Modern Management Techniques.pptx

This exhaustive and vibrant PowerPoint has around 90 slides and explains in detail all the must know concepts of Management in Healthcare. These slides have enough information to use it for 3 hour seminar (2 sessions) on Modern Management Techniques and its application in Healthcare. The session can be further extended if the concepts are explained with appropriate examples.

1. MODERN MANAGEMENT TECHNIQUES APPLICATION OF MMT IN HEALTHCARE Dr. Immanuel Joshua. E Junior Resident (PGT-3) Dept. of Community Medicine Banaras Hindu University 1

2. CONTENTS Definition Relevance in healthcare Traditional vs Modern techniques Description of each technique Classification Challenges References "The first rule of management is delegation. Don't try and do everything yourself because you can't." — Anthea Turner Estimated time: 90-120 minutes 2

3. “Management is getting the right things done in right way , in right time , by right persons, with right amount of resources and effective use of resources.” MANAGEMENT It is the efficient use of resources and to get people to work harmoniously together in order to achieve objective 3

4. Applications of management techniques Marketing Operations Finance Human Resource Information Technology Management Science 4

5. ? Why we need management in healthcare? 5

6. "Management is the opportunity to help people become better people. Practiced that way, it's a magnificent profession" — Clayton Christenson RELEVANCE IN HEALTHCARE Overlapping, conflicting and competing organizations within Health system Widely scattered funding mechanism with little control over costs Decisions on the mixture of facilities and services without reference to population need and with no information about those who do not use the services It has been proved that these techniques are useful in increasing the efficiency by cost reduction as well as ensuring better health care 6

7. Traditional vs Modern Management Techniques Based on behavioral sciences (Personnel selection, training & retraining, motivational methods, leadership development, supervision etc..) TRADITIONAL MODERN B ased on sociology, psychology, educational technology, economics and statistics Needed for larger and complicated organizations with their own unique organizational and structural issues The conventional methods of management are no longer adequate to meet the demand of today’s projects 7

8. Classification of MMT 01 02 03 04 05 Miscellaneous Financial techniques Mathematical techniques Activity analysis Statistical techniques

9. Miscellaneous Financial techniques Statistical techniques Activity analysis Mathematical techniques Time trends and forecasting Decision theory and tree Time and Motion study Work sampling and activity analysis Queuing theory Gantt chart and work schedule Simulation study/ model System analysis Linear programming Inventory control Network analysis PERT CPM 9

10. Miscellaneous Financial techniques Cost accounting and analysis Cost Benefit Analysis Cost Effective Analysis Zero base budgeting Input output analysis Management by exception Situation analysis SWOT Analysis Log frame Analysis 10

11. Statistical techniques 11

12. TIME TRENDS AND FORECASTING ( Eg : Seasonal trend, Cyclical trend, Secular trend) Based on past experience, predictions can be made about the expected occurrence, by using mathematical methods ( Eg : Demographers made projections about population, epidemiologists anticipation of epidemic) Based on information on occurrence of certain events, certain patterns can be recognized 12

13. DECISION TREE A decision tree is a flowchart that starts with one main idea and then branches out based on the consequences of your decisions It’s called a “decision tree” because the model typically looks like a tree with branches  It enables people to decompose a large complex decision problem into several smaller problems 13

14. Types of environment: Decision making under certainty Decision making under uncertainty Decision making under risk Decision tree A method for determining the optimal course of action when a number of alternatives are available and their consequences cannot be forecast with certainty 14

15. DECISION TREE SYMBOLS Decision nodes:  Squares that represent a decision being made on tree. Every decision tree starts with a decision node.  Alternative branches:  Lines that branch out from decision node. These branches show two outcomes that stem from the initial decision. Chance nodes :  C ircles that show multiple possible outcomes . End nodes:  T riangles that show a final outcome . 15

16. Decision node Chance nodes End nodes Alternative branches 16

17. Surgery Drug Disease absent Disease present Disease present Disease absent Survive Operative death Cure No cure Curative Palliative Survive Operative death Cure No cure Survive Operative death Cure No cure 17

18. Surgery Drug Disease absent Disease present Disease present Disease absent Survive Operative death Cure No cure Curative Palliative Survive Operative death Cure No cure Survive Operative death Cure No cure Each path through the tree defines a unique potential result 18

19. Surgery Drug Disease absent Disease present Disease present Disease absent Survive Operative death Cure No cure Curative Palliative Survive Operative death Cure No cure Survive Operative death Cure No cure 10% 10% 90% 90% 90% 90% 90% 90% 99% 98% 10% 1% 10% 2% 10% 10% Insert probabilities at each chance node based on data from literature, modeling, expert judgment, etc. 19

20. Surgery Drug Disease absent Disease present Disease present Disease absent Survive Operative death Cure No cure Curative Palliative Survive Operative death Cure No cure Survive Operative death Cure No cure 10% 10% 90% 90% 90% 90% 90% 90% 99% 98% 10% 1% 10% 2% 10% 10% Assign a value to the outcome at each end points 20 LY 0 LY 20 LY 20 LY 2 LY 0 LY 0 LY 20 LY 20 LY 2 LY 2 LY Average outcome: Operative death = 0 LY Death from progression of disease = 2 LY Cure = 20 LY 20

21. Surgery Drug Disease absent Disease present Disease present Disease absent Survive Operative death Cure No cure Curative Palliative Survive Operative death Cure No cure Survive Operative death Cure No cure 10% 10% 90% 90% 90% 90% 90% 90% 99% 98% 10% 1% 10% 2% 10% 10% 20 LY 0 LY 20 LY 20 LY 2 LY 0 LY 0 LY 20 LY 20 LY 2 LY 2 LY Compute average results, working from right to left Average LY = 10% (20) + 90% (2) = 3.8 LY 21

22. Surgery Drug The outcome for each decision is more apparent now 19.46 LY 18.38 LY Surgery (intending cure) produces average of 19.46 LY Medical management yields an average of 18.38 LY The incremental benefit of surgery versus medical management is 19.46 – 18.38 = 1.08 LY 22

23. • Simple to understand and interpret • Useful to analyze the possible outcomes of complex decisions • Possible scenarios can be added • Most rational decision is taken in terms of resource and effectiveness • Worst, best and expected values can be determined for different scenarios ADVANTAGES OF DECISION TREES 23

24. Miscellaneous Financial techniques Statistical techniques Activity analysis Mathematical techniques Time trends and forecasting Decision theory and tree Time and Motion study Work sampling and activity analysis Queuing theory Gantt chart and work schedule Simulation study/ model System analysis Linear programming Inventory control Network analysis PERT CPM 24

25. Activity analysis 25

26. BASIS TIME STUDY MOTION STUDY Meaning Time study is conducted to find out the standard time for performing a task Motion study is conducted to find out total movements of workers while they are performing the task Purpose To find out standard time to fix day’s work for the workers To eliminate wasteful and unproductive movements of workers to increase their efficiency level Method of conducting It is conducted with the help of a stopwatch It is conducted with the help of a moving camera which keep eyes on movements  “Time is what we want most but what we use worst” – William Penn TIME AND MOTION STUDY 26

27. Modification: One servant from the central lab goes to different ward with trolley at predetermined time. Reports delivered in same way Example: From each ward, lab samples are sent with a servant to central laboratory. Servants take excessive time to return ADVANTAGES • Reduction of physical effort • Time saving • Increase productivity 27

28. Work sampling is a method of finding the percentage occurrence of a certain activity by statistical sampling and random observations WORK SAMPLING Technique in which a large number of instantaneous observations are made at random intervals over a specified period of time on a group of workers machines and processes Each observation records what is happening at that instant (Working/ Not working) The percentage of observations recorded for a particular activity is the measure of percentage of time during which that activity occurs 28

29. STEPS Determine the main objective of the study Define each activity to be measured Obtain the approval of the supervisor of the department where work sampling is to be performed State the desired accuracy limits for the ultimate RESULTS Conduct a pilot study to Estimate the approximate percentage occurrence of the activity (p) Estimate the required number of observations for the desired accuracy set Ensure that the workers have become habitual to the visits of work study engineer Design the actual study Calculate the number of observations (N) to be made by using the following formula N = 4pq/L2 29

30. ADVANTAGES Work sampling is a low cost alternative to continuous monitoring , just as sampling in the audit context is a low cost alternative to 100% evaluation of an account A simultaneous work sampling of several operators or machines can be made by a single observer Ex: There is complain that nursing officers are working only 70% of their duty time in wards Number of observations required for work sampling (N) = 4 (0.7) (0.3)/ (0.05) 2 = 336 Results: Nursing officers were seen working on 252 observations (= 75% of the time) Out of the total working time, 35% were spent on bedside and 65% on clerical ward work 30

31. QUEUING THEORY 31

32. 32

33. Queuing theory was first introduced in the early 20th century by Danish mathematician and engineer Agner Krarup Erlang. Erlang worked for the Copenhagen Telephone Exchange and wanted to analyze and optimize its operations. He sought to determine how many circuits were needed to provide an acceptable level of telephone service, for people not to be “on hold” (or in a telephone queue) for too long. Also to find out how many telephone operators were needed to process a given volume of calls. "Start with the end in mind." — Stephen Covey 33

34. His mathematical analysis culminated in his 1920 paper “Telephone Waiting Times” , which served as the foundation of applied queuing theory . The international unit of telephone traffic is called  the Erlang in his honor. 34

35. Queuing theory is a mathematical approach applied to the analysis of waiting lines At its core, a queuing situation involves two parts Someone who requests a service Someone who delivers the service Customer Server Doctor 35

36. Cost associated with patients having to wait for service Loss of business to HCO. Costs incurred by society. Decreased patient satisfaction and quality of care. Cost of providing the services (capacity cost) Salaries paid to employees. Salaries paid to employees or servers while they wait for service from other server, for eg : waiting for the pathology report, radiology report, labs, etc. Fixed costs – cost of waiting space, facilities, equipment, and supplies. COSTS OF WAITING IN LINES OR QUEUE 36

37. "It's easy to solve a problem that everyone sees, but it's hard to solve a problem that almost no one sees." — Tony Fadell Arrival rate Customers Queue discipline Service rate Queue Service facility Served customers Queuing theory scrutinizes the entire system of waiting in line , including elements like customer arrival rate, number of servers, number of customers, capacity of the waiting area, average service completion time, and queuing discipline. 37

38. The Gantt chart can also include the start and end dates of tasks, milestones, dependencies between tasks, and assignees. GANTT CHART Devised by Henry Gantt , an American engineer and project management consultant A project management tool that illustrates work completed over a period of time in relation to the time planned for the work It typically includes two sections : Left side outlines a list of tasks Right side has a timeline with schedule bars that visualize work 38

39. CHARACTERISTICS 39 The bar in each row identifies the corresponding task The horizontal position of the bar identifies start and end times of the task Bar length represents the duration of the task Task durations can be compared easily Good for allocating resources and re-scheduling Precedence relationships can be represented using arrows Critical activities are usually highlighted Slack times are represented using bars with doted lines The bar of each activity begins at the activity earliest start time (ES) The bar of each activity ends at the activity latest finish time (LF).

40. Choose research area Preliminary research Decide research topic Decide methodology Submit/present proposal Finalize methodology Conduct research Analyze data Write up Submit assignment 10 11 12 13 14 15 16 17 18 19 20 9 8 7 6 5 4 DURATION (in weeks) 40

41. Miscellaneous Financial techniques Statistical techniques Activity analysis Mathematical techniques Time trends and forecasting Decision theory and tree Time and Motion study Work sampling and activity analysis Queuing theory Gantt chart and work schedule Simulation study/ model System analysis Linear programming Inventory control Network analysis PERT CPM 41

42. Mathematical techniques 42

43. SYSTEM ANALYSIS Set of objectives to be achieved is defined and alternatives to achieve these are formulated Alternatives are evaluated in terms of cost-effectiveness Mathematical models may be used 43 Study of inter relationships operating in the various components within a system and also between a system and other systems System: An arrangement and set of relationships among multiple parts functioning as a whole

44. LINEAR PROGRAMMING 44 It is a useful tool for deciding the course of action for a problem in which there are competing alternatives uses for limited resources Mathematical tool where components of a system and its constraints are depicted in a linear equation and the desirable combination of activities with regard to certain given set of objectives and constraints is arrived Linear Programming (LP) problems are optimization problems in which the objective function and the constraints are all linear

45. A Company manufacturers two types of drugs A and B. Each product uses Machine X and Machine Y. The process time per unit of drug a on Machine X is 10 hours and on the Machine Y is 8 hours. The processing time per unit of drug B on Machine X is 15 hours and on the Machine Y is 10 hours. The maximum number of hours available per week on Machine X and Machine Y are 80 hours and 60 hours respectively. Also the profit per unit of selling Drug A and Drug B are Rs 25 and Rs 35 respectively. Formulate a LP model to determine the production volume of each of the drugs such that total profit is maximized. 45

46. 46 Machine Machine hours/ unit Limit on machine hours Drug A Drug B Machine X 10 15 80 Machine Y 8 10 60 Profit/ unit (Rs) 25 35 Maximize Z = 25(A) + 35 (B) 10 (A) + 15 (B) ≤ 80 8 (A) + 10 (B) ≤ 60 A and B  0

47. ABC analysis VED analysis SDE analysis FNSD analysis HML analysis XYZ analysis SOS analysis Types Method of maintaining of stock at a level at which purchasing and storing costs are the lowest possible without interference with supply Objective : To maintain optimum stock INVENTORY MANAGEMENT 47

48. ABC METHOD ITEM % COST % A 10% 70% B 20% 20% C 70% 10% A items: Less quantity; more resources • Tight control • Rigid estimate of requirement • Strict & closer watch • Low safety stock • Managed by top management Also known as ‘Proportional Part Value’ method C items: More quantity; less resources • Ordinary control measures • Purchase based on usage estimates • High safety stocks Different items categorized into three groups based on annual expenditure incurred on these items 48

49. V = Vital life saving drugs ( Absence of which cannot be tolerated ) E = Essential items (Absence can be tolerated for a short time period) D = Desirable (Non availability can be tolerated for a longer period ) VED Analysis Based on criticality in patient care 49

50. A B C CV CE CD BV AV V E D AD BD BE AE Category I Category II Category III Close monitoring & control Combination of ABC & VED Analysis Moderate control No control needed CV CE CD BV AV AD BD BE AE 50

51. It looks at quantity, consumption rate and how often the item is issued and used F = Fast moving (needs constant monitoring) N = Normal moving (consumed on regular basis; purchased once or twice a year) S = Slow moving (periodically reviewed to prevent expiry & obsolescence) D = Dead stock (Items which is no longer required) FNSD Analysis Inventories are classified on the basis of product’s unit price H = High value of inventories (High cost) M = Medium value of inventories (Medium cost) L = Low value of inventories (Low cost) HML Analysis 51

52. Materials are categorized based on the nature of supply S easonal and O ff- S easonal materials Helps to manage purchases and storage of materials which are seasonal in nature SOS Analysis Classification is based on the scarcity of supply This technique handles problem faced in lead time analysis and purchasing strategies S – Scarce (imported; longer time to arrive; supply irregular) D – Difficult to procure E – Easy to procure SDE Classification 52

53. Materials are categorized according to variability of their demand or forecasted consumption X – Very little variation (future demand can be reliably forecasted) Y – Some variation (demand can be predicted to some extent) Z – Most variation (demand forecasting is impossible) XYZ Analysis 53

54. The activities are interrelated in a logical sequence which is known as “Precedence relationship” Project is represented in the form of network for the purpose of analysis to get solutions for scheduling and controlling its activities PROJECT MANAGEMENT (NETWORK ANALYSIS) A project consists of interrelated activities which are to be executed in a certain order before the entire task is completed 54

55. PHASES OF PROJECT MANAGEMENT PLANNING Dividing the project into distinct activities Estimating time requirement for each activity Establishing precedence relationships among the activities Construction of arrow diagram (Network) SCHEDULING CONTROLLING Determines the start and end time of each and every activity Uses the arrow diagram and time chart for continuous monitoring and progress reporting 55

56. GUIDELINES FOR NETWORK CONSTRUCTION The starting event and ending event of an activity are called tail event and head event respectively The network should have a unique starting node (tail event) The network should have a unique completion node (head event) No activity should be represented by more than one arc in the network No two activities should have the same starting node and same ending node 56

57. ACTIVITY PREDECESSOR DURATION A - 1 B - 2 C - 3 D A 4 E B 5 F B 4 G C 6 H D, E 6 I G 2 J F, H, I 3 Construct the CPM network Determine Critical path and Project completion time 57

58. 1 5 2 7 4 3 6 8 A = 1 day C = 3 days B = 2 days D = 4 days E = 5 days F = 4 days G = 6 days H = 6 days I = 2 days J = 3 days 58

59. CPM The critical path of a project network is the longest path in the network 59

60. 1 5 2 7 4 3 6 8 A = 1 day C = 3 days B = 2 days D = 4 days E = 5 days F = 4 days G = 6 days H = 6 days I = 2 days J = 3 days 1 5 2 6 8 7 4 3 1 5 2 6 8 7 4 3 7 4 60 CRITICAL PATH

61. Program Evaluation and Review Technique 61

62. Under PERT, three time-estimates are made Most Likely Time: Time taken most frequently in completing a particular activity. Optimistic Time: Time in which an activity can be completed, if all goes as per the predetermined plan. Pessimistic Time: Time taken to complete an activity under most adverse conditions. This is thus the longest possible time taken to complete a project. Activity Time= [Optimistic time + 4 x (Likely expected time) + Pessimistic time] /6 62

63. Consider the following table summarizing the details of a project: ACTIVITY PREDECESSOR DURATION (WEEKS) OPTIMISTIC MOST LIKELY PESSIMISTIC A - 5 6 7 B - 1 3 5 C - 1 4 7 D A 1 2 3 E B 1 2 9 F C 1 5 9 G C 2 2 8 H E, F 4 4 10 I D 2 5 8 J H, G 2 2 8 Construct the project network Find the expected duration of each activity Find the critical path and the project completion time 63

64. 1 5 2 6 8 7 4 3 A H G F I D E B C J 64

65. ACTIVITY PREDECESSOR DURATION (WEEKS) EXPECTED TIME OPTIMISTIC MOST LIKELY PESSIMISTIC A - 5 6 7 6 B - 1 3 5 3 C - 1 4 7 4 D A 1 2 3 2 E B 1 2 9 3 F C 1 5 9 5 G C 2 2 8 3 H E, F 4 4 10 5 I D 2 5 8 5 J H, G 2 2 8 3 Expected time = [O + (4 x M) + P] / 6 65

66. 1 5 2 6 8 7 4 3 A = 6 H = 5 G = 3 F = 5 I = 5 D = 2 E = 3 B = 3 C = 4 J = 3 Critical path = C-F-H-J Project completion time = 17 weeks 1 5 2 6 8 7 4 3 66

67. Plan service Equipment ordered Equipment installed Start providing service Staff recruited Staff trained 2 months 10 months 1 month 4 months 2 months 1 month 67

68. Miscellaneous Financial techniques Statistical techniques Activity analysis Mathematical techniques Time trends and forecasting Decision theory and tree Time and Motion study Work sampling and activity analysis Queuing theory Gantt chart and work schedule Simulation study /model System analysis Linear programming Inventory control Network analysis PERT CPM 68

69. Miscellaneous Financial techniques Cost accounting and analysis Cost Benefit Analysis Cost Effective Analysis Zero base budgeting Input output analysis Management by exception Situation analysis SWOT Analysis Log frame Analysis 69

70. Financial techniques 70

71. Is there a good evidence of effectiveness of interventions being compared Are the effectiveness of interventions equal? Can the outcome be valued in monetary terms Can outcomes be measured in terms of QALY/ DALY Costing study Cost minimization analysis Cost-benefit analysis Cost effectiveness Cost Utility analysis YES NO YES NO YES NO NO YES 71

72. ZERO-BASED BUDGETING Method of budgeting in which all expenses must be justified for each new year (current need, cost, alternate options) rather than based on previous years Setting objectives Developing decision unit Developing decision packages Ranking decision packages Resource allocation Controlling and Monitoring PROCESS 72

73. BENEFITS Efficient allocation of resources, as it is based on needs and benefits rather than history Drives managers to find cost effective ways to improve operations Detects inflated budgets Increases staff motivation by providing greater initiative and responsibility in decision-making Identifies and eliminates wasteful and obsolete operations Flexible technique Useful for government department 73

74. DRAWBACKS More time-consuming than incremental budgeting Justifying every line item can be problematic for departments with intangible outputs Requires specific training , due to increased complexity High administrative cost Increased paper work and man-power 74

75. INPUT-OUTPUT ANALYSIS Input-output analysis seeks to explain how one industry sector affects others in the same nation There is a circular relationship between inputs and output of an economy Wassily Leontief , a Soviet-American economist developed the input-output analysis method, earning him the Nobel Prize in economics in 1973 Output of A Input of B, C, D 75

76. X1 X2 FD X1 X11 X12 F1 X2 X21 X22 F2 Balancing equation: X1 = X11 + X12 + F1 Purchasing sector Selling sector An input-output table shows how much of each input is needed to produce unit amount of each output 76

77. Miscellaneous Financial techniques Cost accounting and analysis Cost Benefit Analysis Cost Effective Analysis Zero base budgeting Input output analysis Management by exception Situation analysis SWOT Analysis Log frame Analysis 77

78. Miscellaneous 78

79. MANAGEMENT BY EXCEPTION Management by exception is the practice of examining the financial and operational results of a business, and only bringing issues to the attention of management if results represent substantial differences from the budgeted or expected amount. 79

80. Efficient practices Managers can lead their company efficiently by delegating tasks. They focus on achieving the company's vision while other employees work on daily tasks to keep the company operational. Sets clear priorities For example, if an employee knows they should notify a manager if they sign a high-profile client, the employee also understands how important that activity is.  Motivates employees Because management by exception allows employees to work independently, it can motivate employees to take more responsibility at work. Quickly addresses problems ADVANTAGES 80

81. DISADVANTAGES Less focus on preventive measures Because management by exception relies on reacting to a problem, it can neglect to put preventative measures in place.  Requires close monitoring Companies need to establish close monitoring practices ensuring professionals alert the managers when a problem arises.  Requires advanced problem-solving skills All leaders within a company are required to have exceptional problem-solving skills. This helps them quickly address issues and find creative solutions. 81

82. SITUATIONAL ANALYSIS It is an integral component of the management process to find out what the existing situation is, analyze the same, identify, which aspects needs changing, and then plan accordingly This method described as ‘where are we now’, is the means by which a company can identify its own strengths and weaknesses as they relate to external opportunities and threats 82 For example, studies regarding drug prescription and consumption in different types of health facilities. The result of these studies reveal the prescribing habits of Doctors, and the need and ways for improving drug management to make them safer and economical

83. OBJECTIVE INTERVENTION OUTPUTS INDICATORS To increase deliveries by SBA from 20% in 2012 to 80% in 2017 SBAs are posted at PHC on 8 hours duty One MO available at PHC on 8 hours shift basis Referral transport available Number of deliveries by SBA Expected outcome: 80% deliveries by SBA % of deliveries by SBA out of total deliveries Verify from HMIS LOGICAL FRAMEWORK A logical framework or ‘Log Frame’ is a management tool for Planning, Progress Monitoring and Evaluation of the program This tool ensures that planning is result-oriented and outcomes are evidence-based A Logical Framework for safe deliveries 83

84. 84

85. It involves identifying the internal and external factors that are favorable and unfavorable to achieve a objective SWOT ANALYSIS SWOT analysis is a strategic planning method used to evaluate the Strengths , Weaknesses , Opportunities , and Threats involved in a project/ program 85

86. HELPFUL HARMFUL Political will Commitment of key research institutes Framework in form of NCD programs Integration of all chronic diseases Dedicated resources Poor monitoring and evaluation Limited implementation capacity Low levels of community awareness Low utilization rates Low expenditure rates Best buys PEN Intervention Package Health system strengthening NCD surveillance Digitization Adherence monitoring Rising burden of NCDs Low budget allocation for NCD programs Diversity in sub-populations Absence of regulatory mechanism SWOT Analysis of NCD program INTERNAL EXTERNAL S O T W 86

87. Miscellaneous Financial techniques Cost accounting and analysis Cost Benefit Analysis Cost Effective Analysis Zero base budgeting Input output analysis Management by exception Situation analysis SWOT Analysis Log frame Analysis 87

88. Globalization Technology Human resource Social responsibility CHALLENGES 88

89. REFERENCES https://www.gantt.com/ https://queue-it.com/blog/queuing-theory/ WHO Modern management methods and the organization of health services https://www.youtube.com/watch?v=WrAf6zdteXI Park textbook of community medicine Public Health Management by Sunderlal Treatise on Health Management by SC Mohapatra Handbook of Health Planning and Management by Sukamal Bisoi Pdf on MMT by Dr. Sharon (shared in telegram group) YouTube videos (link will be provided on request) 89

90. SUGGESTIONS QUERIES IDEAS OBSERVATIONS 90

91. ! . U O Y K N A H T . . ! !