,u'%i)#.>s per sho#n in the abo&e graph the Eistribution of Staff &ie# on Preferen"e gi&en to patientfor"onsultation. 9utof1=B1==NC staffs/77=NC ofthemsays that#al$-in patient aregi&enthe preferen"es for "onsultation.Baluja LabsK4?. I# 7%,! )( *!%1- $%i!# (')= i# %#- "!$%&m!#D ") -)u 'imi *! #). )( $%i!#, i#!%7* OPDLT%b'! 4.4?: A1!&%.! =%ii#. im! ()& =%'C-i# $%i!#,.C&i!&i% N). )( ,%((,P!&7!#%.!Z= d&an"edsimulationsusingsimulators#ouldhelptheadministratorsto&isuallysee#hat happens #hen #e "hange the resour"es in the system. (n health"are @ueue modeling"an be applied in the areas #here&er queue is in&ol&ed su"h as rationing/ s"heduling/ Bedallo"ation/ laboratory design/ and so on.6 Baluja LabsBIBLIOGRAPHYBaluja Labs1. Ja"obsonS8/8allSN/S#isherJ:B==;CEis"rete-e&entsimulationofhealth"aresystems.(n:8all:BedCPatientflo#:redu"ingdelayinhealth"aredeli&ery.Springer/Ne# 2or$/ pp 1=D5. Tos L/ 1roothuisS1/ &an fr. J. NEC>:9LP:9PPE:/L*aitinglistsand medi"al treatment: >nalysis and poli"iesL/ Chapter ) in 8andboo$ of 8ealth E"onomi"s/===/ &ol. 1/ pp 1=1-14?/ Else&ier1?. :(S(N1/ E./ :. B>:9N/ >NE B. >TE:(LL B1?6)C/ L> System >nalysis of a %ni&ersity8ealth Ser&i"e 9utpatient Clini"/L 9perations :esear"h/ 1/ 5/ 1=)=-1=46.=. B>BES/ NE 1. T. S>: B1??1C/ L9ut-Patient @ueues atthe (bn-:o"hd 8ealthCenter/L Journal of the 9perational :esear"h So"iety/ 4/ 1=/ 745-755.1. S*>:!\N/ 1. B1?6=C/ L!he Patient >rri&al Pro"ess in 8ospitals: Statisti"al>nalysis/L 8ealth Ser&i"es :esear"h/ 5/ 4/ )=-)?.. Hris Siddharthan/ *alter J. Jones/ James >. Johnson/ B1??;C L> priority queuing modelto redu"e #aiting times in emergen"y "areL/ (nternational Journal of 8ealth Care @uality>ssuran"e/ Tol. ? (ss: 5/ pp.1= - 1;65 Baluja LabsBaluja LabsKUESTIONNAIREEear :espondents/( am MOHAMED EI EOGBHY EI BADRAWY a student of MBA/ as a part of my"urri"ulumF(amtota$earesear"hProje"tonARECOMMENDATIONONREDUCINGWAITINGTIMEINTHEOUT-PATIENTDEPARTMENTINTAIBAHOSPITAL!oenabletounderta$eabo&ementionedstudy/(requestyoutogi&eyourfair&ie#s.2ourinsightsandperspe"ti&eareimportantand&aluableformyresear"h.P ) 'i7 -)#C) #(i"! #i % 'i-: Please feel free to gi&e your honest responses. !he"onfidentiality of the information pro&ided by the respondent is "ompletely assured.N%m!: NNNNNNNNNNNN.A.!: NNNNNNNNNNNN.S!G: NNNNNNNNNNNN.A""&!,,: NNNNNNNNNNNN.G!#"!& : NNNNNNNNNNNN.C)#%7 N).: NNNNNNNNNNNN.6; Baluja LabsBaluja LabsF ORPA T IE N TSS!7i)# - IW% i i#.Tim ! :A0 W%ii#. im! ,$!# i# &!7!$i)# ()& &!.i,&%i)#.a. Z15