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1991-10-23 Regular MeetingKODIAK ISLAND HOSPITAL ADVISORYBOARD MEETING OCTOBER 23, 1991 PRESENT: Ben Ardinger, William Brewer, Gretchen Saupe, Betty Springhill, Wayne Stevens, Ed Myers, Administrator, Joe Smith, VP of Operations, LHS Management Company, Keith Vorachek, Financial Services Administrator, Pam Foreman, Director of Human Resources, Corlene Hogg, Director of Ancillary and Patient Information Services, Scott Allen, Business Office Manager. Also present was Jack McDonald, Chief of Police. ABSENT: Jeannie Volker, Gordon Gould, Lorne White With a quorum present, the meeting was called to order at 7:12 p.m. ACCEPTANCE OF AGENDA: Moved, seconded and carried to accept the agenda. APPEARANCES AND COMMUNICATIONS Ms. Springhill welcomed Jack McDonald, Chief of Police. Mr. McDonald stated that his department wants to work closely and carefully with the hospital. He expressed his desire that as a follow-up to the interde- partmental meeting, an ad hoc committee meet to resolve procedural issues, including protocols for the billing process. Mr. Myers stated that he would contact City Manager, Gary Bloomquist, to schedule such a meeting. Mr. McDonald stated that there had been several positive sessions with Dr. Mala during his recent visit with regard to mental health and youth service issues. He said that he would be working to create a closer relationship between the Police Department and the hospital. Keith Vorachek introduced Scott Allen, who has accepted the position as Business Office Manager. Mr. Allen stated that his position is chal- lenging, requiring that he walk a fine line between firm and profes- sional. He stated that his department is working to improve billings and that collections are up from the month previous. Mr. Scott said that it would take some time to recover the over $1 million in private pay accounts receivable. Mr. Scott will be meeting with representatives of CHAMPUS, Blue Cross and Medicare when he travels to Seattle. He stated that he has clarified the status of concerns raised by Mrs. Kalcic regarding evening and weekend collections with the Federal Trade Commission and the Attorney General's office. Advisory Board Meeting October 23, 1991 Page Two Ms. Saupe voiced a concern on behalf of a patient regarding the cost of chemotherapy drugs. Mr. Myers requested that Ms. Saupe have the patient involved contact him. Mr. Myers pointed out that this situation may be one in which there is misunderstanding in the community regarding charg- es for services. He said that staff is willing to discuss rates and charges with anyone having a question regarding them. Ms. Springhill read a letter from a patient regarding billing. Mr. Myers indicated that he has responded to the patient. MEETING MINUTES Moved, seconded and carried to approve the meeting minutes of October 9, 1991. CONIlq=E REPORTS Keith Vorachek reported that the Finance Committee met and reviewed the September financial statement. He reported that the facility has an overall year to date loss of $888,000, which includes the recent legal settlement. He reviewed the status of the Accounts Receivable, stating that cash flow has stabilized and that the facility should begin to realize an increased cash flow in response to intensified collections. OLD BUSINESS A. Long Range Planning committee Mr. Myers stated that the facility will follow a similar procedure as that used by the School District to identify and establish a Long Range Planning committee. Mr. Myers said that he did not feel it would be possible to establish a functional committee before the first of the year. LHS has indicated that they are agreeable to establishment of the committee in this manner, although they would prefer to proceed with the completion of the Plan more rapidly. Mr. Stevens asked if the Long Range Plan previously completed had been located. Mr. Myers stated that LHS had used it in the preparation of the Certificate of Need and had returned it to the facility. Mr. Stevens suggested that Don Johnson, the principal at Port Lions School, had facilitated the school district through their process and might be helpful to the committee as it pre- pares the plan. Mr. Smith cautioned that although the previous plan can be used as a base, that emphasis in health care issues have changed, and that the demographics contained in that report were no longer valid. Advisory Board Meeting October 23, 1991 Page Three B. PR Plan - Kodiak Marketing and Consulting Pam Foreman presented the marketing and public relations proposal pre- pared by Kodiak Marketing and Consulting. She stated that the PR Com- mittee had reviewed the proposal and was positive about the services provided and the cost. Ms. Foreman pointed out that some services were not included in the proposal, including the preparation of the Annual Report, quarterly newsletter, and the preparation of the Facts Program (a program designed to get employees and medical staff involved in marketing and public relations). Ms. Foreman explained that the devel- opment of a facility video would create a recruitment tool which could also be used at trade shows. The need for better signs for the facility has been identified. Maintenance will be preparing quotes as to cost of replacing the painted sign with one visible from the road. Mr. Stevens stated that he felt the proposal incorporated Board concerns voiced in the past, and that the proposal would be useful in improving the hospital's image and community support. He pointed out that it was necessary to involve the staff so they would be positive emissaries for the facility, and stated that he felt this proposal was a step in the right direction. Ms. Foreman said that staff and administration would be working closely with Kodiak Marketing and Consulting. Mr. Ardinger stated that such a comprehensive marketing and public relations plan was long overdue for the facility. Ben Ardinger moved and Dr. Brewer seconded the motion that the Advisory Board recommended acceptance of Kodiak Marketing and Consulting's propo- sal in the amount of $17,500 to provide marketing and public relations services to Kodiak Island Hospital B Care Center. Roll Call vote: Ardinger, Aye; Brewer, Aye; Saupe, Aye; Springhill, Aye; Stevens, Aye. Motion Carried. C. Credit and Collection Policy Pursuant to a request by the Finance Committee, the information regard- ing the credit and collection policy contained in the Patient Financial Information sheet was amended to include a statement that the facility is a revenue fund and does not receive tax support. It was suggested that #6 contained in the policy be rewritten to read as follows: "There have been occasions when it has been necessary to refer an account to a collection agency. Once an account has been turned over to a collection agency, it will not be recalled." Mr. Ardinger asked why this statement was necessary. Mr. Myers explained that there is a common perception that the hospital can recall accounts once they have been turned over to collections, when in fact, they cannot. It was suggested that the statement regarding acceptance of credit cards be renumbered as #2. Advisory Board Meeting October 23, 1991 Page Four NEW BUSINESS A. KIB Ordinance 91-26 Mr. Myers reviewed the changes in the ordinance as recommended by Mayor Selby. It was the recommendation of the Advisory Board that the Kodiak Borough Assembly accept Ordinance No. 91-26 amending KIB Code 8.04.030, Hospital and Health Facilities Advisory Board Powers and Duties. B. Budget FY -92 Mr. Myers asked that this item be deferred until a later meeting, so that the Board would have ample opportunity to review the proposed budget. The budget will be delivered by courier. C. Promissory Note - ICF Resident Mr. Myers stated that the facility was considering accepting a promisso- ry note on property owned by an ICF resident as partial payment of the amount owed. Acceptance of the note would enable the resident to become Medicaid eligible. ADMEWSTRATOR'S REPORT Written report as attached. Mr. Ardinger asked for clarification of statements made by Mr. Myers at the KIB meeting of October 17. Mr. Myers explained that he had made the statement that it was the opinion of some people that if the new hospi- tal was not built, that the community would save $19 million. He ex- plained that Mayor Selby had felt it important to explain that if a new facility was not built, that major capital outlays would still be re- quired to bring the current facility to code. Noting that the Borough's health powers and responsibilities are as important as their education powers, Ms. Springhill suggested that the Advisory Board continue meet- ing with the City and Borough to keep them informed about the need for a new facility. Ms. Saupe stated it was important to point out the great inconvenience which would be experienced by patients and the community if the facility was required to undergo major renovation and remodeling while continuing to provide services. Mr. Myers distributed copies of the Risk Management consultant's assess- ment of the facility. He stressed the confidentiality of the report and asked that each member taking a copy of the report return it at the next meeting. Advisory Board Meeting October 23, 1991 Page Five Mr. McDonald thanked the Advisory Board for the opportunity to attend the meeting. He noted that the hospital and police department shared common problems and concerns. Corlene Hogg stated that the department heads who attended the last Board meeting had shared with her their positive observations and in- creased understanding about the Board and its function. Dr. Brewer stated that KANA and the facility had signed a contract this date. Ms. Saupe noted that the sign at the new facility site needed repair and repainting. She stated that she felt it was important for the facility to continue to stress and address wellness issues such as weight con- trol, cholesterol screening, smoking cessation, etc. Mr. Ardinger stated that he would like to see the credit and collection policy worded less aggressively. Mr. Stevens stated that he had discussed the Dutch Harbor situation with representatives last week at Fish Expo. The chairperson for the board of the clinic noted in conversations with fishing companies that they were working closely with Kodiak. Mr. Stevens said that he felt an affiliation with Dutch Harbor was forthcoming. Several members of the Board commended Mr. Stevens for the diligence and enthusiasm he has brought to this venture. There was a brief discussion of the general surgeon and his recruitment for a partner. Mr. Smith noted that Dr. Mason has indicated a strong desire to provide surgical services for Dutch Harbor and other Southwest Alaska communities. Mr. Smith also noted that LHS will be presenting a proposal to the Bristol Bay health facility for management services. Ms. Springhill asked when the Advisory Board would meet with the Assem- bly in work session to discuss quality assurance matters and patient surveys. The recording secretary was asked to contact the Borough Clerk to determine the date for such a work session. Ms. Springhill noted that the Auxiliary had asked for a "wish list" from staff. Ms. Spring- hill asked about the status of the security service. Mr. Myers stated that the hospital now has its own security staff. He stated that Mr. Gregory has been very helpful and supportive of the new staff. Advisory Board Meeting October 23, 1991 Page Six Ms. Springhill asked about the status of the surgical equipment request- ed by Dr. Mason for gallbladder surgery. Dr. Mason has stated that the facility is losing two surgeries per month because of lack of this equipment. Mr. Myers stated that Requests for Proposals have been sent out. EXECUTIVE SESSION Moved and seconded to adjourn to Executive Session to discuss legal and personnel matters at 9:00 p.m. Motion Carried. Returned to Regular Session at 9:30 p.m. ADJOURNMENT Moved, seconded and carried to adjourn at 9:30 p.m. Recorded by Debra Raper. I / - A)36 k4 t CSCUSSION PAPER KIH/CC ISSUES I have been asked to address several issues which came before the last Borough Assembly meeting, namely medical -surgical staffing, quality of care, and the need for a replacement hospital. I want to preface my comments by saying that the staff of KIH/CC works very hard to provide the very best care possible and we take exception to any comments that we provide any lower quality of care than other small hospitals or any urban or large hospitals. I know that for the most part, there was no intent to impugn the quality of care at the Hospital without something to measure quality against. ON THE ISSUE OF MEDICAL -SURGICAL STAFFING: The Hospital employs an acuity staffing system which is common in Hospitals throughout the U.S. Acuity staffing is a method which measures the intensity of nursing needs, number of patients, and related needs to a scoring system. Hence, you may have ten medical patients whose nursing needs are less demanding than ten post-surgical patients who have high nursing needs. There would be lower staffing requirements for the former as opposed to the latter. This is scored in an acuity system. However, I want to stress that at all times the charge nurse has the option to call in additional staff at any time the need exists. I assure you that the staffing ratios are generally higher at our Hospital than many urban hospitals facing serious financial constraints. Discussion Paper October 17, 1991 Page Two Our lowest level is generally 3 staff, often to 5 or 6 patients, or a 1 to 2 ratio. As to the possibility of a momentary instance where where all staff are tied up - it happens here and in very large hospitals. You simply cannot predict every eventuality and staff it - NO ONE could afford the care. Even unit secretaries have duties which take them away from the nurses station to the Emergency Room and other places. Night time is our lowest activity level, averaging less than 2.0 patients per night in the ER. Hence, while every eventuality cannot be forecast, there are safeguards built in which permit response to unusual situations. With the change to in-house security service, that person will also be available to the charge nurse when not actively involved in patient safety. ON THE ISSUE OF QUALITY: Quality of care is a very formal program at our hospital and extends from patient care activities to laundry activities. No other organization expends more effort on quality of care issues than Kodiak Island Hospital. In your packet, you have access to one measure used in our Quality Assurance Program, which is patient evaluations. I am proud to state that even the casual observer can see that our services are rated very highly by the patients using them. The fact is that patients who use our services generally like the care they receive. What we cannot provide to Discussion Paper October 17, 1991 Page Three you because of confidentiality are the many hours in our quality care program devoted to clinical care, peer review, physician credentialing and risk management. I can assure you that these issues are handled seriously and with impact. We have an exceptional risk manager in Corlene Hogg, a member of the Hospital management team, who spends many hours in these activities. AS TO THE PRIORITY AND NEED FOR A NEW HOSPITAL: I want to emphasize that our commmunity survey indicates that the community understands the need for a replacement facility -- 62% responded positively to this need. I would also like to advise you that after an extensive tour of our facility that the Commissioner of the Department of Health and Social Service, Ted Mala, stated that he clearly understood our need for a new facility. I think that there are some who believe that we can save $19 million by not building a new facility (actually $2 million has already been spent), but that is simply not the case. If we do not build a replacement facility, we will have to raise $12-$14 million to bring the current facility up to required standards. Eventually, this expense cannot be avoided, not to mention that we will still be left with a limited and inadequate facility. In my opinion, it is better to get the funds from the state to build a new facility rather than to task the local population to Discussion Paper October 17, 1991 Page Four spend these funds. Keep in mind that just to maintain the status quo over the next few years, it will require in excess of $1 - $2 million in plant maintenance and replacement of worn out equipment. The real question is whether we want to make an all out effort to obtain state funding or face the likelihood that the Borough would have to fund $12 million to bring the existing facility up to current hospital standards, or to make no changes -- something which I am sure none of us want. The state has been kind to us because they know we have been attempting to obtain state funds for construction, but should we structurally renovate any area, we will be held to bringing the entire facility up to standards. Thank you - I and my management staff will be happy to answer any questions. Ed Myers, Administrator Kodiak Island Hospital & Care Center 1915 E. Rezanof Drive Kodiak, AK 99615 (907) 486-3281 SUMMARY KODIAK ISLAND HOSPITAL & CARE CENTER MEDICARE/STATE LICENSE SURVEY The Hospital and Care Center were surveyed during the week of September 9, 1991. The survey team consisted of six people (large for this size facility) and the Hospital and Care Center were inspected for compliance with federal and state laws. Every aspect of operations were reviewed including staffing, quality assurance, clinical operations, administration, and support services. The entire Hospital management structure was outbriefed on September 13, 1991 and I am happy to say that there were no MAJOR deficiencies defined by the survey team. The only item of major concern of which we were advised by the team chief was a mechanical problem in surgery. Our old structure is unable to maintain adequate temperatures in the operating room. We are having this looked at for possible solutions. Overall, the survey was cordial, informative, and constructive. Because of patient confidentiality issues, if the Assembly desires to review and discuss the survey in detail, I will be happy to have appropriate people attend a work session. KODIAK ISLAND HOSPITAL AND CARE CENTER BUSINESS SURVEY AND QUESTIONNAIRE DRUG TESTING Are you familiar with drug testing laws? Is your company required to do drug testing? Do you currently do drug testing of employees? If not currently testing, are you interested in a testing service? If currently testing, would be interested in using a local laboratory for testing? Yes _ No _ Yes _ No Yes _ No Yes _ No _ Yes _ No EMPLOYEE ASSISTANCE PROGRAMS Are you familiar with Employee Assistance Programs (EAP) to improve workplace performance? _ Yes _ No Do you currently have an EAP in place? _ Yes _ No If yes, what type of program do you have? _ Assessment & Referral _ Comprehensive If you do not have an EAP in place, would you like to learn more about the benefits of a program? _ Yes _ No Contact Name: Telephone #: WELLNESS Do you offer any wellness programs to employees? _ Yes _ No If yes, what type: Cardiac Screening Lifestyle Screening Cholesterol Physical Fitness _ Health Fair Other (Please specify) If "No," would you be interested in a low cost program? _ Yes _ No CONTINUED ON REVERSE 0 DISCUSSION PAPER KIH/CC ISSUES I have been asked to address several issues which came before the last Borough Assembly meeting, namely medical -surgical staffing, quality of care, and the need for a replacement hospital. I want to preface my comments by saying that the staff of KIH/CC works very hard to provide the very best care possible and we take exception to any comments that we provide any lower quality of care than other small hospitals or any urban or large hospitals. I know that for the most part, there was no intent to impugn the quality of care at the Hospital without something to measure quality against. ON THE ISSUE OF MEDICAL -SURGICAL STAFFING: The Hospital employs an acuity staffing system which is common in Hospitals throughout the U.S. Acuity staffing is a method which measures the intensity of nursing needs, number of patients, and related needs to a scoring system. Hence, you may have ten medical patients whose nursing needs are less demanding than ten post-surgical patients who have high nursing needs. There would be lower staffing requirements for the former as opposed to the latter. This is scored in an acuity system. However, I want to stress that at all times the charge nurse has the option to call in additional staff at any time the need exists. I assure you that the staffing ratios are generally higher at our Hospital than many urban hospitals facing serious financial constraints. KODIAK ISLAND HOSPITAL & CARE CENTER BUSINESS SURVEY SUMMARY KIH/CC conducted an informal survey of 231 businesses utilizing mailing labels provided by the Kodiak Island Chamber of Commerce. Sixty-seven responses were received, representing a 29% response rate. Respondent businesses ranged in size from one employee to over 450 employees. The responses indicated high interest in employee assistance programs, wellness programs, and drug free workplace programs. Other program interest areas were pre-employment and periodic physicals, health insur- ance claims analysis, and other trust consulting servicess (self-insured health care trusts). Each specific area of interest will be covered in detail at future KIH/CC sponsored seminars. Presenter: Ed Myers, Administrator Kodiak Island Hospital & Care Center 1915 E. Rezanof Drive Kodiak, AK 99615 (907) 486-3281 I m co m O z m z Cf) N CJ CO m m m T O z 0 z CD CO r D z 0 M N :0 5 C co �c V_/ Z m CD CO CO c �o O O 5 C co �c V_/ Z m CD CO CO c �o c c CD Z m cn m cn m D 2 Z W " N W A 0 O O O O O O O V O O m m m n ^ m G) m m z z mm m T Z D r z O z CO r D z 0 WELLNESS PROGRAM (COMPONENTS) SMOKING CESSATION WEIGHT CONTROL HEALTH HEART DIET CHOLESTERAL CHECKS HEART NUTRITION FITNESS/EXERCISE STRESS EDUCATION/REDUCTION GENERAL NUTRITION SCREENING EXAMS TRIGGERED BY AGE OR HISTORY Footnote: (9% of Respondents had One or More Elements) EMPLOYEE ASSISTANCE * TELEPHONE ASSESSMENT * SHORT-TERM COUNSELING * COMPREHENSIVE SUPERVISORY TRAINING EDUCATION DRUG TESTING * APPLICANT TESTING (PRE-EMPLOYMENT) *RANDOM * SAFETY TESTING * VOLUNTARY * FOLLOW-UP TO COUNSELING/ REHAB IMPACT * MORALE * LABOR RELATIONS * WHO IS INCLUDED I KODIAK ISLAND HOSPITAL CommunityHealthcareSurvey I & CARE CENTER Kodiak Island Hospital & Care Center is committed to providing high quality health care services at a reasonable cost, and in a manner that is accessible to everyone in the communities we serve. Your answers are strictly confidential and cannot be attributed to you. This survey affords you the opportunity to help plan for the future of medical services in your community. Please complete and return this survey in the enclosed return envelope as soon as possible. Thank you for your input. It is valuable! 1. Do you have a family doctor or clinic you generally use? ❑ Yes ❑ No If yes, please name the town where your family doctor is located. 2. During the last 2 years, have you or any member of your household visited a doctor outside of Kodiak? ❑ Yes ❑ No If yes, why did you visit a doctor or clinic outside of Kodiak? Services or specialty not available locally (Please list service or specialty): Quality of services better elsewhere Referred by local physician Referred by non -local physician Takes too long to get an appointment Was away from Kodiak when medical need arose Other (please specify): 3. Have yon. ever been treated by a: Nurse Practitioner ❑ Yes ❑ No Midwife ❑ Yes ❑ No If yes, was the care you received: As good as that provided by a physician Better or Not as Good 4. Are more physicians needed in the Kodiak area? ❑ Yes ❑ No 5. What additional physician specialties are needed? OB/GYN (childbirth) Pediatrics Family Practice Internal Medicine General Surgery Other (please specify): 6. Has any member of your household (including yourself) been hospitalized in the past 2 years? ❑ Yes ❑ No 7. If yes, what is the name of the hospital most recently used? Kodiak Island Hospital Providence Hospital, Anchorage Humana Hospital, Anchorage Fairbanks Memorial Hospital Other (please specify): If other than Kodiak Island Hospital, why was this hospital chosen? Services or specialty not available locally Quality of services better elsewhere Referred by local physician Referred by non -local physician Most convenient Other (please specify): 8. Would you use the same hospital again? ❑ Yes ❑ No 9. What Cher types of services should be provided in Kodiak? 10. Based upon your own experience and/or the reputation of Kodiak Island Hospital & Care Center in the community, please rate the following characteristics on a scale of 1 to 5 (1 = poor; 5 = excellent). Hospital Catetory: 1 to S No Opinion Services provided Quality Courtesy Physical plant (building, etc.) Equipment Teamwork Cost (compared to area) Cleanliness Hospital Departments & Staff. Medical services Surgical services Obstetrical services Emergency Room services Nursing qualifications Qualifications of staff Quality of meals Lab, X -Ray, etc. services Business Office & Admissions Physician Services in the Clfnie & Hosnitah Qualifications Quality of care Timeliness of care Patient relations Support for Kodiak Island Hospital/ Care Center 11. How knowledgeable do you feel you are about the kind of services provided at Kodiak Island Hospital? (1 = not at all; 5 = very knowledgeable about services) 11 El 11 11 D 12. How long have you lived in the Kodiak area. Years What is your Zip Code? 13. What is your age? _ Years What is your gender? ❑ Male ❑ Female 14. As you may have heard, the Advisory Board and Borough Assembly are considering building a new hospital. Do you feel a new hospital should be built? ❑ Yes ❑ No Comments: Please feel free to provide any other comments that may assist Kodiak Island Hospital & Care Center in planning to meet your future health care needs. Thank you for completing this survey. We appreciate you taking the time to answer these questions. Please return this surrey within one week in the enclosed stamped, addressed envelope. Facility owned by residents of the Kodiak Island Borough LHS Management Company A Subsidiary of Lutheran Health Systems ................................................. KODIAK ISLAND HOSPITAL & CARE CENTER COMMUNITY SURVEY RESULTS Of 2,361 surveys in a random sampling of registered voters, 481 were returned (a 20.37% return). The majority of respondents were females between the ages of 30 and 49. (Graph #1.) ' 47.19% of respondents or family members have been hospitalized in last two years. ` Of those, 60.33% (or 146) were hospitalized at Kodiak Island Hospital & Care Center. 34.24% would stay at KIH again, 7.53% would not, 58.23% had no opinion. (Graph #2.) Of those hospitalized in the past two years in places other than Kodiak, the reasons listed are as follows (Graph #3): Services or specialty not available locally 31.3% Referred by local physician 22.0% Quality of services better elsewhere 13.2% Most convenient 4.4% Referred by Non -local physician 1.8% Other 6.2% ` 50.72% of respondents felt there is a need for additional physicians in Kodiak. ' The following chart (Graph #4) demonstrates the areas of need as seen by the respondents. (Reminder, the survey was sent out prior to the arrival of Dr. Mason.) In the "other" category, the following represent the top five. 1) Dermatology (tied with #2) 2) Orthopedics 3) Cardiology 4) Women's Health (other than OB/GYN) 5) Ear/Nose/Throat • When survey participants were asked "Based upon your own experience and/or the reputation of KIH/CC in the community, please rate the following characteristics." The following graphs represent those ratings (Graphs #5, 6, 7). ' When survey respondents were asked "Do you feel a new hospital should be built?", 62% said "yes", 22% said "no", and 16% had no opinion. —LN W A AI W V W O O O O O O O O O W O CO) co rn 0 M co 0 O 3 �3 ch O Q CD r Vl (n C C 4t— A O m O D o � 3 v' m co m rn 0 M co 0 O 3 �3 ch O Q CD r Vl (n C C 4t— O O O O O O O O O 11 u 0. 0 C [D CD 0 Y- 3CD CD n � '-1• T i O D W J C r CL) �c N 6 (D (D 73cD m (D CD N CT N 0> O _ O D n i pi O — O O cn rn0 N ZY CD co CD 0 O co w D O �lJ CD CD 00 V/ O 1 o 3 CD N� Q. V CD CD `V CD CD MMI CD O a m a v O O m m m m I- Z 0 CL m F w S O N A O OD O N A O O O O O O O O nn CL Q3 r --F 5 CD 0. C 0) r -F � C co CD N 0 1 4 m m 0 o w � w v 'a a p n � W c -o M O ® � A 0 �'• 0 0 0 CL m c - 0 O _3 0 3 V C ICD _ c . .A j I 0 00 CD B �3 3 �■ CD �f �< CD �a ro a n a w o m x m o (p C n 0 in 0 S D r A G CL a 5 n m a� o wo In s - tS2 y y I 0 00 CD B �3 3 �■ CD �f �< CD 1 f N ? O co O N O O O O O O O n� a u °' o p X A O ¢ O � o „7. O ® A A O t OAl Y� O a 0 ?o a a i A a 0 .Q w c e a s w c V s � y O 1 S I k) W 75 Q CO O W CO n CC Z r O O N Z N