philosophy of hospita l 2003

8/6/2019 Philosophy of Hospita l 2003

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GENERAL HOSPITAL

Philosophy of hospital

The ethos of this hospital is 'LIFE IS TOO PRECIOUS SAVE IT AT ALL

COSTS. Service before self has been the motto of the pioneers of this in always

situation which has percolated down to next generation who have joined the line.

The philosophy of the hospital is that no patient should been turned away

because he is too poor to pay.Pride Values

V - Value Diversity other cultures, other perspectives

A - Anticipate what people needL - Listen actively

U - Understand the power of teamwork

E - Excel in service

We all envision a system in which those who give care take great pride in theirwork, and those who receive care are confident in trusting the care they receive.Providing a safe environment with the highest possible quality healthcare is atthe very core of our Patients First philosophy. It is deeply embedded in the fabricof this hospital. here are some of the highlights of our emphasis on quality:

First, we work hard to recruit and retain a highly qualified and experienced staff.We are extremely fortunate to have all professional nursing staff (only RN's orLPN's) in all of our departments or services. Few other hospitals can make thisstatement. All our physicians must be credentialed before they can practice inthe hospital and are regularly monitored via a rigorous peer review process.

Second, we maintain an active Quality Program, supported by a Medical directorand the equivalent of two full time staff persons. This program follows up onpatient feedback, and proactively searches for performance improvement andrisk reduction opportunities. For instance, they are currently working to minimizehandwritten orders errors by improving penmanship and eliminatingmisinterpretations from potentially confusing abbreviations.

In addition, our quality program tracks our progress on national Patient SafetyGoals and evidence based medicine, comparing our results against otherhospitals across the country. Action steps are implemented to remedy situationswhere gaps exist between our results and "Best Practice'. We are one of very fewhospitals having public goals that are published twice each year so thecommunity can clearly see our results.

Third, a major initiative ,General is continuity of care. As much as possible wetry to assign the same care team to each patient. This helps minimize errors that


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can happen at the hand off as a series of different care providers treat the sameperson. Additionally, we have recently made provisions to have a full-timehospitalist physician available to care for inpatients. This will assure that the careteam has maximum opportunity to work together to provide excellent care. Thiscontinuum of care is further supported by a follow up phone call from a nurse

shortly after discharge, and the option for continuing services through ouroutpatient departments or Home Health Care.

Finally, it is committed to having well informed patients and families playing anactive role in treatment decisions. We know that family and patient involvementspeeds recovery. If you or a family member utilizes hospital services, pleaseknow that all our staff welcomes questions and supports your desire to becomeinvolved. Dont be afraid to ask. No question is unimportant. No caregiver is toobusy to stop and talk with you. Some key areas you might want to ask aboutare:

Medications Expectations and care options

Comfort items such as the temperature in the room, getting something

to eat or even changing to a different bed.

The issue can be resolved.

Also, never lie silent in the face of pain. Always let your care team know if youare in pain. Should you worry about falling, please ask for assistance if you haveto get out of bed. You and your family are a critical part of your care team.Become involved, it will speed your recovery.

As with everything, the proof is in the pudding. The main goal of our activequality program is your overall experience with our care delivery system. If youare not satisfied, we have failed, no matter how good your clinical care. Werecognize every patient defines quality for themselves, and therefore, we mustgive you the personalized service you expect. High patient satisfaction is vital toour continuing ability to serve the community in the manner you demand. Werealize that quality is a never-ending journey that requires our daily focus anddedication.

OBJECTIVES

Objectives of a hospital are

Provide care of sick & injured.

Prevention of diseases & promotion of health

Diagnosis & treatment of diseases

Rehabilitation & vocational training

Medical education

Research


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Staffing patterns of 200 bed hospital in India:-

LISTOF STAFF S. NO.

OF STAFF

MEDICAL OFFICER PCMS I

2

MEDICAL OFFICER PCMS II 4

ANAESTHETIST 1

PATHOLOGIST

1

RADIOLOGIST1

BIOCHEMIST

1

DENTAL SURGEON

1

CASUALTY MEDICAL OFFICER

3

HOUSE SURGEONS

1O

MATRON

1

NURSING SISTERS 10

STAFF NURSES 32

RADIOGRAPHER

1

PHERMACISTS

5

LAB.ASSTT.GRADE I

4

LAB. ASSTT.GRADE II

LAB .ATTENDANTS

2


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DIETICIAN

1

COOKS

4

HEAD COOK

1

STENOGRAPHER

1

ACCOUNANT

1

STOREKEEPERS

3

CLERKS

2

DENTAL MECHANIC

1

CARPENTER/PAINTER

1

CARETAKER/STEWARD

1

CHOWKIDAR

3

MALI

2

OTHER CLASS IV POSTS INCLUDING SWEEPERS 81

REGISTRAR

-

HAWALDAR

-

ASSISTANT MATRON

1

CASHIER

1

HEAD CLERK

2


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OPERATION ROPM ASSISTANT

1

ELECTRICION

1

BARBAR

-

PLUMBER

1

RECRUITMENT POLICY- it has been accepted that here is a need for the

sound recruitment policy,because faulty recruitment policy inflicts a

permanent weakness upon the administration .

The basic elements of the sound recruitment policy should include thefollowing-

Discovery and cultivation of the employment market for post

marketing a job in the public private services.

Use of attractive recruitment literature and publicity.

Use of scientific test for determining abilities of the candidates.

Tapping capable candidatesfrom within the services.

Placement programme which assigns the right man to right job.

A follow up probationary programme as an integral part of the

recruitment process.

PROCESS OF RECRUITMENT

Strategy

development

where when Applicants

Personnel

Job

Job analysis

Recruitment

planning

numbers,

Employer

Searching

activation, selling

message,media

appl

ican

scre

enin

hire selec

Evaluation and

control


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METHODS OF RECRUITMENT-

Direct methods- it includes employee contacts, manned exhibits and

waiting list are used .

In scouting representatives of the organization are sent to educational and

training institutions.

Manned exhibits include sending recruiters to seminars and conventions,

some organization prepare the waiting list of the candidate who have

indicated there interest in jobs ,through mails and telephone.

Indirect methods-

advertisement in newspaper,journals and radio.

Third party methods-

public employment exchange

management consulting firms

professionals societies

temporary help societies

trade unions

labour contractors

reservations- reservations for the persons belonging to particularcastes and communities

Interview assessment form

Name: Date time:

job title: ref.no.


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Criteria

Questions

Answers/reference

Applicantsanswers

scores

Signature:

Name:

TRAINING IN HOSPITALS-

Every teaching hospital institution has an attached hospital which

provides clinical material for teaching and training of the student in such

hospitals also provide facilities for research both for the teachers and the

students. The method of teaching the patient in a research cum teaching

hospital varies from available in a general hospital. Apart from the training

the patient is used for teaching and research. Here the patient is firsthandled by the trainee who examines him thoroughly ,records his details

history and suggest the diagnosis and treatment.the case is then

presented by the trainee to the teacher . the treatment is prescribed by

the consultant only.

In this way the patient besides receiving the treatment also acts as the

material for teaching. He is used for research by the teachers and the

trainee.

The objectives of the training institutions are-

To develop pattern of teaching for diploma, undergraduates and post

graduates in all the branches of the hospital also as to demonstrate the

high standard of education.

To bring together as far as may be in one place educational facilities of

the highest order for the training of personnel in all important branches.

To attain self sufficiency by the students to meet the needs for specialist

and medical teachers in the country.


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THE NEHRU HOSPITAL IN NEW DELHI HAS A BED STRENGTH OF 798; .the

research is carried in various departments of the institution .members of

the faculty implemented research schemes funded by various agencies

including 30 by institutions over 160 by ICMR 15 by CISR,one by

department of science and technology ,govt of India ,6 by ministry ofhealth and family welfare.

In addition to the basic and applied research on the national priority areas

such as malnutrition ,leprosy, cancer malaria,rehablitaion therapies,

parasitic diseases including the prevention and treatment of diseases to

the lower classes of the societies.

The institution is equally involved in the research for the rural and

community health problems. the institute has recently recognized for

carrying out research on immediate health priorities areas of UTChandigarh with particular reference to environmental pollution related

diseases, their diagnosis prevention and treatment.

PHYSICAL SETUP

OUT PATIENT DEPARTMENT:-

OBJECTIVE & SCOPE OF SERVICES1 Provision of general medical services to outpatients on

scheduled/unscheduled basis:-

Preventive & promotive services [immunization, screening,antenatal clinics, well baby clinics]

Curative[consultation, investigations ,therapeutic procedures,speciality services]

Follow-up of discharged patients, chronic illnesses, postnal clinic. Rehabilitation[physiotherapy, occupational therapy, prosthetics &

orthotics]

2 Family welfare services; counseling

3 Health educations

4 Medical, nursing paramedical education

LOCATION OF O OPD:-

Near the main roads & close to main hospital entrance, but withsufficient space to provide for parking etc.& to noise &dust

pollution.


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The outpatient department should be located close to mainentrance& with independent approach, should be segregated fromthe inpatient so that pt. visiting the outpatient department neednot passthrough the inpatient department.

Separate from in patient &other department but connect with

them. OPD SHOULD BE CLOSE To:

-Medical records

-Laboratory

-Radiology

-Pharmacy

Patient Flow

Dispensed with

prescription

New patient Reception OPD Counter Respective OPDs

Laboratory X-Ray Ultrasound

Follow up patient Inpatient Department counter

IPD

OT

OPD Clinics in the hospital

There are following OPDs in the hospital:

General Medicine

Pediatrics

General surgery

Orthopedic

Obstetrics & Gynecology


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Physiotherapy

Neurosurgery

Dietary

Dental surgery

EMERGENCY DEPARTMENT

The emergency department is a very critical& sensitive unit of any

hospital & is involved in the management of emergency cases. The

emergency service provides immediate, emergency diagnostic &therapeutic care to the patients with-injuries by accidents ,sudden

attacks of illness or exacerbation of disease

OBJECTIVES & SCOPE OF SERVICES

Provision of immediate relief to & management of the arriving atthe hospital with acute medical & surgical emergencies forexampleAcute myocardial infraction, Shock ,Status asthmaticsetc.

Managing accidents victims providing first aid, treatment of minorinjuries & referred to appropriate specialized or hospital, in casespecialized care is necessary & can not be provided in thehospital.

Attending all medico-legal formalities, including documentation ofclinical conditions & other particular & initiation to & liaison withthe police.

Attending the patients coming outside the routine outpatientworking hours & screening them for admission.

Observation them for short period to determine whether theyneed admission

Providing out patient care.

Consultation& the Examination Room Equipped with:-

Doctors seating arrangement with office furniture Examination couch

BP Instrument Stethoscope Clinical thermometer Torch

PROCEDURE ROOM Equipped with facilities for minor

procedures like suturing ,Endotracheal intubation Dressing ,

Plaster , Catherterisation ,Ryles tube,Operation theatre


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light,Suction machine,Oxygen cylinders,Boiler,Drip stand,

Glucometer etc.

TREATMENT ROOM Equipped

-DC Shock machine

2 beds for treatment

Cardiac table

Instrument for vaccination

TOILET

TREATMENT ROOM

The department has one treatment room, which isused in case the patient has to be kept under observation for

some time. The treatment room is used for vaccination

purpose as well as for chemotherapy &blood transfusion in

case of thalassemia patient .Vaccination are done daily except

on Sundays by the sister incharge in emargency treatment

room . She vaccinates around 20bcases on an average per

day. The patient who are receive blood opera transfusion&

chemotherapy are taken of sister incharge.

FUNITURE SET-UP

Bed-5,cardiac table& defibrillator

OPERATION THEATRE -Minor operations are performed in

the procedure room, which can be called minor operation

theater .In case of any major operation such as Head

injury the operations are performed in main operation

theatre of the hospital by the consultants.

FACILITIES PROVIDED IN THE EMERGENCY DEPARTMENT:-

Medical-

All medical emergency cases such as Gstroenteritis, Pyrexia, Malaria

etc can be managed in emergency department

Surgery-

Patients of head Injury, Infraction &Shock etc. can be handled at the

emergency department.

Diagnostic


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The diagnostic services that can be done in emergency department

are-ECG, Blood sugar etc.

OTHER SERVICES

Vaccination Blood transfusion Injection

Critical Patient Flow

Critical Emergency consultant

Patient Department Examines

Payment & Vitals

Registration at OPD Checked

Investigations (ECG,blood suger etc)

Emergency care given to the patient

(IV Fluids, Suction, Endotracheal intubation)

Treatment Initialled

Discharged Admitted to hospita

Inpatient Department(IDP)-

IPD that department of the hospital in which the

patients are generally kept for more than a day for close

monitoring.

General Ward- Wards of the patients who are not critically ill but

need continues care or observation & have to be in bed. Theseinclude wards for medical, Surgical, ENT & eye disciplines.


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Wards For Specialties-Wards for patient who are suffering &

needs hospitalization in a particular Specialties like

orthopedic,paediatric, obstetric & gynecology.

Intensive care unit Wards for acute coronary , post operative &

critically ill patient.

DISTRIBUTION OF BEDS

DEPARTMENT NO.OF BED

MEDICAL 4O

SURGICAL WARD 40

ORTHOPAEDIC 3O

ISOLATION 5 EY E & ENT 10

MATERNITY 30

NEUROLOGY 20

PEADIATRIC 1O

RECOVERY 5

EMERGENCY 10

Patient flow Reception OPD

IPD IPD

Counter counter

Dispen

sed with prescription

Emergency

General ward facilities:-

Nursing station

Treatment room

Ward pantry

Ward store

Sluice room

Day space Sanitary


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Ward ventilation:-

Mechanical ventilation is costly & lacks flexibility

Natural ventilation is cheap

Ward lighting

The lighting of patients room & other areas in the ward has to

satisfy the needs of the pts. well as requirements of the nsg.

staff.The total lighting effect should be such as to contribute to

the general dcor& be free of glare to the recumbent pt. Lighting

installing in a ward call for:-

General lighting

Reading lighting

Examination lighting

Night lighting

A TYPICAL GENERAL MEDICAL WARD

It has the following:-

Doctors duty room

Nursing station

Two halls separated by a wall for the bed of the patients

Examination room

Store

Kitchen

Toilets in the corridor

Seating arrangements for attendants in corridor.

VARIOUSE OTHER ARTICLES PRESENT IN A TYPICAL GENERAL

WARD:-

Medicine trolley Oxygen cylinder

IV Drip stands

Fowlers bed[28]

Side table

Stool for attendants

Cardiac table

Thermometer

BP Instrument

AP Bottle with stand ,for humidification purpose


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Suction apparatus

Wheel chairs

Fire extinguishers

A TYPICAL PRIVATE ROOM IN THE PRIVATE WARD:-It has the following

2 Rooms, one for pt & other for attendant

Room are separated by curtain

It is Centrally air cooled

Attached toilets

2 beds

Chair,table&support stand

Cardic table

INTENSIVE CARE UNITS

The superspeciality hospital has intensive care unit, which

provide services to the pts suffering from acute conditions such

as myocardial infraction,strock, angina etc.These units are

divided into the following specialities:-

ICCU

ICU NICU

CCU

MICU

SCNU

PHYSICAL FACILYTIES & LAYOUT- The ICU& ICCU has:-

-Doctors duty room equipped with beds& other necessary

furniture

-Hall with curtains separating the floler beds

-Shoe removing room

-Toilet

-Waiting space for attendants in the corridor

-Telephone

-There are beds, cardiac tables& side table for pt.


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-The doors are in two parts,&1 part is smaller wich remains

close& is opened only when the streastcher has to be passed.

BED CAPACITY-

ICCU& ICU CAN ACCOMMODATE 8 &10 BED RESPECTIVELY

TYPE OF BED IS FOWLER

EQUIPMENT-

-ICCU EQUIPMENT

Bed side monitors

Central monitor 8 channel

ECG Machine

Glucometer

Humidifier

Pulse oxymeter

Ophalmoscope

Defibrillatir

Ventilator

Sphygmomanometer

Stethoscope

Clinical thermometer Torch

ICU EQUIPMETS :-

-Bed side monitors

-ECG Machine

-Humidifier

-Infusion pump

-Pulse oxymeter

-Nebulizer

-Ventilatior

-Opthalmoscope

-Pressure monitoring line with monitors

-Sphygmomanometer


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-Stethoscope

-Clinical thermometer

-Torch

STAFF

-Consultant Doctor

-Resident Doctor

-Sister incharge

-Nursing Staff

-Technicians

-Ward boys

-Sanitary attendants

EMERGENCY TROLLEY

DRESSING TROLLEY

TWO BUCKETS FOR STERILISATION WHICH HAVE CIDEX.

Operation Theatre(OT)-

OT suit of a hospital is a very complex

workshop & most important facility of the surgical

department. The hospital has the following OT

o 2 Emergency OT tables

o Orthopedic -3Tables

1 OT table for general operations

2 OT tables for orthopaedic operation

o 2 OT tables

1 OT tables for general operation

1OT table for gynaecology operations


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o 2 OT tables

On alternative days Cardiac, Eye &

ENT

Physical facilities- The OT has-

Show- removing room

Changing room with attached toilets

Sister incharge & nursing room

Gynecology OT room

Scrubbing & wash up room

Minor OT room

Sterilization room

Post operative room

The entire OT is AC.

Diagnostic Department

The diagnosis department in the hospital-

1. X- Ray department

2. Sonography

3. Endoscopy

4. 2-D colour Dopper

5. ECG

6. EEG

7. Laboratory Department

The space required for these facilities are given beiow-

Reception cum Registration with waiting areas & toilets

Radiography & Fluorocscopy room


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Film Developing & processing Room

Film Drying

Contrast Studies & preparation room

Stores

X Ray Record room

Radiologiests Room

Room for techinician, nurses

Toilets ( Male/ Female)

Patient Flow-

Patient investigation cash counter

reception counter

Diagnosticdepartment

SUPPORTIVE SURVICES

The supportive services in the hospital are:

-Blood bank

-Central sterile Supply Department (CSSD)

-Medical record Department

-Laundry

-Housekeeping

-Electronics Data Processing Department

-Communication System

-Public relation


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-Materials Department

-Maintenance Department

AUXILIARY SERVICES:-

Registration& indoor case records-

Registration is a must for a hospital to enroll no patient with

proper entry in OPD cards & keep track of the revisit of the

patients. Medical records help in regulating admission of

patients. It helps in codifying the record according to internal

disease index. It also collects statistics of hospital stay of

patients, i c, admission, discharge, average stay ,etc for future

planning & management.

Stores

The central store receives, stores & issues bulk items

which can, with advantage, be stored centrally. Stores are of

different typesPharmacy store, chemical stores, Linen store,

Surgical stores, glassware stores, Stock-policy should be devised

in such a way that visit & essential items are always available. It

should be managed by a competent stores officer.

Transport

Transport requiremenets for the carriage of supplies&

patients are:-

A] trolleys

B] Stretchers

C] Wheel chairs

It is preferable to have a central transport gang to shift

the patients. Supplies should also be distributed to all wards by

the central areas.

Mortuary

Each hospital should have a cold storage area or mortuary,

where dead bodies are kept before they are claimed by the

relations. Sometimes post-mortems need to be done for medico-

legal reasons. Unclaimed bodies should he disposed off

according to rules.

Dietary services


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The dietics department plays an important role in providing

the hospitals menu to the specific needs of the patients as the

quality of diet contributes a great deal in the treatment of the

patients. This department is to ensure the selection of the food to

meet the requirements of the patients. The department should beadequately & correctly fed with daily information regarding the

number of patients & types of patients so that food can be

prepared accordingly . This department must be managed by

well-qualified& trained dietician

Engineering& maintenance services

The hospital building ,furniture& other equipments are

essential for the efficient functioning of the hospital especially in

a large hospital. Therefore, there is need to have a separatedepartment of engineering & maintenance service to provide

immediate services and keep the hospital effective & efficient.

Hospital security:-

Hospitals are not immune from the threat of societys criminal

element. Thus ,establishment of hospital security force is

essential to ensure the safety of patients & the staff. In a

teaching-cum-research hospital & other large hospitals,

appointment of the security staff has become a matter of greatimportance. The security officer must be appointed on the basis

of his experience either in defense services or police services.

Under him, there can be other staff depending upon the size of

the hospital. Hospital security department must have active

liaison with the local police in the area so that they can

supplement each others effort.

MATERIAL MANAGEMENT-

Men money and material are the keys to the development .they assume

considerable importance in corporate functioning as well as in national

economy.

ESSENTIALS PRINCIPLES-

Right item

Right quantity

Right price


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Right source

Right delivery

Right methods

Right people

PURPOSES OF MATERIAL MANAGEMENT-

To develop a system of supplies whereby there will be right quantity of

stock of items properly stored ,easily retrievable and distributed close

to the points of usage ,wherever required ata given time.

The reduction in the inventory costs both carrying cost and ordering

cost.

To ensure that the resources available are used most effectively and

the stores are purchased at the most economical price consistent with

quality.

To bring about the coordination among the various sections in the

organization.

To ensure that the production does not suffer.

To ensure that the sale of finished goods is not effected.

To avoid the wide fluctuations in production.

PRINCIPLES OF INVENTORY MANAGEMENT-

1. Determination of order of quantity.

2. Determination of reorder point of record level.

DRUG MANAGEMENT-

The purpose of drug management is to use drug wisely and avoid

drugs and therefore to enough for patients needs.

EDUCATING STAFF IN THE USE OF DRUGS.

Put one or more copies of simple book on

pharmacology in the library


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Make notes on the common drugs

Make notes on the common drugs.

Set out the doses of common drugs.

Hold staff meetings to discuss staff wastge

Inform all staff about the cost of various drugs

EDUCATING PATIENTS ABOUT DRUGS-very often patients take drugs in a

wrong way .they either reduce the dose to make the treatment last longer

or increase it hoping for a quicker cure.

EXPLAINING PATIENT THE USE OF DRUGS-

Each drug has a specific action .adrug used in one condition is not used inother condition.

The size of the drug is very important if it is too little it acts to weakto cure

the condition,if it is too large it may poison the patient.

CONTROLLING LIFE SAVING DRUGS-

Make a list of life saving drugs

Place them together in one shelf

Check the shelf frequently

PREPACKING DRUGS FOR OUT PATIENT DEPARTMENT-

This means that full course of treatment with a certain table is put in

small envelops or folded papers before the out patient sessions.

MANAGING EQUIPMENT-

It include- ordering ,storing ,controlling, maintaining and standardization.

Ordering- it is to analyse the requirement based on past experience and

future requirements.this has to done carefully otherwise it can result in

unnecessary purchases.

Storing equipment must be stored carefully otherwise there is degree if

pilferage or breakage. inventory of store must be maintained an d proper

accounts must be maintained.

Issuing each ward and unit must be responsible for the equipment

issued to them. They should keep li aison with the store to replenish theconsumed articles or repairs of some other articles.


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Controlling and maintaining equipment- this is the most important aspects

of equipment management as it has been observed that most of the non

expendable equipment remains out of order for along time.

Codification not Standardization- in any undertaking having a large

number of items ,codification

Is essential.it hardly needs any emphasis that codification of items is

prerequistee for introduction of mechanization in stock control and

purchase.

RECORD MANAGEMENT-

Record management is a programme that involves the

functions of creating, administering, retaining, submitting

& destroying records.

o Medical record

Medical record is a clear, concise & accurate history

of the patients life & illness, written from health &

medical point of view . thus the medical record

comprises three general section-

I. A general section covering administrative &

personal data. The socio economic record of

the patient include-the name of the patient ,

fathers or husband name, Age , sex , religion,

income, patients Address & adders of the

nearest relative . other admission information

include are-date of admission , in patient

number, the name of the nursing unit & bed

number. This sheet is prepared in the central

Admitting office.

II. A nurse section where the observations of the

trained nurses & detail of treatment

administrated. The part of the medical record

consists of graphic charts relating to

Temperature, Respiration, BP& other

observations maintained, intake output charts

& medicine administrated.

III. A medical section containing statements on thestudies , observations , conclusions & activities


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of a them ending doctors or of the intern or

resident worker under him. Medical section of

record consist:

o History Sheet

o Physical examination sheet

o Provisional diagnosis

o All the investigation reports

o Physician order sheet

o Treatment, medical or surgical

o Anesthesia record

o Operation record

o Obstetric record

o Consultancy record

o Progress report

o Final diagnosis

o Discharge summary

o In death- cause of death

o Autopsy report

OTHERS ARE

Vital signs

Operation theater records

Emergency records

Turnbed patient record etc

BIBLIOGRAPHY:-


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Faisal Khan Dr. Mohd , khan dr. Humera,Management of superspeciality hospitals Ed.-1st

2005. Pp-76

Barrett jean, Ward Management& teaching

Ed.-1st p-147.

Basavanthappa B.T. Nursing

administrationEd-1st, ,2005,pp-155

Goel S. E. Hospital administration &

managementEd 2nd .2007 pp- 1-70

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philosophy of hospita l 2003

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