jack lynch, fache president & ceo main line health...
TRANSCRIPT
Jack Lynch, FACHE
President & CEO
Main Line Health
May 28, 2014
Professionalism and Ethics *
This area focuses on the development, monitoring and maintenance
of procedures to ensure the needs of professional staff are met.
Ethics includes identifying, monitoring and disseminating codes of
professional conduct; understanding the implications of ethical
decisions; providing procedures to monitor standards to behavior
within the organization; and determining, maintaining and monitoring
accountability procedures.
* ACHE Reference Manual
2
16 (or 8%) of the 230 questions are on the topic of Professionalism and
Ethics
Eight Knowledge Areas Under Professionalism and Ethics:
1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic
Oath, AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
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Familiarize Yourself With The Following (all on www.ache.org):
• ACHE By-Laws
• ACHE Code of Ethics
• ACHE Ethical Policy Statements (9)
• ACHE Professional Policy Statements (10)
• ACHE Public Policy Statements (6)
• ACHE Ethics Self-Assessment
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1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic
Oath, AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
5
Purpose is to bring together persons with like
professional interests for educational, social and
shared goals.
Members have an obligation to their profession to
mentor and educate, maintain standards and encourage
those who are interested in joining.
6
From its founding in 1933, when it was known as the
American College of Hospital Administrators, to the present,
the American College of Healthcare Executives (ACHE) has
been a leader in establishing the profession of healthcare
management.
Generic hallmarks of professions include a public service
orientation, self-regulation, a Code of Ethics and expectations
such as assuring competence of members through continuing
professional education.
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8
Preamble:
Standard of conduct for
executives in their professional
relationships and individual
behaviors
Merit the trust, confidence and
respect of colleagues and the
public
Protect the rights, dignity and
interests of all seeking healthcare
Support an equitable, accessible,
effective and efficient healthcare
system
You have responsibilities to: Your Profession
Your Patients
Your Organization
Your Employees
Your Community
Report
Hippocratic Oath
+
American Medical Society
+
American Nurses Association
+
American Osteopathic Association
+
American Academy of Physician Assistants
9
When a healthcare organization’s goals conflict with the
stated position of a professional society, the professional
individual’s responsibility is to:
1) Make known the stance of the profession and
reconcile the divergent positions.
2) Enlist the support of professional colleagues to alter
the organization’s position.
3) Support the professional society’s position.
4) Support the organization’s position.
10
When a healthcare organization’s goals conflict with the
stated position of a professional society, the professional
individual’s responsibility is to:
1) Make known the stance of the profession and
reconcile the divergent positions.
2) Enlist the support of professional colleagues to alter
the organization’s position.
3) Support the professional society’s position.
4) Support the organization’s position.
11
When considering ethical principles useful to healthcare
executives, which of the following is incorrect?
1) Respect for persons, including Autonomy, Truth
Telling, Confidentiality, Fidelity.
2) Beneficence - an obligation to act in charity and
kindness.
3) Non-maleficence - first do no harm.
4) Justice - maintain different levels of care and services
based on social status and the ability to pay.
12
When considering ethical principles useful to healthcare
executives, which of the following is incorrect?
1) Respect for persons, including Autonomy, Truth
Telling, Confidentiality, Fidelity.
2) Beneficence - an obligation to act in charity and
kindness.
3) Non-maleficence - first do no harm.
4) Justice - maintain different levels of care and
services based on social status and the ability to
pay.
13
1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,
AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
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Utilitarianism Measuring the end result
produced by a certain action
Deontology A moral philosophy based on
duty (there are right & wrong
actions, regardless of the result)
Respect
Autonomy
Confidentiality
Fidelity
Truth
Beneficence
Non-maleficence
Justice
Complete and Truthful
Information
Participation in
Healthcare Decisions
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Respect
Non-discrimination
Confidentiality
Privacy
Ethics is the driving force…
Law is the answer (“how to”)…
And the law is HIPAA
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The "HIPAA Preliminaries" must be in place:
Privacy Officer
Policies and Procedures
Notice of Privacy Practices POSTED
Releasing only what is "Minimally Necessary“
Business Associate Agreements if:
a) NOT an employee
b) NOT already covered by HIPAA
c) CANNOT do their job without access to PHI
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You may release PHI to
another provider for:
Treatment
Payment
Operations
Other disclosures require
patient authorization
“Covered entities are free to
engage in communications as
required for quick, effective and
high-quality healthcare.”
HHS Guidance on HIPAA
FAQs on Incidental Uses & Disclosures
Question No. 6
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“Tiers” of penalties based on type
of violation:
“Reasonable”
“Knowing”
Constituting “willful neglect”
Which tier is enforced is
discretionary based on the
nature and extent of the
violation and the extent of
any harm done.
$100 per violation not to exceed $25,000 per calendar year
$1,000 per violation not to exceed $100,000 per calendar year
$10,000 per violation not to exceed $250,000 per calendar year
$50,000 per violation not to exceed $1,500,000 per calendar year
21
American Recovery and Reinvestment Act of 2009 - expands
protection of protected health information (PHI), especially patient
information that is in digital format and transferred electronically
Definition of a “Breach”:
1) The unauthorized acquisition, access use, or
disclosure of PHI.
2) Acquisition, access use, or disclosure of PHI in
good faith within the scope of employment is
not a breach.
3) An "inadvertent disclosure" within a provider's
office is not a breach.
22
If you have a breach, you must notify the affected
patient within 60 days of discovery.
You must notify the Secretary of Health and Human
Services and media outlets if your breach affects
more than 500 patients.
Vendors also must notify patients.
Attorneys general in every state are now empowered
to enforce HIPAA violations.
23
The Department of Health and Human Services has been
answering "Frequently Asked Questions“ (FAQs) since
early in the Privacy Rule creation process, and they have
been posting the questions and answers on the web.
This is the most definitive information you can obtain
about HIPAA. It’s free, easily accessible and extremely
accurate (http://www.hhs.gov/ocr/hipaa)
TRUE OR FALSE: All of the following are commonly
recognized to be a right of each patient:
1) Receive considerate and respectful care.
2) Access protective services.
3) Communicate with a caregiver in the language of
the patient’s choosing.
4) Be informed about and participate in decisions
regarding their care.
24
TRUE OR FALSE: All of the following are commonly
recognized to be a right of each patient:
1) Receive considerate and respectful care.
2) Access protective services.
3) Communicate with a caregiver in the language of
the patient’s choosing.
4) Be informed about and participate in decisions
regarding their care.
25
With respect to the processes by which healthcare organizations maintain the
confidentiality, security and integrity of the medical record, all of the following
statements are true except:
1) The original medical record of a patient being transferred from one healthcare
organization to another may accompany the patient to the new organization.
2) Healthcare organizations must have a mechanism to preserve the
confidentiality of data / information identified as sensitive.
3) The organization must have a mechanism to safeguard records against loss,
destruction, tampering and unauthorized access or use.
4) Written policies must require that medical records may be removed from the
organization’s jurisdiction only in accordance with a court order, subpoena or
statute.
26
With respect to the processes by which healthcare organizations maintain the
confidentiality, security and integrity of the medical record, all of the following
statements are true except:
1) The original medical record of a patient being transferred from one
healthcare organization to another may accompany the patient to the
new organization.
2) Healthcare organizations must have a mechanism to preserve the
confidentiality of data / information identified as sensitive.
3) The organization must have a mechanism to safeguard records against
loss, destruction, tampering and unauthorized access or use.
4) Written policies must require that medical records may be removed from the
organization’s jurisdiction only in accordance with a court order, subpoena or
statute.
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1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,
AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
28
Institutional Ethics Committees
Interdisciplinary (should include physicians, nurses,
administration, clergy, patient representatives)
Committee may extend advice, consultation, education &
analysis
Ethics Committees are historically focused on Biomedical
issues [Quinlan, 1976)
Over time have also been used to resolve administrative
ethical issues; may be required under your State Law
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Individuals
Physician-Assisted Suicide
Treatment Refusal by Surrogate or Legal
Representative (Terry Schiavo)
Refusing Treatment Absent Terminal
Illness (Nancy Cruzan)
Moral Status of Gametes and Embryos -
storage and surrogacy
New Reproductive Technologies: IVF,
embryo transplants, egg and sperm
donors, surrogate mothers
Abortion / Human Cloning / Organ
Donation
The Elderly and Access to Long-Term
Care
Autonomy of Persons in Nursing Homes
Hydration and Nutrition
Organizations
Promotion of common good
Role of the community in the
healthcare system
Preservation of human resources
Definition of health
Role of law and government
regulation
Promoting access
Conflicts of interest
Allocation of resources in era of
cost containment
Technology
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Institutional Review Board
Required if your institution is involved
in research that may pose harm to
human subjects
HHS, State Law & various state &
federal agencies
Prospectively review research that
involves human subjects
Issues of consent, risk, value of
research
Infant Care
Federal Child Abuse
Amendments of 1984
Involved when a child has a life-
threatening condition
Review of any case involving
the withholding of care
Should be involved in the
education of families and staff
on issues involving the
possibility of withholding of care
Person states their wishes about accepting or refusing
medical and surgical treatment.
Types of advance directives:
1) living wills
2) natural death acts and death with dignity laws
3) do not resuscitate
4) substituted judgment
Patient Self-Determination Act (PSDA) requires health
services organizations that participate in Medicare or
Medicaid to inform people they serve about advance
directives.
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Benefits to healthcare organizations:
1) They recognize / maximize patient autonomy and
develop a covenantal relationship with patients
2) Give caregivers decisions and decrease uncertainty
as to patient wishes
3) Decrease patient and surrogate / family dissatisfaction
with the organization
4) Decrease need for legal intervention
5) Make more efficient use of organizational resources
33
Which of the following is not an Advanced Medical
Directive?
1) Living wills
2) Euthanasia
3) Surrogate decision making
4) Do not resuscitate
34
Which of the following is not an Advanced Medical
Directive?
1) Living wills
2) Euthanasia
3) Surrogate decision making
4) Do not resuscitate
35
The purpose of the ACHE Ethics Committee is to
review and recommend action on ethical violations to
which group?
1) Executive Committee
2) Board of Governors
3) Council of Regents
4) Membership Committee
36
The purpose of the ACHE Ethics Committee is to
review and recommend action on ethical violations to
which group?
1) Executive Committee
2) Board of Governors
3) Council of Regents
4) Membership Committee
37
1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,
AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
38
This definition and focus incorporates the strengths that
divergent backgrounds bring to any interaction.
It shifts the philosophy from one of ethnocentrism
(“normal is what I define and expect”) to one of ethno-
relativism (“normal” is a context-based term; what is
“normal” for you is something I need to learn).
39
Cultural and Spiritual Diversity Impact:
-- health literacy
-- definition of a family
-- patient interactions, including personal space,
gestures, eye contact, body language, and
preferences for whether / how bad news should be
shared
-- language use; sense and respect for time
-- patient role with the physician (goal is to move away
from paternalistic to collaborative relationship)
-- cultural context of illness and disease
-- the use of traditional and alternative health care
40
1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,
AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
41
Worthley has provided five hallmarks of conflict of interest to assist
healthcare executives in determining whether a conflict is present:
1) Competing obligations: obligation to organization vs.
obligation to friend
2) Appearance standard: the “appearance of impropriety” may
compromise the interests of the organization. Would a
reasonable person be suspicious of misconduct?
3) Myopia: people close to the situation do not see it as
clearly as others
4) Fairness: actions taken within a conflict-of-interest situation
can be unfair to the legitimate stakeholder
5) Confusion: between official and unofficial power; informal,
unofficial, interactions support confusion
42
ACHE Code of Ethics states: “Avoid the improper
exploitation of professional relationships for personal gain”
and “Disclose financial and other conflicts of interest”.
ACHE members should ensure that they personally
disclose any potential conflict of interest situations, and
have an expectation and system in place for board
members, medical staff members, management team and
clinicians to make full disclosure of any possible conflicts
of interest before pursuing or entering into relationships
with potential business partners.
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44
The scandals of Enron, WorldCom
and Tyco led to greater demands for
self-disclosure, transparency and
internal controls
Sarbanes-Oxley Act of 2002
imposes guidelines to improve
the accuracy and reliability of
corporate disclosures
45
Encourage employees to report
unethical behavior (with protection)
Code of ethics and standards of
conduct for executive officers &
board members
Continuously search for conflicts of
interest in the organization
Certification of financial reports
by CEOs and CFOs
Ban on personal loans
Public reporting of CEO and
CFO compensation and profits
Internal independent audit, with
external audit certification
G. Pozgar
“Legal Aspects of Health Care
Administration”
Consciously seek to avoid situations before they
occur (i.e., prevention)
Once a conflict has developed, the individual must
disclose the conflict and remove themselves from a
position of decision making
Institute a “no-gratuities / no-gift” policy so it leaves
nothing to chance (gifts of all kinds, meals and
entertainment)
46
According to ACHE’s Code of Ethics, one way that
healthcare executives can avoid or minimize the
negative implications of conflict of interest is to:
1) Develop a public relations plan to address potential
conflict-of-interest scenarios.
2) Not participate in the specific decision where conflict
may exist.
3) Ensure members submit annual lists of major activities
and holdings for inspections.
4) Make the conflict known to those in superior positions.
47
According to ACHE’s Code of Ethics, one way that healthcare executives can avoid or minimize the negative implications of conflict of interest is to:
1) Develop a public relations plan to address potential conflict-of-interest scenarios.
2) Not participate in the specific decision where conflict may exist.
3) Ensure members submit annual lists of major activities and holdings for inspections.
4) Make the conflict known to those in superior positions.
48
What type of problem arises when a healthcare
executive knowingly allows the organization to
continue double billing?
1) An ethical problem for the healthcare executive, but may not
be grounds for dismissal if organizational policy is not clearly
stated.
2) An actual conflict of interest, even absent a direct economic
benefit to the healthcare executive.
3) An ethical problem for the employee if the healthcare
executive receives direct economic benefit.
4) An ethical problem if it clearly violates state or federal laws.
49
What type of problem arises when a healthcare
executive knowingly allows the organization to
continue double billing?
1) An ethical problem for the healthcare executive, but may not
be grounds for dismissal if organizational policy is not clearly
stated.
2) An actual conflict of interest, even absent a direct
economic benefit to the healthcare executive.
3) An ethical problem for the employee if the healthcare
executive receives direct economic benefit.
4) An ethical problem if it clearly violates state or federal laws.
50
1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,
AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
51
Support and further activities of clinicians, especially
Licensed Independent Practitioners (LIPs).
Cannot interfere in the LIP relationship with patients,
unless patients are at risk or the executive needs to
enforce decisions of clinicians who are performing peer
review or judging clinical competence.
Executives minimize LIP concerns regarding indepen-
dence and patient relations by working through the
professional staff organization (PSO) and the medical
director.
52
Process that reviews LIP qualifications.
Health services organizations are ethically and legally
obligated to determine if the LIP (i.e., MDs and DOs) is
qualified to have independent access to patients.
Depending on the state in which they reside, the
credentialing process may extend to dentists,
podiatrists, chiropractors, etc.
53
If an LIP is deemed incompetent to have privileges, the
practitioner must stop providing treatment and undergo a
review.
Ethical and Legal Obligations:
1) obligation to work to safeguard the “patient or
others served” from risk of harm
2) legal obligations to protect the patient from harm
as defined by statute and court decisions
54
The establishment of an appropriate credentialing
procedure for members of the medical / professional
staff should ultimately be a decision of the:
1) Entire medical / professional staff
2) Credentials Committee
3) Governing authority
4) Medical / professional Executive Committee
55
The establishment of an appropriate credentialing
procedure for members of the medical / professional
staff should ultimately be a decision of the:
1) Entire medical / professional staff
2) Credentials Committee
3) Governing authority
4) Medical / professional Executive Committee
56
The governing authority of a healthcare facility can
terminate the privileges of any member of the medical /
professional staff:
1) At any time if it follows its own adopted procedures
2) At any time with or without due process
3) Only if termination is recommended by the medical /
professional Executive Committee
4) Only if termination is recommended by the medical /
professional staff
57
The governing authority of a healthcare facility can
terminate the privileges of any member of the medical /
professional staff:
1) At any time if it follows its own adopted procedures
2) At any time with or without due process
3) Only if termination is recommended by the medical /
professional Executive Committee
4) Only if termination is recommended by the medical /
professional staff
58
1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,
AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
59
“A member of ACHE who has reasonable grounds to
believe that another member has violated this Code has
a duty to communicate such facts to the Ethics
Committee."
VI. The Healthcare Executive's Responsibility
to Report Violations of the Code
ACHE Code of Ethics
(as amended by the Board of Governors 11/14/11)
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ACHE members are obliged to bring to the attention of the ACHE
Ethics Committee any information that reasonably causes them to
believe there has been an infraction of the Code.
Alleged infractions of the code are reviewed by the Ethics
Committee, and this Committee makes a recommendation to the
Board of Governors, which has final authority.
The CEO sets the moral and ethical tone for the organization which
permeates the norms that govern the behavior of people in the
organization. Ethical leadership is critical to success as a
leader. Patients expect it, staff need it, and regulators demand
it.
The maximum penalty the College may impose is expulsion.
61
According to the ACHE Code of Ethics, what action
can the Ethics Committee take against a member after
a grievance procedure has been initiated?
1) Fine the member
2) Report the violation to the member’s employer
3) Issue a written reprimand to the member
4) Recommend expulsion of the member
62
According to the ACHE Code of Ethics, what action
can the Ethics Committee take against a member after
a grievance procedure has been initiated?
1) Fine the member
2) Report the violation to the member’s employer
3) Issue a written reprimand to the member
4) Recommend expulsion of the member
63
1) Professional Codes of Ethical Behavior (i.e., ACHE, Hippocratic Oath,
AMA)
2) Patient Rights and Responsibilities (i.e., HIPPA and the ARRA)
3) Ethics Committee’s Roles, Structure and Functions
4) Cultural and Spiritual Diversity
5) Conflict of Interest Situations
6) Professional Norms and Behaviors
7) Consequences of Unethical Actions
8) Ethical Implications of Human-Subject Research
64
Institutional Review Boards
1) purpose is to protect human rights
2) developed in direct response to research abuses early in the
20th century (i.e., experiments by Nazi physicians; the
Tuskegee Syphilis Study, a project conducted between 1932-
1972 by the US Public Health Service on black men in rural
Alabama)
In September 1978, the National Commission for the Protection of
Human Subjects of Biomedical and Behavioral Research issued
“The Belmont Report: Ethical Principles and Guidelines for the
Protection of Human Subjects of Research”
65
Report outlined three quintessential requirements for ethical
conduct of research:
1) Respect for Persons - recognition of personal dignity and
autonomy of individuals
2) Beneficence - obligation to protect persons from harm by
maximizing anticipated benefits and minimizing possible risk
3) Justice - benefits and burdens of research be distributed
fairly
66
Which one of the following conditions must be met for human subjects to be used in a medical research program?
1) No suitable animal model exists for use instead of people.
2) The research program has been approved by the medical staff.
3) The research program has been approved by the governing authority.
4) Risks should be clearly explained in understandable language to each individual subject
67
Which one of the following conditions must be met for
human subjects to be used in a medical research
program?
1) No suitable animal model exists for use instead of
people.
2) The research program has been approved by the
medical staff.
3) The research program has been approved by the
governing authority.
4) Risks should be clearly explained in understandable
language to each individual subject.
68
Purpose is to help you identify areas in which you are
on strong ethical ground, areas that you may wish to
examine the basis for your responses, and
opportunities for further reflection
No scoring mechanism
Can be found on www.ache.org (under “Ethics” link)
69
Vision Statement - framework for strategic planning…
“where do we want to go?”
Mission Statement - the purpose of the company or
organization…“why do we exist?”
Organizational Philosophy - that from which the
organization’s vision and mission arise; reflects the
organization’s values
70
Study Guidelines Learn the specific expectations found in ACHE’s Code of
Ethics
Become generally knowledgeable about the codes of other
major medical professional groups
Know the rights and responsibilities of patients
Learn the types and functions of various types of
committees that deal with ethical issues
Understand the concept of conflict of interest and be able to
apply it in operational settings
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ACHE, Manual for the BOG Exam
QUESTIONS ??
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