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Part 4

  1. 1. y,1981.t Care of:eds andt,4144. PartfVtological t.rse Con-1971. Flacilitatingzrm Cares. and the Battle Professionalting: antologicalre of the Nursing Practice in insti-r elderly416..setting:is/, JuneNursing, in long-.H., andrns withGeronto-t, inThect of the198r.qn Care:)rnment
  2. 2. 13Decirsion Makingin Clinical SettingsFlorence M. Johnston The purpose of this chapter is to examine decision making as a fundamental, generic component of nursing administration. Nurse administrators must balance clinical and organizational impera- tives in managing the professional practice environment. On com- pletion of this chapter, the reader will be able to: l. Discuss decision making within a clinical and administrative framework. 2. Describe the components of the decision process 3. Explain "satisficing" as a descriptive model for decision mak- ing. 4. Relate decision techniques to problem identification. 5. Describe the importance of quantitative analytical methods in clarifying decision problems and expected outcomes.Shall we implement an all-RN staff? Should we purchase a computerizedstaffing and scheduling system? If so, which one? Which candidate forthe assistant director position is likely to be most satisfactory? Is theexisting clinical nurse specialist role appropriate with our new organ-izational structure? How many nurses will we need for the new outreachprogram? What marketing strategies should I recommend for nursing?And the list goes on, leading some people to say that the work of man-agement is decision making. Whether or not one wishes to support thisview, it is clear that the quality of the decisions made by managers iscritical to the well-being of any organization. In the case of health careorganizations, managerial decisions not only promote and maintain theorganization itself, but also promote, channel, or constrain the effec-tiveness, humaneness, and safety of the client care provided by the or-ganization. Nursing administrators with skills and knowledge in both 173
  3. 3. l74 iAqrlIIAING r&qlqqsler14! iru&slxc r&4ErlcEclinical and managerial decision making can balance clinical and or- DECIIganizational imperatives to ensure that one is not consistently promotedto the detriment of the other. In thin Nurses, throughout their basic education and clinical practice, develop procesrand hone their knowledge and skills in making clinical decisions. Similar interreformal, supervised training in managerial decision making is seldom As suclprovided. Types of decisions, techniques of decision making, and the lectualcontext of decision making in health care organizations are seldom ana- procesrlyzed and taught in schools of nursing, except in some graduate programs processin nursing administration. Although the information required for clinical often vdecision making and that required for managerial decision making are Comldifferent and techniques may vary widely, the nature of the underlying underlSdecision process and its use in health care organizations is similar. derived Alternative choices of action bridge the gap between a problem and a ratiora goal. The generation of alternative problem solutions assists in for- the infcmulating a plan of action. It is a rare problem that has only one solution, prescrilalthough people sometimes believe that problem solving means looking in arrivfor the right answer or the correct or logical solution. Basically, decisionmaking is a cognitive process of choice that precedes the chosen behavior.Nurses in all settings exercise decision making in: 1. Recc cisiol. Personal actions. 2. Ident2. Care of a single patient or groups of patients. 3. Detet3. A nursing unit. and l4. A division of nursing. 4. Selec5. A school of nursing,6. Other organizations. While making, Although everyone is programmed to make decisions of little conse- makers .quence on a regular basis, the decision making of the nurse administrator decisionin rapidly changing health care settings is becoming increasingly com- cision rrplex. According to Ackhoff (1), there is no such thing as a single problem. influentProblems do not exist in isolation: they are elements of a system. Problem model rrsolving is not enough, for problems do not stay solved. Or they give rise cision prto new problems. of all avz Ackhoff further defines a svstem in terms of four characteristics: but even that voh.1. It has two or more parts. tisficing.2. Each part can affect the behavior or properties of the whole. is found3. The parts are interdependent: the effect each part can have on the solution. whole depends on at least one other part. satisficir4. Any subgroup of parts yields subsets that have the same properties as parts: each can affect the whole, and the effect of each on the whole 1. Recog depends on the other subsets. cision
  4. 4. DECISION MAKING IN CLINICAL SETTINGS 175rnd or- DECISION PROCESS)moted In thinking about decisions, it can be useful to differentiate the decisionlevelop process from decision making itself. The decision process is a series ofSimilar interrelated steps for systematically and logically coming to a decision.seldom As such, it is analogous to other systematic processes that guide intel-rnd the lectual work, for example, the scientific method, the problem-solvingrm ana- process, and the nursing process. Decision making is the point in theograms process at which the choice, or selection, of alternatives is made and is clinical often viewed as the culmination of the decision process.:ing are Components of the decision process vary, depending on whether thelerlying underlying model is prescriptive or descriptive. Prescriptive models areilar. derived from economic theories of choice. They rest on assumptions thatem and a rational decision maker strives to reach optimal outcomes and that; in for- the information necessary to determine these outcomes is available. Arolution, prescriptive decision process includes the steps that should be followedlooking in arriving at a decision:decisionehavior. l. Recognition and analysis of the problem or situation requiring a de- cision 2. Identification of all feasible alternative solutions 3. Determination of potential favorable and unfavorable consequences and their likelihood for each alternative 4. Selection of the alternative that will result in optimal outcomes While the prescriptive model could serve as a general guide to decision making, it is apparent that, except for very simple problems, decision[e conse- makers have neither the time nor the information to seek optimizingnistrator decisions. This fact led to the development of descriptive models of de-gly com- cision making, based on how decisions are actually made. The mostproblem. influential of these has been formulated by Herbert Simon (2). This Problem model rests on the assumptions that for most reasonably complex de-give rise cision problems, not only is it impossible to generate an exhaustive list of all available alternatives and their positive and negative consequences,stics: but even if this could be done, human decision makers could not process that volume of information. So, what is actually done Simon calls "sa- tisficing." This is, the decision maker searches for alternatives until onele. is found that provides an acceptable solution rather than the optimal solution. Steps in a decision process based on the descriptive model ofve on the satisficing include:rropertiesthe whole I . Recognition and analysis of lhe problem or situation requiring a de- cision.
  5. 5. T76 FACILITATINGPROFESSIONALNURSINGPRACTICE2. Development of criteria for an acceptable outcome. possib3. Identification of alternatives. to the How4. Evaluation of whether the alternatives will lead to acceptable out- r traver comes. problr5. Selection of a satisfactory alternative: each alternative may be iden- propel tified and evaluated sequentially until the first one is found that is use, lT expected to produce an acceptable outcome, or several alternatives Forr may be identified and evaluated before selecting from among them. techni itored Other, less formal decision processes are frequently used but are con- the prsidered less likely to consistently produce good decisions. One such pro- problecess could be called the stimulus-response decision process. In this sit- informuation, the steps of identification and evaluation of alternatives are So, altiomitted, and the decision maker goes directly from identification of the manyproblem to the choice of solution, which has usually been predetermined. and thThis process can be useful for simple, repeated, and structured decision compl<problems that can be handled through procedures, rules, and policies requirebut is unlikely to produce high-quality outcomes in administrative de- Problcision situations that are complex, novel, and ill-defined. relies r Another decision process has been labeled the "Oh, hell!" decision (3). reportsIn this process, the decision maker either bypasses or ignores the in- sonnelformation from a systematic decision analysis and makes a decision and trebased on intuition or instinct-a tempting but dangerous method for nursingbusy, overloaded decision makers. and me Often, two additional steps are included as components of the decision of identprocess: implementation of the decision and evaluation of decision out- and thecomes. No decision process is considered complete without these final One csteps, including feedback loops to earlier steps However, the imple- informamentation of change in organizations and the evaluation of organiza- ministritional performance are also major, generic administrative responsibil- gossip, iities within a broader context than decision making and the decision the admprocess. The old the grou FactorTECHNIQUES the psyc pect the<Various techniques have been developed to assist in carrying out the and antibasic steps of the decision process, although some steps have received ployed imuch more attention in the literature than have others. The first step, this worthe identification and analysis of the problem or situation requiring a is of potdecision, has received relatively little attention, in view of its importance sought ofor all subsequent work. The decision maker must first be sure that he alternatior she is answering the right question by ascertaining, to the extent Hower
  6. 6. DECISION MAKING IN CLINICAL SETTINGS I77 possible, whether the problem as first stated defines root aspects, central to the situation, or whether it is primarily a symptomatic statement. How often have we responded to a problem such as a shortage of in-le out- travenous infusion pumps by purchasing more pumps when the root problem was the distribution system, frequent breakdowns due to im-e iden- p.op". use or inadequate maintenance, or some combination of number,that is use, maintenance, and distribution of pumps?ratives Formal techniques for problem definition are few. Quality control;them. techniques, in which specific performance standards are set and mon- itored and exception reports produced when performance falls belowre con- the predetermined level, can be of assistance in identifying decisionch pro- problems. However, such techniques usually rely heavily on automatedhis sit- information systems and require quantifiable performance standards.i/es afe So, although they can be helpful at least as indicators in some situations,r of the many critical decision problems in nursing administration are novelmined. and thus not captured by routine monitoring of standards, or are tooecision complex or unquantifiable for the kind of measurable standard settingrolicies required.:ive de- Problem identification, although assisted by exception reporting, often relies more heavily on the managers own monitoring of managemention (3). reports, such as financial statements, patient activity reports, or per-the in- sonnel data, to identify significant variations and to look for patternsecision and trends. Nursing administrators need to define relevant reports forhod for nursing, such as trend reports for such incidents as patient accidents and medication errors. Kepner and Tregoe (4) have outlined some wayslecision of identifying problems through a search for factors that have changedon out- and the conditions of the change.se final One of the most useful sources for early problem identification is the imple- informal communication network within an organization. While the ad-ganiza- ministrator who relies on the informal network of casual conversation,cnsibil- gossip, and rumor for problem definition is likely to be in trouble, so isLecision the administrator who ignores these sources for problem identification. The old heuristics of keeping your "finger on the pulse," "your ear to the ground," and "all your antennae out" are exceedingly useful. Factors in framing the decision problem have received attention by the psychologists Tversky and Kahneman (5,6). In initial work on pros- pect theory, they have found that the order of presentation of alternativcsout the and anticipated outcomes, positive and negative, and the language em-eceived ployed in stating them have subsequent influence on choice. Although:st step, this work has not yet been tested in organizational decision making, ituiring a is of potential importance, especially when consensus decisions are-)ortance sought or when the administrator seeks support for his or her chosen that he alternative solution.l extent However, even without formal, well-defined techniques for problem
  7. 7. 178 FACILITATINGPRoFESSIoNALNURSING PNNCTICE definition, a systematic analysis of a problem using the steps suggested lems ti by Behn and Vaupel (3) would provide an improved information base not usr for the rest of the decision process. Anol Similarly, little attention has been devoted to the design of alternatives (MAUl in decision problems. Alexander (7) has developed a model for analyzing plicate the design of alternatives in organizational contexts and discusses both termin the creation of new and innovative alternatives and the search for ex- signed isting but unidentified alternatives. Although creating new alternatives alterna and identifying existing ones are similar processes, the domains searched criteria are different. The act of defining two separate domains helps clarify the The f activity, although the same techniques may be used to design alterna- to assis tives. Usual techniques include brainstorming, lateral thinking, nominal theory,group technique, and the Delphi technique (8). Also useful are searches analysirof the literature or of the experience of colleagues and the use of analogies analyti,or other simple heuristics, such as "working backwards." In this heu- quencesristic, one begins with the desired destination and works backwards, consequstep by step, identifying the various activities or pathways that lead to compar.the desired result. ternativ With the evaluation and selection of alternatives, it is not the paucity, tir.enessbut, rather, the plethora, of techniques that is a problem. Although a as disabcomplete listing of techniques and tools is beyond the scope of this pressedchapter, some examples illustrate the range available. Examples of avoided.qualitative approaches include values clarification (9,10) and ethical but are ranalysis (ll,l2,l3,l4). These qualitative analyses are most useful whenthe decision problem itself contains significant intangible, unquantifi-able components. Such decision problems, however, often include some MAKINaspects amenable to analysis through quantitative techniques. Much ofthe power of quantitative models is the promise of concrete, clear-cut Once thesolutions, often achieved by assuming away the cloud of intangibles also has beeninfluencing the situation. The systematic use of qualitative analysis in remain. iconcert with quantitative methods can help to achieve a more balanced cess in reevaluation. In his critical analysis of quantitative methodology, partic- oroblemsularly in relation to "squishy," partially quantifiable problems, Ralph decision-Strauch (15,16) reminds us that most models are only perspectives on support)a situation and that their uncritical use as surrogates for a complex Vroomproblem is fraught with peril. alternatir Nevertheless, despite such caveats, quantitative analytical methods :om an ihave great power to clarify decision problems and expected outcomes. of arrivirThe use of such a tool as a decision tree, also called a decision-flowdiagram, maps the problem in a series of chronological steps of choices Autocracontrolled by the decision maker and choices determined by chance, indeperwith associated probabilities of occurrence (17). Each branch of the tree Autocraends with a numerical statement of expected value, or utility, of the ordinatroutcome. Decision trees can be useful analytical tools for nursing prob- Subordi
  8. 8. DECISION MAKING IN CLINICAL SETTINGS I79ggested lems that can be structured and specified in the necessary way but areon base not used much in practice (18,19,20). Another quantitative approach, the multi-attribute utility methodrnatives (MAUT), disaggregates and evaluates separately the elements of a com-ralyzing plicated decision according to determined criteria (21). Weights are de-;es both termined for criteria, and probabilities of meeting the criteria are as-r for ex- signed to alternative solutions. The resultant expected value for eachrnatives alternative identifies the alternatives that maximize achievement of therearched criteria (22).rrify the The field of operations research utilizes many mathematical modelsalterna- to assist in managerial decision making, including queuing theory, gamenominal theory, simulation, and linear programm ing (23,24,25). Cost-benefit;earches analysis (CBA) and cost-effectiveness analysis (CEA) are closely relatednalogies analytical techniques of comparing the positive and negative conse-his heu- quences of alternative uses of resources (26). In cost-benefit analysis, allkwards, consequences, that is, benefits, are valued in monetary terms. This allowst lead to comparisons to determine whether benefits exceed costs and which al- ternative produces the greatest benefits for the least cost. In cost-effec-paucity, tiveness analysis, outcomes are measured in nonmonetary units, suchhough a as disability avoided or days of hospital stay decreased. Values are ex-: of this pressed as cost (dollars) per day of hospitalization reduced or disabilitynples of avoided. CBA and CEA are used extensively in public sector decisionslethical but are only beginning to be utilized in nursing (27,28).ul whenluantifi-de some MAKING DECISIONS ABOUT DECISION MAKINGMuch of:lear-cut Once the need for a decision has been identified and the decision processbles also has been accepted as a useful, systematic approach, two additional pointsalysis in remain. Preceding sections have dealt with the steps of the decision pro-ralanced cess in relation to substantive decision problems. Next, the substantive, partic- problems must be examined in relation to the selection of an appropriates, Ralph decision-making style and to the amount of scarce resources (time, staff,:tives on support) to be allocated to the decision problem.complex Vroom and Yetton (29) present an algorithm for selecting among five alternative styles of decision making. These styles range on a continuummethods from an independent, autocratic style to a participative, consensual stylertcomes. o[ arriving at a decision:ion-flowI choices Autocratic I: the manager solves the problem or makes the decision chance, independently, using information available at the time. the tree Autocratic II: the manager obtains necessary information from sub-y, of the ordinates and then decides the solution to the problem independently.ng prob- Subordinates may or may not be informed about the problem for which
  9. 9. 180 FACILITATINGPROFESSIONAL NURSING PRACTICE information is sought. Their role is clearly that of providing infor- Certai mation, not of generating or evaluating alternatives. clear i. Consultative I: the manager shares information with relevant subor- signifi dinates individually, soliciting individual suggestions; the manager Quant then makes the decision, which may or may not reflect the partici- accur€ pation of subordinates. tance. Consultative II: the manager shares the problem with a group of sub- Huma ordinates, soliciting their collective ideas and suggestions; the decision high o is made by the manager and may or may not be influenced by sub- cant r€ ordinates suggestions. a redel Group II: the problem is shared with subordinates as a group; the a staffi group generates and evaluates alternatives and attempts to reach con- sensus on a solution; the manager participates as a group member and The m accepts the decision of the group. decision tient car evaluatir A series of questions based upon attributes of the problem and situ- is the lilational variables from the algorithm that identifies the appropriate style humaneris developed. Examples of such questions include (29): patient < process. To what degree is the problem structured?. Does the manager have sufficient information to make the decision?. Is acceptance by subordinates critical to implementation? THE P( The subs A determination of resources to be allocated to any decision problem decisionshould be guided by an assessment of the imfortance of the decision to incomplethe organization or its likely organizational impact. Decisions of lesser in the orimportance or impact do not require a highly detailed implementation politicalof ill steps of the decision process, and simpler techniques can be em- determinployed. Such decisions can often be delegated. High-impact decisions Pfefferiequire a greater commitment of resources and a higher level of re- t decisionssources. affect or Factors to be considered in evaluating the importance of a decision terdepenrinclude (30): The se< ogenous c. Size and length of commitment: decisions that are likely to require a levels of r long-term commitment of a significant amount of organizational re- Scarcit sources in order to be implemented also require a heavier investment scarcity ir of resources in the decision-making process; examples include the de- Since a velopment of training programs and the use of management contracts. care setti. Flexibility of plans: decisions that, once made, offer little possibility necessary of modification, with significant penalty, during the implementation alternativ process require detailed attention to the decision process; typical ex- In addit amples of this factor include construction decisions. ing goals,
  10. 10. DEClSION MAKING IN CLINICAL SETTINGS 181g infor- . Certainty of goals and premises: when goals and premises are fairly clear and accepted, a decision based on them, although it may be oft subor- significant organizational impact, may often be delegated.nanager . Quantifiability of variables: decisions based on variables that can bepartici- accurately quantified may require significant resources, if the impor- tance to the organization is high, but may frequently be delegated.r of sub- . Human impact: decisions that have high impact on personnel havedecision high organizational importance and require the allocation of signifi- by sub- cant resources to the decision process; for example, decisions regarding a redefinition of R.N.-L.P.N. responsibilities or the implementation of)up; the a staffing and scheduling system merit detailed decision processes.ach con-rber and The most significant factor in evaluating the importance of managerial decisions in clinical settings, is, of course, the anticipated effect on pa- tient care. The above-mentioned variables are components of such anrnd situ- evaluation, but additional ones must be considered, for example, whatate style is the likely impact on such dimensions as continuity, access, safety, humaneness? The greater the expected impact, positive or negative, on patient care, the more resources should be dedicated to the decision process.ecision? THE POLITICAL CONTEXTproblem The substantive decision problem, decision processes and styles, and decision importance are all important components for analysis but arecision to incomplete without consideration of the political context of the decision of lesser entation in the organization. Most organizational decisions are made within a political framework, that is, in a context in which differential powern be em-lecisions determines decision outcomes. Pfeffer (31) lists three conditions for the use of power in organizationalel of re- decisions. The first is interdependence, that is, the actions of one groupdecision affect or are affected by the actions of another in significant ways. In- terdependence can be both cooperative and competitive. The second condition for the use of power is the existence of heter- ogenous or inconsistent goals among individuals or groups and at variousequire a levels of the organization.ional re- Scarcity is the third condition for the use of power; the greater the/estment scarcity in relation to demand, the greater the conflict and use of power.e the de- Since all three conditions are present for most decisions in healthntracts. care settings, nurse managers must develop their political skills. It isrssibility necessary, but not sufficient, that the nurse manager present decisionLentation alternatives based on a systematic, well-documented decision process.pical ex- In addition, preparatory identification of interdependencies, compet- ing goals, and resource demands provides important information for
  11. 11. 182 nacILttlttNcpRopEssroNaLNunstNGpRACTrcEselection and implementation of political tactics to be employed in in- 6. Kahn,fluencing the decision. Nurse managers need to add such political skills risk. ,las negotiation, bargaining, persuasion, use of political language, com- 7. Alexa studypromise, and coalition formation to their repertoire in order to maximize 8. Moscctheir power in the decision situation or to minimize the level of conflict resealthat politicizes the situation. healtt 388-4 9. KirsclSUMMARY and a 114.Decision making is a cognitive process of interrelated steps for system- 10. Steele pletonatically and logically coming to a decision. Decision making can be based 11. Holmeon a prescriptive or a descriptive model, and various decision-making Medicttechniques may be used. Competing goals and resource demands are 12. Institufactors contributing to the political context of decision making. York: 13. Davis, AppletSTUDY QUESTIONS 1.1. Frome 15. Strauc1. Define decision making as a process. ences, .2. From your experience, what kinds of problems are appropriately 16. Strauc evaluated through a decision process? Winter 17. Raiffa,3. What are three key factors in framing a decision problem? Readin4. How do informal communication networks contribute to your un- 18. Aspina derstanding and definition of problems? ing Res5. Identify decision-making styles. 19. LaMon Admini6. What factors are used to assess the organizational importance of a 20. Taylor, decision? of Nurs7. How can knowledge of the conditions that lead to political decision 21. Edwarr making be of assistance to the manager? to evah Sage P 22. PosavaREFERENCES Engleu 23. Eden, ( Ackhoff, R. Beyond problem solving. Paper presented at the fifth annual York: meeting of the American Institute for Decision Sciences. Boston: November l-1. Parker, 1973. policy 2. Simon, H. Administrative Behavior. New York: The Free Press, 1976. 389-42 J. Behn,R. and Vaupel, J. Teaching analytical thinking. Policy Analysls, Fall 25. Warner 1976,2(4),663-692. Admini 4. Kepner, C. H. and Tregoe, B.B. The Rational Manager. New York: McGraw- 16. Warner Hill, 1965. Care. A .5. Tversky, A. and Kahneman, D. The framing of decisions and the psychology 17. Stokey, ofchoice. Science, January 30, 1981, 211(4481),453-458. 1 978.
  12. 12. DECISION MAKING IN CLINICAL SET]:INGS 183ed in in- 6. Kahneman, D. and Tversky, A. Prospect theory: an analysis of decision under risk. Econometrica, March 1979 , 47(2), 263-291 .cal skillsge, com- 7. Alexander, E. The design of alternatives in organizational contexts: a pilot study. Administreftive Science Quarterb, September 1979, 24(3), 382-404naximize 8. Moscovice, L Armstrong, P., Shortelle, S. and Bennett, R. Health servicesf conflict rcsearch for decision makers: the use of thc Delphi technique to determine health priorities. Jountal of Health Politics, Policy and Law, Fall 1977 , 2(3), 38 8-4 I 0. 9. Kirschenbaum, H. Clarifying values clarification: some theoretical issues and a review of research. Group and Organizational Studies , 197 6 1(2) , 99- 1.14.r system- 10. Steele, S. and Harmon, Y.Values Clarification in Nursing New York: Ap- pleton-Century-Crofts, 1979. be based 11. Holmes, C. Bioethical decision making: an approach to improve the process.r-making Medical Care, November 1979, 27(ll), 1131-1138.,ands are 12. Institute of Society Ethics and the Life Sciences. Hastings on-Hudson, NewrOb York: the Hastings Center. The Hastings Center Reports. 13. Davis, A. and Arosk ar, M. Ethical Dilemmas and Nursing Ptactice. New York: Appleton-Century-Crofts, 197 8. 14. Fromer, M. Ethical Issues in Health Care. St. Louis: Mosby, 1981. 15. Strauch, R. E. "squishy" problems and quantitative methods. Policy Sci- ences, June 197 5, 6(2), 175-184.cpriately 16. Strauch, R. E. A critical look at quantitative methodology. Policy Analysis, Winter 197 6, 2(1), l2l-144.I 17. Raiffa, H. Decision Analysis: Introductoty Lectures on Choices Under Certainty. Reading, Mass.: Addison-Wesley, 1968. your un- 18. Aspinall, M. J. Use of a decision tree to improve accuracy of diagnosis.Nzrs- ing Research, May/June 1979, 28(3), 182-185. 19. LaMonica, E. and Finch, F. Managerial decision r;raking. Journal of Nursing Administration, MaylJune 1977 ,7(5 and 6),20-28. ance of a 20. Taylor, A. G. Decision making in nursing: an analytical approach. Joutnal of Nursing Administration, Novemb er 197 8 , 8(l l) , 22-30.I decision 21 . Edwards, W., Guttentag, M., and Snapper, K. A decision-theoretic approach to evaluation research, tn H andbook of Evaluation Research, vol. I . London : Sage Publications, 1975. 22. Posavac, E. and Carey, R. Program Evaluation: Methods and Case Studies. Englewood Cliffs, N.J.: Prentice-Hall, 1980. 23. Eden, C. and Harris, J. Management Decision and Decision Arzalysls. New[th annual York: Wiley, 1975.November 21. Parker, B. Quantitative decision techniques for the health/public sector p<rlicy maker. Joumal ol-Health Politics, Policy and Lrnv, Fall 1978, 3(3),976. 389,429. 25. Warner, D. M. and Holloway, D. C. Decision Making ttnd Control for Healthalysis, Fall Administration. Ann Arbor, Mi.: Health Administration Press, 1978.:McGrarv- 26. Warner, K. and Luce, B. Cost-Benefit and Cost-Effectiveness Analysis in Health Care. Ann Arbor, Mi.: Health Administration Press, 1982. 27 Stokey, E. and Zeckhauser, R. A Primer for Policy Analysis. New York: Norton,rsychologl 1978.
  13. 13. 184 FACILITATING PROFESSIONAL NURSING PRACTICE28. Crabtree, M. Application of cost-benefit analysis to clinical nursing practice: a comparison of individual and group preoperative teaching. Journal of N ursing Administration, December 197 8, 8( 1 2), 1 l-1 6.29. Vroom, V. and Yetton, P. Leadership and Decision Making. Pittsburgh: Uni- versity of Pittsburgh Press, 1973.30. Koontz, H., ODonnell, C., and Weihrich, H. Management, Tth ed. New York: u McGraw-Hill, 1980.31. Pfeffer, J. Power in Organizations. Marshfield, Mass.: Pitman, 1981. Fiar Judith The p proces care f able tr l.t 2.r S, 3. I n 4. I( e Conceptu ognition human o: nursing c health ca in facilitS For an5 ministrat tives, dete that the d skill requ the desigr thinking: ning. Strateg an organi: in more d ment, strr tions mis
  14. 14. practice:ournal ofLrgh: Uni- 14Iew York:,l - Fiacilitiesf@ Judith A. Bernhardt The purpose of this chapter is to provide basic knowledge of the process and content of planning the physical environment for health care facilities. On completion of this chapter, the reader will be able to: l. Describe the phases of a facility planning project. 2. Discuss the nursing role in the facility planning process and space management. 3. Describe the operational concepts that affect nursing in plan- ning and designing facilities. 4. Identify resources and techniques available for making and evaluating planning and design decisions. Conceptualization of the physical environment has resulted in the rec- ognition that staff functioning and patient recovery are affecled by the human organization within health care facilities. Since the delivery of nursing care extends into and is dependent upon all other areas in a health care facility, the importance of effective nursing administration in facility planning cannot be underestimated. For any administrator, planning is an essential component of the ad- ministrative process and includes the major activities of setting objec- tives, determining policies and resources, making decisions, and assuring that the desired outcomes are achieved. Planning is the first conceptual skill required in an administrative role and is the dominant process in the design and construction of health care facilities. A useful way of thinking about planning is to consider both strategic and tactical plan- ning. Strategic planning encompasses long-range goals and objectives for an organization, while tactical planning focuses on goals and objectives in more detail and for a shorter time span. In the health care environ- ment, strategic planning includes such tasks as describing an institu- tions mission and role, determining the scope of services and the level 185
  15. 15. 1E6 lacl_LII4.IINQ_lBqI_ES_spN4,L_Nrr&QINGrBAlT,rcEof care to be provided, and choosing the site location and design for a whethtnew health care facility. Tactical planning includes budgeting, identi- portiorfying staffing ratios, and determining patient admission and scheduling the derprocedures ( I ). The function of facilities planning is to strategically con- For zceptualize and plan how an individual health care environment will erationfunction in the future. To strategically plan facilities is to commit to repres€the risk of conceptualizing about the future, since buildings are sub- staff arstantial investments that will stand for long periods of time. physici Addi world rTHE ROLE OF NURSING IN FACILITY PLANNING brings unfamiNurse administrators have a significant role in the facility planning minololprocess because of their clinical experience related to the technical and in ordesophisticated nursing and medical services provided today. Nursing ac- formaticounts for more than 50 percent of a hospitals payroll, and total payroll design rconstitutes more than 50 percent of all hospital operating costs. Nursing ments fmerits active involvement throughout the planning process in order to por:atedproduce management and operating efficiencies. The very nature of The finursings role as nursing services representative and patient advocate sultant:makes it a source of invaluable experience and insight about nursingpractice, the flow of materials and people, functional requirements of 1. Coor,space, and environmental issues important to nursing staff, patients, decisfamilies, and other health care providers. All of these elements can be 2. Gathrenhanced or hindered by the design of the environment (2). 3. Exan The planning and design of building programs require a decision- ganizmaking process that involves several levels within an organization. For to plimajor building programs, there is usually a director of planning who 4. Reviefunctions as the representative of hospital administration, a planning requicommittee, special committees with broad and diverse user represen- 5. Act altation, and the governing board, which retains ultimate authority and tweerresponsibility for the entire building program. Smaller building pro- apprcgrams and renovation projects may compress these decision-makinglevels. Nursing has an opportunity to provide input into the organization 6. Monitat the levels where strategic program management and operational plannplanning occur throughout the planning and design process. The task of strategically planning health facilities is generally accom- Since 1plished by a planning committee typically composed of representatives a numbe.from various departments or disciplines. Nursing administration must in facilitbe represented at this level, where needs and future programs of the that recoorganization will be determined. At the same time, nursing can develop needs ofits own internal organizational structure to designate the appropriate nursingsstaff who need to be involved on any special committees to influence the healtithe management of the program design and provide educated direction ily needson nursing practice and function. Such organization is important care facil
  16. 16. FACILITIES PLANNING I87gn for a whether the facility planning project is large or small, for the design portion of the process itself demands significant time commitments to, identi-Leduling the development, review, and approval of final design schemes.rlly con- For a large replacement project spanning a number of years, consid-ent will eration should be given to establishing and assigning a full-time nursingmmit to representative to serve as a consultant and a link between the nursingare sub- staff and the architect, providing knowledge about the impacts of the physical environment on nursing practice. Additionally, the facility planning arena introduces nursing to the world of planners, architects, engineers, and health consultants and brings with it techniques and terminology that are relatively new and unfamiliar. The nurse consultant must learn such techniques and ter-,lanning minology through daily interaction with these planning professionalsLical and in order to be able to communicate in planning jargon, anticipate in-rsing ac- formation needed by the architect in each design phase, and evaluateI payroll design schemes. Well-prepared and relevant functional spatial require- Nursing ments for nursing have a good chance of successfully becoming incor- order to porated into the final design..ature of The following responsibilities are essential to the role of nurse con-rdvocate sultant: nursingments of 1. Coordinate the involvement of nursing in the planning and designpatients, decision-making processes.-s can be 2. Gather data and prepare documentation to facilitate decision making. 3. Examine and evaluate innovative design concepts, care delivery or-lecision- ganization, and new technology, and make recommendations relatedtion. For to planning objectives.ring who 4. Review program plans and assist in the definition of nursing practiceplanning requirements.represen- 5. Act as liaison to interpret terminology and professional concerns be-rrity and tween the staff, consultants, and external planning and regulatoryling pro- approval agencies.L-makinganization 6. Monitor the design and construction for consistency with the original:rational planning concepts. (3)y accom- Since the profession of nursing serves as a patient advocate, there areentatives a number of patient and family needs that can be coordinated by nursingion must in facility planning. Nursing care is approached from a holistic viewns of the that recognizes the physical, spiritual, psychosocial, and developmentalr develop needs of patients, with the patient, family, and community central topropriate nursings concern and program implementation. The design or plan ofinfluence the health care environment, therefore, should support patient and fam-direction ily needs for a therapeutic milieu. However, more often than not, healthnportant care facilities are designed primarily to meet health professionals needs
  17. 17. 188 FACILITATING PROFESSIONAL NURSING PRACTICEfor efficiency of practice and often fail to provide an environment thatsupports recovery (4). While there is currently a dearth of information in the literature di-rectly pertaining to hospital design and human behavior, nursing can,through experience, sensitize planners and architects to environmentaldesign and behavior as it affects not only staff, but patients and theirfamilies as well. The needs of patients and their families basically relateto the degree of control they have over an otherwise stressful environ-ment. Six such needs have been identified:l. The ability to find ones way between destinations.2. The ability to control what is likely to be seen and heard as a result of space relationships.3. The ability to regulate the amount of interaction with others visually and acoustically.4. The security and safety of the environment.5. The convenience with which various amenities and destinations can be reached.6. Special needs due to age or to physical or mental limitations.Incorporating these needs into design enhances the delivery of qualitypatient care (5).THE FACILITY PLANNING AND DESIGN PROCESSWhether in building a new health care facility or accomplishing majoradditions or alterations to an existing facility, optimal long-term out-comes are achieved when those involved have a basic understanding ofthe planning process and a concept of design objectives (6). This sectiondescribes the process phases and discusses ways in which nursing canpositively influence the phases (see Figure 14.1).Mission and Role StudyThe first phase of the planning process defines the facilities mission androle for at least l0 years in terms of programs, physical facilities, andgeneral space requirements for departments of all types. Recently, healthfacilities have employed independent, professional consultants to de-FIGURE 14.1 The planning and design process continuum. (From the Office ofPlanning, Research and Development. The University of Michigan Hospitals,Ann Arbor, MI.)
  18. 18. r9d ;PSnent that 6oature di-sing can,rnmentalrnd their lly relate environ-sa results visuallytions can)ns.rf qualityng maJor-erm out-anding ofis sectionrsing can;sion andities, andly, healthrts to de-e Office ofHospitals, s- ; li i 9i 189
  19. 19. 190 FACILITATING PROFESSIONAL NURSING PRACTICEvelop long-range role and program plans. The mission and role study 6. Thehas the dimensions of a community-wide survey and includes such ele- 7. Sepaments as patient origin studies, population projections, utilization 8. Privztrends, length of stay, patient days, average daily census, and bed re- 9. Buil<quirements. The study includes the examination of plans of other healthcare providers in the area, community characteristics, the effects of leg- The funislation, and its primary, secondary, and tertiary care roles on a defined health carea-wide basis. niques o At the same time, required health care resources, the role of the health rhose chcare facility in education and research, and long-range personnel re- Ifamquirements are evaluated. Upon completion and acceptance by the fa- and funrcility of this survey of health care needs and the services to be provided, process icapital costs and the ability to finance the project must be determined the decirby a financial feasibility study. Effective nursing involvement later in out procthe design process as it relates to types of patients and services to be lolveme.provided requires that nursing be part of the prior development of long- not unrerange goals for the facility and be aware of the impetus for the building be assigrproject (6). project. I The mission and role study is also necessitated by the high degree of :e desigrregulation of the health care environment. Nursing may be involved in :he projecollecting and analyzing data to convince review agencies of the need The imfor and economics of the project. quality o Jepends , erchitectPhysical and Functional Evaluation :lex relalThe basic purpose of the physical evaluation is to determine the degree rents, arof physical obsolescence of the existing facility, identify major code vi- .eries ofolations, and project the facilitys usability in the future. The functional :reate a Fevaluation assesses the facilitys ability to serve as an efficient work -s of reas<place for personnel and to provide a supportive environment for patients llLlOYeS fitand their families. The methodology used to functionally evaluate a fa- ,nd assis.cility compares functional attributes to adopted criteria. Minimum Re : romisesquirements of Construction and Equipment for Hospitals and Medical Fa-cilities, HEW Publication (HRA) 79-14500, and pertinent state rules andregulations serve as the basis for criteria laster P In addition to the codes and regulations, a number of functional con- fhe mastrcepts provide standards for evaluating functional features The more :-rual descommon concepts include: :rich a fe :ires, reql1. Viewing the whole facility as a single, efficient system. - re projec2. Physical relationships required between departments. .lmissionr -3. Room size and shape needed to accommodate function. - le study.4. The ability of the facility to expand. faster p _ _ .-r- maste5. Space and equipment flexibility.
  20. 20. FACILITIES PLANNING 191 6. The degree of automation.le studyuch ele- 7. Separation of cleaned and soiled zones.lization 8. Privacy accommodations for patients. bed re- 9. Building circulation patterns. (6),rhealthls of leg- The functional concept of flexibility deserves much emphasis. For a defined health care facility, flexibility is critical in allowing for changing tech- niques of professional practice, alteration of department layouts to meetLe health those changes, and addition of new departments in the future.nnel re- If a major design effort is to be undertaken as a result of the physicaly the fa- and functional evaluation, then usually at this phase of the planningrovided, process a project team is formed, roles of the members are defined, andermined the decision-making process is clarified. This is when a well thought- later in out process of designating staff or nursing committees for ongoing in-:es to be volvement in the remainder of the process can also be developed. It is. of long- not unreasonable to request that a nurse consultant or several nursesbuilding be assigned to the project team on a major renovation or replacement project. For minor projects, a consistent point of contact in nursing canlegree of be designated to coordinate and provide input at each major phase inolved in the project.lhe need The importance of this involvement cannot be overemphasized. The quality of a facility planning and design effort in the remaining phases depends on those assigned to plan the building in detail and upon the architect who will design it. Health care facilities are composed of com- plex relationships, flows of people and supplies, technological require-e degree ments, and operational procedures. These relationships necessitate a code vi- series of planning and design decisions and compromises in order to.nctional create a project that balances user needs, is aesthetically pleasing, and:nt work is of reasonable cost and optimal utility. To achieve these goals, it be- patients hooves nursing to be an integral part of the decision-making processrate a fa- and assist in determining which program planning and design com-mum Re- promises minimally affect the functions required to care for patients.dical Fa-ules and Master Programrnal con- The master program phase of planning health care facilities precedeshe more actual design efforts. The master program describes the concepts upon which a facility will operate and specifies functions in terms of proce- dures, required equipment, and numbers and categories of space users. The projected number of procedures or tests is based on the number of admissions, patient days, and clinic visits projected in the mission and role study. Master programming is one of the most important planning activities. The master program is reviewed by external regulatory agencies and
  21. 21. t92 EAqluIAIINe rQIESQIONAL NU RsrNG pRACrrcEbecomes the major approved policy document. It serves as a guide forthe architect, the manager responsible for constructing the facility, thestadministration, and the people who will use the space. This program- pers(ming effort, once the province of the design architect, is now frequently in otconducted by planners familiar with health care functions. Titled func- throttional planners, such professionals usually have a background in hospital viewsmanagement, and many are trained by consulting firms that specialize to pr,in both health care programs and facility planning. quire A number of nursing-related operational concepts require decisions perfo.at this stage (6): tain s1. Types and mix of patient rooms (single, double, four-bed)2. Centralized versus decentralized supply processing and material dis- Spac tribution systems A spa,3. Size of nursing units is assi4, Presence or absence of a nursing station the m5. Type of care delivery (team, primary, functional) needs6. Degree of automation for processing data The tr7. Degree of centralization for laboratories and pharmacies. unit ot of eaclIt is in this part of the planning process that the nurse administrator underscan make a significant contribution by utilizing designated nursing but thrplanning resources to describe and document for the planners the plan- ditionning objectives and design concepts that are not only required but de- followssired in order to implement nursing practice in a new setting. depart. The planning objectives and design concepts can begin with a de- Sevescription of the patient population and the philosophy of delivering sions anursing care within the overall mission and role of the health care fa- ner forcility. Such objectives include but are not limited to the operational architrconcepts previously described. gramII Once the philosophy of care and the patient population are identified, equateit is useful to identify the program goals and assumptions for nursing, :he arcincluding definition of terms. An example of a program goal is to main- ,or thetain a system of decentralized nursing administration. Once all the goals ,ne imhave been listed, with objectives stated for each, the operational and .pens,physical space requirements to implement each goal can be identified. AnotExamples of operational and physical space requirements for the goal :Qu3I€of decentralized nursing administration are to locate units with similar siate alpatient populations in close geographical proximity and to require office :rinimrspace for each head nurse on the unit for which he or she is responsible ., be la(7). .r -.,spita As part of the master program, it is valuable if the documentation o: ,.:ructi<planning objectives and design concepts for nursing itself are stated i; :Strict,a format that all parties can understand. To assist in the description o- .. hen t ni:rrsinl
  22. 22. FACILITIES PLANNING 193uide for these objectives and concepts, the nurse consultant, designated nursingfacility, personnel, or both should review layouts of nursing areas and systemsrogram- in other health care facilities. Such a review can be accomplished:quently through carefully documented visits to other health care facilities; re-ed func- views of hospital, medical, and design journals; and operational analyses hospital to prepare adequate documentation to support the proposed space re-lecialize quirements. An example of an operational analysis that may need to be performed is to describe and document the rationale for desiring a cer-lecisions tain size nursing unit.erial dis- Space Program A space program is a listing of every room or area to which a function is assigned in a proposed construction project. As a direct derivative of the master program, a space program is used to communicate facility needs to the architect and is frequently prepared by a functional planner. The traditional space program lists the type of room required within a unit or department and the quantity, size, and functional requirements of each. The space program should provide the architect with a clear understanding of not only what function is to be performed in the space,nistrator but the quantity and type of personnel required for the function, in ad-I nursing dition to the equipment and environmental needs. The listing of rooms the plan- follows the order of the master program, and rooms are grouped byd but de- department, functional entity, or both (see Table 14.1). Several factors influence the space program phase. Different conclu-rith a de- sions about the dimensions and space identified by the functional plan-elivering ner for a room can be arrived at during the actual design by differenth care fa- architects. For example, an intensive care patient care room pro-rerational grammed for a certain size might need a generous width to allow ad- equate clearance at the foot of the bed during a cardiac arrest. However,dentified, the architect might believe that the length dimension is more importantr nursing, for the medical gas outlets and equipment required at the bedside. Thus,s to main- one important requirement might be needlessly compromised at theL the goals expense of another equally important functional requirement. ional and Another factor influencing the space program includes minimumidentified. square footage assignments or the amount of space stipulated by most,r the goal state and federal regulatory agencies for certain functions. While these th similar minimum requirements must be met for licensure, certain spaces needluire office to be larger to accommodate specific functions; for example, a teaching:sponsible hospital would require spaces to accommodate students. Finally, con- struction budgets influence space assignment size. When budgets are:ntation of restricted, space sizes for rooms are usually at their functional minimum;e stated in when budgets are unrestricted, optimal space sizing can be achieved.cription of Nursing can provide assistance in monitoring those essential spaces that
  23. 23. s may t *lL O 9 O (6). @ oo Oo <) Ac: ^ Ll O^ o- O Fi:l N gram d5t care f I desigr S .! ^. qiJ (il often r o xtl O @ O+ c.l o ca .x{l Block >,t Block o co$ which c.l simple o faciliti r-.u partm( .5;.€ tE- 9< i! E! p TiF intensi ill pati, 6ii *,; Fi :.iEE I E;+; Ev9 lit: ?€E iiSa ;=s: -O d I it relat and ele iFigc ,r x I oq i f. ) q ^qrej o :,oto a d tr- O l El=tr I .iGqO .:o-oco grd up the ;u5: -=t c3? ; _.O63 ,-{!;s !r= !g;; €;e# E< -Cg:3 fit on t I Gn -o v; I At th a,2 i6tl oEE c,T#t ii==i 5 )i CJ .! ;j brr ;!q." ci";! 9.6;E EEU,9 (dE I alterna r:FG HfE EsE€ FEaE a> l52 tr o,F! .-a5 i tionshil 1=;S.i; t*E iiar = 2a .9 o. termini -l -E.:Hoe;u co s 3 b o .! i o Fgi.s ,^tt:7JLt::-LJ--;P o f 6; " : o 5 cdl I rvrthin oh criteria p uoi g;EI ,F€3.i*iEE i:+E ua Ari Et I rional r : A;5:E;;E :Ei; I 6 E€E; ^,J UC ieria of lil *lnri::Ee.9iT :: L-.r9 6rlo -cJ l :he locr zl !ti ol E;E:;iii;;Eii H;t; <E $ P;iiE:3e je s.tP !E[-E tr,o O= cdP I As bl< This pr tr d .:;iJ z==?, }J= E > i ia " Jevelop i€E c.,.93F- tt: cli sl !i riiE 6i6o a g:16;?l*c Lv LI ll part n, g bo o h ;i=:.1=6 L- E1 rCCOmn O(! ol :eriod f o ol (g A al S I ;;!€r E;:i 5 s; -*e F+€t .Bl .raffic f .rd lan d =l _3re, pr, LI o XYl. .. an irr cdl A] b0 =A The b + 01 a).-* ,e bui a- d^^ ^ -- ho .:uippe HG.l F-l r!P -.alth c l trl o li <x FEl OL tr tu a :(e a0< z -ree di194
  24. 24. FACILITIES PLANNING 195may be in danger of becoming dysfunctional under budget constraints(6). A carefully prepared master program and a well-defined space pro-gram can assist in achieving functional rooms and spaces for a healthcare facility, which enables administration to make many importantdesign-related decisions without repeating the trial-and-error processoften encountered in design.Block Plan DrawingsBlock plan drawings represent the beginning of design, the point atwhich the architect translates the program and space descriptions into simple drawings of blocks of space. Block plans graphically depict afacilities evaluation of necessary functional adjacencies between de-partments; for example, the emergency room should be located near the intensive care units in order to minimize travel distance for critically ill patients. The block of space for each department and the departmentsit relates to are shown by building level, along with major corridorsand elevators. Alternative ways in which these blocks of space that makeup the building can be designed are then evaluated as to how well theyfit on the site designated for the facility. At this phase, three-dimensional models are useful in demonstratingalternative building forms to assist in the selection of optimum rela-tionships and configurations. Since the nursing unit is the major de-terminant of the buildings shape, the architect focuses on its locationwithin the building first. Nursing can assist the architect by providingcriteria on departmental adjacencies important.to nursing and on func-tional requirements that will influence the shape of a nursing area. Cri-teria of importance include nursing travel distances between spaces andthe location of supplies for those spaces. As block plan drawings are developed, a master site plan is formulated.This process encompasses selection of a site, analysis of the site, anddevelopment of drawings to visually portray the buildings and uses ofall parts of the site. A site plan is the rational selection of a location toaccommodate all construction envisioned during a l5-to-2}-year futureperiod for a health care facility. The plan reflects vehicle and pedestriantraffic flows, parking, building configuration, placement, organization,and landscape details. With the advancement of technology in healthcare, provisions for flexibility of site use and expandability of structuresis an important part of the facility planning process (6). The block plan phase is also the stage in the design process at whichthe building and evaluation of full-size mock-ups of various fullyequipped rooms are of extreme importance. In planning and designinghealth care facilities, no other adequate substitute for seeing spaces inthree dimensions exists. Users of the space can be involved at this point
  25. 25. W FACrLlrArrNG pReIEqQloNAL_Nu&sI_c pB4erllEto evaluate function and predict the operational quality of certain spaces,building materials, equipment, and furnishings. Mock-ups can also beof significant value to administration in introducing the new facility tothe community. In fact, mock-ups should be installed permanently inthe new facility as an in-service education tool for everyone from health q$ "i;;"%,care personnel to maintenance and housekeeping. t^ fii As part of the initial design phase, a mock-up program can be un- :a,,-...dertaken in several steps: Il. The project team and architect can evaluate two-dimensional draw- ings (sketches or floor plans).2. Visits can be made to mock-up displays prepared by manufacturers o[ specilic health care equipment.3. The team can study three-dimensional scale models of specific spaces and participate in evaluating full-scale mock-ups with actual or sim- ulated equipment and furnishings. Full-scale mock-ups can be built in the existing facility or in a nearby building and can be constructed for a small percentage of the overall project budget, particularly if planned from the onset. A space can be considered a prime candidate for mocking up if:1. The space recurs frequently in the design.2. The space is complex and needs to be visualized in order to under- stand its functional relationships with people, equipment, and other spaces.3. A mock-up is the best way to acquire, evaluate, and transmit mean- ingful user input about the space.4. The capital and operating costs of the space are great.5. The space is expensive to renovate after occupancy. s u .?E >cSpaces that might be mocked up include a general and an intensive care o < og ufo ,. opatient bedroom, a nursing station, an exam room, and an operatingroom. If full-scale room mock-ups are not financially feasible for a proj- ; ss aect, three-dimensional models should be used as a fallback predesignevaluation tool (8). The first step in evaluating full-scale mock-up rooms is to developperformance criteria for how the space is expected to function; for ex-ample, there should be adequate space in a two-patient room at the footof the bed to allow the second bed to be removed during a cardiac arrestwithout unduly disrupting the arrest procedure. The next step is to de-termine what tools will be used to evaluate the spaces, for example,questionnaires, interviews, and checklists. Activities that will routinelyoccur in the space can be role-played or simulated and can be photo-
  26. 26. spaces,also be:ility to:ntly in health be un-I draw-.cturers) spaces or sim-re builttructed :-H=€-3 E*6rlarly if E: y.o; tr 6 i q cd -:c cd<o !: ! P dZ U- *ll Q i "-oF- -v) dN s : ;: c ;, if: E e" 9 5E,!; H=tg aJtVh- (g.: H 9E{ - c.9E EiAt656.9a ..t#_i-- F L,under-rd other ; I3E l? 8.sS qI a,"--:-XJ ".:-q= p..x|{ =; .::-*C,^@<!tr ! -t mean- H! E; S ;U :, O / Y H i#5 * 8 3 cr o :: o eOPX--.!-= Lril.oyrg(J(rl.! ^ Bz EE vo I nr ! v , ? 6 ii o F H Xa ? N+ * :: tE -s !8 -- - E i. b-. >b d 9 :3E-f; re:i A.= 6 Y ()* s h t 6 5T: it..: G ! s3 Pa -EE r$ trC.Y!o66Xdr Frve carererating : U oO 6E -* $g €g sE o ;s <: 6- cE O! 1Yl sE ;: * E er! P ETo.,trF!X.:<1l O s: i is€ ql<r a proj- AaN-€edesign E.H€EEAgTb d=- O-art!Vi> v._ l3Q!ltr ! ---{!develop Hi > Y D A.-- _ Y : o = 9 F:". u o =; for ex- 2a9!-=o:-! O! reili.r4 C (s,J the foot N -= >: c) 6 E ! S ",rc arrest +E b !; H;!i F tr eis to de-xample, EE J /i ** E Aa .) !* L: s:3!t; d E;rutinely : i 6F ?.: , s- o S or -e, Er i OE s 6-: photo- 197

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