Quantifying Reliability in Surgical Teams

Amanda Baty, Industrial Engineering PhD StudentDr. Timothy Matis, Industrial Engineering Associate Professor Texas Tech UniversityLubbock, TX

Achieving Safe and High Reliable Healthcare, Strategies and Solutions Pg 32Michael Leonard, Allan Frankel, Terri Simmonds, with Kathleen Vega

Healthcare quality has traditionally been seen as a function of the professionals providing care; going forward, quality and safety will need to be measurable and visible to patients and purchasers of that care.

Human Error in Medicine

Human error in medicine, and the adverse events which may follow, are problems of psychology and engineering not of medicine.

John Senders, 1993Professor Emeritus, Industrial Engineering, University of TorontoAlma Mater: Experimental Psychology, Harvard College (1948)

Outline

Communication Failures in Healthcare HRO principles Recurrence Plots and Analysis Quantitative Assessment Framework

Communication Failures in Healthcare

Types of Communication Failures Occasion (45.7%)

poor timing

Content (35.7%) info missing or inaccurate

Purpose (24.0%) issued were not resolved

Audience (20.9%) key individual excluded

Top 4 Observed Effects of Failures No visible effect (63.6%) Inefficiency (17.8%) Team Tension (12.3%) Delay (7.7%)

Greenberg, C.C., S.E. Regenbogen, D.M. Studdert, S.R. Lipsitz, S.O. Rogers, M.J. Zinner, A.A. Gawande. Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients. Journal of American College of Surgeons. 2007. 533-540.

Weick and Sutcliffes Principles of HROs

Weick and Sutcliffe Processes

Brief explanation

Preoccupation with failure Embrace failures and weak signals

Reluctance to simplify Categories unavoidable, but carried lightly

Sensitivity to operations Recognize that accidents not result of 1 error

Commitment to resilience Identify, control, and recover from errors

Deference to expertise Encourages communication from all levels

(Weick et al. 2007, 19-25)

Recurrence Plots

Introduced by J.P. Eckmann, 1987 Department of Physics Theory University of Geneva

2-dimensional representation of data Array of dots in an N x N square Dot is placed if at (i,j) whenever x(j) is close to (or exactly, if discrete) x(i).

Instantly apparent whether a system is periodic or chaotic

recurrence plots are rather easily obtained aids for the diagnosis of dynamical systems. They display important and easily interpretable information about time scales which are otherwise rather inaccessible. Eckmann, 1987

Characteristics within Recurrence Plots

Diagonal lines Events in the line occur at both time x and time y

Diagonal length Time span of recurrent events Deterministic system longer diagonals Stochastic or heavily fluctuating data short diagonals

Simple examples from Dr. Suess

Example 1: Green Eggs and Ham

22 2 34 22 2 34 34 22 2 39 34 22 2 39 34 22 2 22I 22 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22am 2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 0Sam 34 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 0I 22 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22am 2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 0Sam 34 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 0Sam 34 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 0I 22 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22am 2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 0That 39 0 0 0 0 0 0 0 0 0 39 0 0 0 39 0 0 0 0Sam 34 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 0I 22 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22am 2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 0That 39 0 0 0 0 0 0 0 0 0 39 0 0 0 39 0 0 0 0Sam 34 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 0I 22 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22am 2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 0I 22 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22

Diagonal lines are several blocks long because book is repetitive (deterministic)

Recurrent Points

Reflected about main diagonal

Example 2: Oh, The Places Youll Go

193 281 215 341 113 65 292 141 342 72 343 192 291 115 215 343 192 17 26Oh 193 193 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0the 281 0 281 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Places 215 0 0 215 0 0 0 0 0 0 0 0 0 0 0 215 0 0 0 0You'll 341 0 0 0 341 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Go 113 0 0 0 0 113 0 0 0 0 0 0 0 0 0 0 0 0 0 0Congratula 65 0 0 0 0 0 65 0 0 0 0 0 0 0 0 0 0 0 0 0Today 292 0 0 0 0 0 0 292 0 0 0 0 0 0 0 0 0 0 0 0is 141 0 0 0 0 0 0 0 141 0 0 0 0 0 0 0 0 0 0 0your 342 0 0 0 0 0 0 0 0 342 0 0 0 0 0 0 0 0 0 0day 72 0 0 0 0 0 0 0 0 0 72 0 0 0 0 0 0 0 0 0You're 343 0 0 0 0 0 0 0 0 0 0 343 0 0 0 0 343 0 0 0off 192 0 0 0 0 0 0 0 0 0 0 0 192 0 0 0 0 192 0 0to 291 0 0 0 0 0 0 0 0 0 0 0 0 291 0 0 0 0 0 0Great 115 0 0 0 0 0 0 0 0 0 0 0 0 0 115 0 0 0 0 0Places 215 0 0 215 0 0 0 0 0 0 0 0 0 0 0 215 0 0 0 0You're 343 0 0 0 0 0 0 0 0 0 0 343 0 0 0 0 343 0 0 0off 192 0 0 0 0 0 0 0 0 0 0 0 192 0 0 0 0 192 0 0and 17 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17 0away 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26

Shorter diagonal lines because book is not repetitive (stochastic)

Reflected about main diagonal

Quantification of Recurrence Plots

Recurrence Rate Percentage of Recurrent Points to total possible points

Determinism Percentage of Recurrent Points that form diagonal lines

Average diagonal lengthLongest diagonal length

Why Quantify Surgical Teams?

Most research focused: On development of HRO characteristics Retrospectively based Does not apply empirical based methods

We want to... Develop method to quantify teams,

specifically surgical teams Based on communication patterns Identify communication patterns that

directly link to HRO principles

22 2 34 22 2 34 34 22 2 39 34 22 2 39 34 22 2 2222 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22

2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 034 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 022 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22

2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 034 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 034 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 022 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22

2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 039 0 0 0 0 0 0 0 0 0 39 0 0 0 39 0 0 0 034 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 022 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22

2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 039 0 0 0 0 0 0 0 0 0 39 0 0 0 39 0 0 0 034 0 0 34 0 0 34 34 0 0 0 34 0 0 0 34 0 0 022 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22

2 0 2 0 0 2 0 0 0 2 0 0 0 2 0 0 0 2 022 22 0 0 22 0 0 0 22 0 0 0 22 0 0 0 22 0 22

Using Recurrence Plots

We observed surgeries and recorded on four categories: Who spoke (transmitter)

Surgeon, Surgical Tech, Nurse Who they spoke to (receiver)

Surgeon, Surgical Tech, Nurse Type of communication (type)

Statement, Question, Command/Order

Communication from time out until doctor steps away

Then, we created recurrence plots for each category using Microsoft Excel

193 281 215 341 113 65 292 141 342 72 343 192 291 115 215 343 192 17 26193 193 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0281 0 281 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0215 0 0 215 0 0 0 0 0 0 0 0 0 0 0 215 0 0 0 0341 0 0 0 341 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0113 0 0 0 0 113 0 0 0 0 0 0 0 0 0 0 0 0 0 065 0 0 0 0 0 65 0 0 0 0 0 0 0 0 0 0 0 0 0

292 0 0 0 0 0 0 292 0 0 0 0 0 0 0 0 0 0 0 0141 0 0 0 0 0 0 0 141 0 0 0 0 0 0 0 0 0 0 0342 0 0 0 0 0 0 0 0 342 0 0 0 0 0 0 0 0 0 0

72 0 0 0 0 0 0 0 0 0 72 0 0 0 0 0 0 0 0 0343 0 0 0 0 0 0 0 0 0 0 343 0 0 0 0 343 0 0 0192 0 0 0 0 0 0 0 0 0 0 0 192 0 0 0 0 192 0 0291 0 0 0 0 0 0 0 0 0 0 0 0 291 0 0 0 0 0 0115 0 0 0 0 0 0 0 0 0 0 0 0 0 115 0 0 0 0 0215 0 0 215 0 0 0 0 0 0 0 0 0 0 0 215 0 0 0 0343 0 0 0 0 0 0 0 0 0 0 343 0 0 0 0 343 0 0 0192 0 0 0 0 0 0 0 0 0 0 0 192 0 0 0 0 192 0 0

17 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17 026 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26

OR

Transmitter (Person Communicating)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132w 4 4 6 4 6 4 1 3 1 3 1 3 1 2 3 4 3 3 3 3 1 3 3 1 4 3 3 4 3 4 3 4 3 3 3 2 3 2 3 2 3 2 3 2 1 3 1 3 3 1 3 6 3 6 3 3 4 6 4 6 4 6 4 3 1 3 1 3 3 41 3 3 1 3 3 6 3 6 3 3 3 1 3 3 41 2 1 1 3 1 1 1 1 3 3 1 3 1 3 4 3 1 1 3 1 4 1 3 4 1 3 3 2 3 2 2 1 3 1 3 1 4 41 3 1 3 4 3 4 3 1 1

1 4 4 4 0 4 0 4 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 4 0 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 4 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 4 0 4 0 0 02 4 4 4 0 4 0 4 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 4 0 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 4 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 4 0 4 0 0 03 6 0 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 6 0 0 0 6 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 04 4 4 4 0 4 0 4 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 4 0 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 4 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 4 0 4 0 0 05 6 0 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 6 0 0 0 6 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 6 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 06 4 4 4 0 4 0 4 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 4 0 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 4 0 4 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 4 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 4 0 4 0 0 07 1 0 0 0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 1 1 1 0 0 1 0 1 0 0 0 1 1 0 1 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0 0 0 0 1 18 3 0 0 0 0 0 0 0 3 0 3 0 3 0 0 3 0 3 3 3 3 0 3 3 0 0 3 3 0 3 0 3 0 3 3 3 0 3 0 3 0 3 0 3 0 0 3 0 3 3 0 3 0 3 0 3 3 0 0 0 0 0 0 0 3 0 3 0 3 3 0 3 3 0 3 3 0 3 0 3 3 3 0 3 3 0 0 0 0 3 0 0 0 0 3 3 0 3 0 3 0 3 0 0 3 0 0 0 3 0 0 3 3 0 3 0 0 0 3 0 3 0 0 0 3 0 3 0 3 0 3 0 09 1 0 0 0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 0 0 0 1 1 0 1 1 1 1 0 0 1 0 1 0 0 0 1 1 0 1 0 1 0 0 1 0 0 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0 0 0 0 1 1

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Transmitter CodeRecurrence

RateSurg Tech 1 1 5.9%Surg Tech 2 2 0.6%Surgeon 3 20.0%RN 4 2.1%Operating Room 5 0.0%Anesthesiologist or Anesthetist 6 0.5%

Recurrence Rate 29%Points in Diagonals 1148Recurrent Points 2245% Determinism 51%Longest diagonal line 8

Timeout RN and Ane.- Preoccupation with Failure-Reluctance to Simplify-Sensitivity to Operations

We would want to see all members of the surgical team communicating. This would show Commitment to Resilience.

Receiver (Person being Communicated to)

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0 0130 14 0 0 14 0 14 0 0 0 0 0 0 0 0 0 14 0 14 14 14 0 0 14 0 0 0 14 14 0 14 0 14 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 14 0 14 0 14 0 0 0 0 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 0 0 14 0 0 0 14 14 0 0 0 0 0 0 14 14 0 14 14 14 0 0 0 14 14 0 0 0 14 14 0 0 0 0 0 0 0 14 0 0 14 0 0 0 14 0 14 14 14131 14 0 0 14 0 14 0 0 0 0 0 0 0 0 0 14 0 14 14 14 0 0 14 0 0 0 14 14 0 14 0 14 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 14 0 14 0 14 0 0 0 0 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 0 0 14 0 0 0 14 14 0 0 0 0 0 0 14 14 0 14 14 14 0 0 0 14 14 0 0 0 14 14 0 0 0 0 0 0 0 14 0 0 14 0 0 0 14 0 14 14 14132 14 0 0 14 0 14 0 0 0 0 0 0 0 0 0 14 0 14 14 14 0 0 14 0 0 0 14 14 0 14 0 14 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 14 0 14 0 14 0 0 0 0 0 0 0 0 0 0 0 14 0 0 0 0 0 0 0 0 0 0 0 14 0 0 0 14 14 0 0 0 0 0 0 14 14 0 14 14 14 0 0 0 14 14 0 0 0 14 14 0 0 0 0 0 0 0 14 0 0 14 0 0 0 14 0 14 14 14

Receiver CodeRecurrence

RateSurg Tech 1 11 4%Surg Tech 2 12 0%Surgeon 13 8%RN 14 7%Operating Room 15 0%Anesthesiologist or Anesthetist 16 1%

Recurrence Rate 20%Points in Diagonals 684Recurrent Points 1355% Determinism 50%Longest Diagonal Line 6

Timeout RN and Ane.- Preoccupation with Failure-Reluctance to Simplify-Sensitivity to Operations

We would want to see all members of the surgical team being communicated to in order to show- Commitment to Resilience and - Deference to Expertise.

Type of Communication

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132w 21 23 24 23 24 23 26 26 26 26 26 26 26 26 21 23 35 21 21 21 24 21 23 24 23 23 21 24 26 26 26 26 21 21 26 26 26 26 21 26 26 26 26 26 26 23 24 21 21 26 35 23 24 21 21 35 23 24 23 24 21 23 24 21 24 21 24 21 26 26 23 21 21 23 21 24 21 23 24 21 21 23 21 21 23 21 24 26 21 22 21 25 26 26 26 26 26 21 21 24 26 26 21 26 26 23 21 21 21 23 24 21 21 21 21 23 24 23 23 24 21 24 23 24 23 24 21 23 24 21 23 21

1 21 21 0 0 0 0 0 0 0 0 0 0 0 0 0 21 0 0 21 21 21 0 21 0 0 0 0 21 0 0 0 0 0 21 21 0 0 0 0 21 0 0 0 0 0 0 0 0 21 21 0 0 0 0 21 21 0 0 0 0 0 21 0 0 21 0 21 0 21 0 0 0 21 21 0 21 0 21 0 0 21 21 0 21 21 0 21 0 0 21 0 21 0 0 0 0 0 0 21 21 0 0 0 21 0 0 0 21 21 21 0 0 21 21 21 21 0 0 0 0 0 21 0 0 0 0 0 21 0 0 21 0 212 23 0 23 0 23 0 23 0 0 0 0 0 0 0 0 0 23 0 0 0 0 0 0 23 0 23 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 0 0 0 0 0 23 0 0 0 0 23 0 23 0 0 23 0 0 0 0 0 0 0 0 23 0 0 23 0 0 0 23 0 0 0 23 0 0 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 0 0 0 23 0 0 0 0 0 23 0 23 23 0 0 0 23 0 23 0 0 23 0 0 23 03 24 0 0 24 0 24 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 0 0 24 0 0 0 24 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 0 0 0 0 0 24 0 0 0 0 24 0 24 0 0 24 0 24 0 24 0 0 0 0 0 0 0 0 24 0 0 24 0 0 0 0 0 0 0 24 0 0 0 0 0 0 0 0 0 0 0 0 24 0 0 0 0 0 0 0 0 0 0 24 0 0 0 0 0 24 0 0 24 0 24 0 24 0 24 0 0 24 0 0 04 23 0 23 0 23 0 23 0 0 0 0 0 0 0 0 0 23 0 0 0 0 0 0 23 0 23 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 0 0 0 0 0 23 0 0 0 0 23 0 23 0 0 23 0 0 0 0 0 0 0 0 23 0 0 23 0 0 0 23 0 0 0 23 0 0 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 0 0 0 23 0 0 0 0 0 23 0 23 23 0 0 0 23 0 23 0 0 23 0 0 23 05 24 0 0 24 0 24 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 0 0 24 0 0 0 24 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24 0 0 0 0 0 24 0 0 0 0 24 0 24 0 0 24 0 24 0 24 0 0 0 0 0 0 0 0 24 0 0 24 0 0 0 0 0 0 0 24 0 0 0 0 0 0 0 0 0 0 0 0 24 0 0 0 0 0 0 0 0 0 0 24 0 0 0 0 0 24 0 0 24 0 24 0 24 0 24 0 0 24 0 0 06 23 0 23 0 23 0 23 0 0 0 0 0 0 0 0 0 23 0 0 0 0 0 0 23 0 23 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 0 0 0 0 0 23 0 0 0 0 23 0 23 0 0 23 0 0 0 0 0 0 0 0 23 0 0 23 0 0 0 23 0 0 0 23 0 0 23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23 0 0 0 23 0 0 0 0 0 23 0 23 23 0 0 0 23 0 23 0 0 23 0 0 23 07 26 0 0 0 0 0 0 26 26 26 26 26 26 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 26 26 0 0 26 26 26 26 0 26 26 26 26 26 26 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 0 0 0 0 26 26 26 26 26 0 0 0 26 26 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 08 26 0 0 0 0 0 0 26 26 26 26 26 26 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 26 26 0 0 26 26 26 26 0 26 26 26 26 26 26 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 0 0 0 0 26 26 26 26 26 0 0 0 26 26 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 09 26 0 0 0 0 0 0 26 26 26 26 26 26 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 26 26 0 0 26 26 26 26 0 26 26 26 26 26 26 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 0 0 0 0 26 26 26 26 26 0 0 0 26 26 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

10 26 0 0 0 0 0 0 26 26 26 26 26 26 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 26 26 0 0 26 26 26 26 0 26 26 26 26 26 26 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 0 0 0 0 26 26 26 26 26 0 0 0 26 26 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 011 26 0 0 0 0 0 0 26 26 26 26 26 26 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 26 26 0 0 26 26 26 26 0 26 26 26 26 26 26 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 0 0 0 0 26 26 26 26 26 0 0 0 26 26 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 012 26 0 0 0 0 0 0 26 26 26 26 26 26 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 26 26 0 0 26 26 26 26 0 26 26 26 26 26 26 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 0 0 0 0 26 26 26 26 26 0 0 0 26 26 0 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 013 26 0 0 0 0 0 0 26 26 26 26 26 26 26 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26 26 26 26 0 0 26 26 26 26 0 26 26 26 26 26 26 0 0 0 0 26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2