Background Academic fellowships in quality improvement (QI) and patient safety (PS) have emerged as one strategy to fill a need for physicians who possess this expertise. The authors aimed to characterise the impact of two such programmes on the graduates and their value to the institutions in which they are housed.
Methods In 2018, a qualitative study of two US QIPS postgraduate fellowship programmes was conducted. Graduates’ demographics and titles were collected from programme files,while perspectives of the graduates and their institutional mentors were collected through individual interviews and analysed using thematic analysis.
Results Twenty-eight out of 31 graduates (90%) and 16 out of 17 (94%) mentors participated in the study across both institutions. At a median of 3 years (IQR 2–4) postgraduation, QIPS fellowship programme graduates’ effort distribution was: 50% clinical care (IQR 30–61.8), 48% QIPS administration (IQR 20–60), 28% QIPS research (IQR 17.5–50) and 15% education (7.1–30.4). 68% of graduates were hired in the health system where they trained. Graduates described learning the requisite hard and soft skills to succeed in QIPS roles. Mentors described the impact of the programme on patient outcomes and increasing the acceptability of the field within academic medicine culture.
Conclusion Graduates from two QIPS fellowship programmes and their mentors perceive programmatic benefits related to individual career goal attainment and institutional impact. The results and conceptual framework presented here may be useful to other academic medical centres seeking to develop fellowships for advanced physician training programmes in QIPS.
- continuing education, continuing professional development
- health professions education
- quality improvement
- patient safety
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- continuing education, continuing professional development
- health professions education
- quality improvement
- patient safety
Quality improvement (QI) and patient safety (PS) are areas of increasing importance and investment within healthcare, and physicians are often called on to lead these efforts.1 In the first decade after the publication of the national landmark reports, To Err is Human and Crossing the Quality Chasm, physicians in newly created QIPS leadership roles largely acquired the requisite knowledge and skills on the job.2 3 Shortly thereafter, ‘on the job’ QIPS training began to appear in multiple forms, including online and in-person professional development programmes sponsored by national quality organisations.4–6 As the healthcare quality landscape continued to evolve, with reimbursement increasingly tied to value over volume, QIPS emerged as a viable career pathway for physicians and an increasing number of them aspired to this career.7 8
While many healthcare organisations developed local training programmes in QIPS to develop their workforce, a few academic medical centres developed training pathways, fellowships and graduate degrees in this field.9 10 As a testament to the growth of the field, a taskforce of academics from graduate programmes in quality and safety and representatives from the Commission on Healthcare Accreditation Management Education was recently formed to develop accreditation of graduate programmes in this field.11 Most of these programmes pair formal instruction in the science of QIPS and related topics with a mentored capstone project. While these programmes vary widely in their student population, some recruit students who work clinically and perform their improvement work within the same institution that is offering the training, thereby providing an added value to the organisation. Despite the proliferation of QIPS training opportunities, there are few descriptions of the outcomes and value that these educational programmes might provide.
We aimed to describe the impact of postgraduate QIPS fellowship training programmes for physicians on graduates’ career outcomes and illustrate the value to the institutions in which they are housed. By soliciting perspectives from the graduates of two such programmes and their institutional mentors, we also sought to identify the ideal attributes of QIPS fellowship programmes to guide the iterative development of our own programmes and inform the broader educational landscape in this field.
This was a mixed-methods (QUAL+quan) prospective cross-sectional interview study.12 To facilitate complete reporting in this manuscript, we used the Consolidated Criteria for Reporting Qualitative Research checklist.13
We studied graduates of two postgraduate QIPS fellowship programmes for physicians in USA. The Center for Healthcare Improvement and Patient Safety Fellowship at the University of Pennsylvania began in 2009 to build physician capacity for QIPS and advance research in the field. The Harvard Medical School Fellowship in Patient Safety and Quality began in 2012 to train operational leaders in quality and safety across sites of our captive malpractice insurer which is an insurance company that is owned and controlled by its insured. In this case, Controlled Risk Insurance Company (CRICO) insurance company is owned by the Harvard Medical Institutions. Fellows worked clinically and performed their QIPS work at one of seven institutions within these two health systems. Both programmes provide coursework, access to a master’s degree and opportunities to complete projects within the health system. A comparison of the structure of the two programmes is shown in figure 1. While this figure highlights the similarities and differences of the programme, the intent of our research was not to identify differences in the programmes, but rather to elucidate common characteristics and perspectives from the programme graduates and their institutional mentors.
All 31 eligible graduates from fellowship inception (2009 for University of Pennsylvania, 2012 for Harvard) to June 2017 were eligible for the study. Graduates were contacted via email by the fellowship programme directors (JSM, AT), informed of the purpose of the study and asked to identify the institutional mentor for their most impactful QIPS project. When there was ambiguity between advisors, mentors and sponsors, graduates were asked to select the individual with the most insight into how their project affected patient care and the workplace. Institutional mentors were subsequently contacted by the fellowship programme directors over email and invited to participate. When a single mentor supervised more than one graduate, the mentor was asked to speak about each of their mentees and their individual contributions in one interview. No incentives were given for participation. A trained research assistant (ARP) conducted the interviews.
Two separate interview instruments were developed by the authors (JSM, MBL-F, ARP, AT) for the graduates and their mentors (see online supplementary digital material). The instruments were pilot-tested with three graduates and mentors of a residency training pathway in QI at one of the sites and subsequently adjusted for clarity, efficiency and to explore emerging ideas.14 Interview questions that focused on the amount of time graduates spent in different areas (ie, clinical care, QIPS administration, research, education) and the title and level of their first QIPS position after fellowships were more quantitative in nature. The remainder of the interview questions were semistructured and qualitative in nature. The organisational impact of the fellows’ QI capstone projects arose during the first few interviews. Therefore, a question about organisational impact was added to the interview instrument and used during the final 25 interviews. All interviews were conducted by telephone, audio-recorded, deidentified and professionally transcribed verbatim between February and June 2018.
Identifying information was removed from the transcripts before analysis and data were stored on a secure server. Access to primary data was restricted such that programme faculty at each institution did not have access to the data from their alumni.
Continuous data (number of years from QIPS fellowship graduation and percent of time spent in various activities postgraduation) were analysed and reported using medians and interquartile ranges (IQRs). The QIPS position level was analysed and reported as a categorical variable: division, department or institution.
A thematic analytical approach to coding qualitative data was iteratively applied to identify themes relevant to the value of physician fellowships in quality and safety.15 16 Both deductive and inductive coding were used to balance the ability to map participants’ responses to an educational evaluation framework (Kirkpatrick) with the ability to discern important themes that were not represented in this model.17 18 The Kirkpatrick model was useful in making distinctions between learning, behavioural change and organisational change in the evaluation of our fellowships. To address more specific programme outcomes and characteristics of graduates and their work, an open coding approach was used to identify concepts grounded in the participants’ responses.19 The final codebook, therefore, combined the Kirkpatrick levels with concepts arising from the data themselves.
Coding was supervised by a researcher with expertise in qualitative inquiry (MBL-F). An experienced research assistant (ARP) coded the data using NVivo qualitative data analysis software (V.11.0, QSR International, Doncaster, Victoria, Australia). A second trained research assistant double-coded a random selection of 20% of the transcripts to ensure consistency. Data analysis was coincident with data collection, and the codebook evolved throughout the data collection process. Data were coded using the constant comparative method in which codebook changes are applied to previously coded data.20 The research team met periodically during data collection to discuss emerging themes and, on completion, reviewed a summary of the results and agreed on themes to group similar concepts that emerged.
The graduation rate for both programmes was 100%. Masters degree programmes were pursued and completed for all graduates. All graduates from Penn’s QIPS fellowship programme completed a Master of Science in Health Policy Research. All graduates from Harvard’s QIPS fellowship programme completed a Master of Public Health, except for one graduate who completed a Masters of Business Administration. Twenty-eight out of 31 eligible graduates (90%) participated in the study, 9 (32%) were males and 19 (68%) were females. Among the graduates, 20 (71%) were white, 5 (18%) were Asian, 2 (7%) were African American and 1 (4%) was Hispanic/Latino. On average, graduates matriculated into the QIPS fellowship programme 5 years (median=5; range=3–22) after medical school graduation. Upon graduation, 68% (19/28) of the graduates from the two programmes combined were hired by the health system where they trained. On average, graduates were interviewed 3 years (median=3; range=1–7) after their QIPS fellowship graduation. At the time of the study, 96% of graduates were in academic positions and 96% were involved in QIPS administration, research or education. Graduates’ specialty, first QIPS position after graduation and their work effort allocation is displayed in table 1.
Seventeen programme mentors were contacted. This number is lower that the number of graduates (28) in our study because several graduates had the same mentor and one graduate did not consent to contacting their mentor. The 17 programme mentors collectively mentored 93% (26 out of 28) of the graduates that we interviewed. Out of 17 programme mentors contacted, 16 (94%) participated in interviews. Graduate interviews lasted between 20 min and 71 min and mentor interviews lasted between 8 min and 36 min. Data saturation was achieved as determined by a consensus of the coding team.
Themes that emerged from the interviews with programme graduates and their mentors are presented below.
Factors considered in the decision to enroll in a QIPS fellowship
Graduates had similar goals when joining the programme. Overwhelmingly, their primary goal was to obtain and apply a new skill set (n=18) that would support a career in QIPS (n=14). Other goals that were mentioned included research skill development (n=12), establishing a network in the field (n=8) and leadership skill acquisition (n=3).
Graduates weighed several factors when considering whether to join their programme. First, they weighed the advantages of formal training over informal involvement in QIPS. Programme advantages included structure, protected time to do QIPS work and a credential that legitimised their expertise. The fellowship was thought of as a ‘jumping-off point’ for a range of careers and generally believed to be an asset in the job world, opening up unique career opportunities, providing credibility and a ‘leg up.’
When considering the time commitment of the programme, some graduates acknowledged that they viewed it as a quicker way to gain QIPS training compared with accumulating experience ‘the slow way’ through less formal, long-term involvement in organisational QIPS efforts. Some graduates viewed the fellowship as an alternative academic career to basic science or clinical research but one that still afforded them the opportunity to use scientific methodology and publish. For some, the master’s programme was especially appealing. The combination of research training from a widely recognised institution combined with QIPS training and mentorship was seen as valuable. A few considered pursuing a QIPS certificate instead of the fellowship, and in fact, some graduates recommended that future applicants consider whether there is a less time-intensive programme that better meets their needs. Additional considerations included the financial impact of additional time spent in training, particularly for those in higher-reimbursed specialties, concerns about how to combine a new skill set in QIPS with their role as a clinical specialist, and whether joining a relatively new fellowship programme was a liability or an asset.
While most graduates were encouraged by outside mentors to join the programme, some were not. Individuals in this latter category experienced discouragement from some of their clinical fellowship programme directors and mentors who were more familiar with traditional forms of research within their specialties.
Impact of fellowship training on learning and behaviour
Graduates reported gaining new knowledge, skills and attitudes from the fellowship through classroom instruction and hands-on experiences. These experiences, such as leading a capstone project, participating in meetings and involvement in institutional initiatives, were described as deeply valuable and provided knowledge and skills difficult to learn elsewhere. Similarly, mentors described observed behaviours as the fellows progressed through the programme.
Knowledge gained ranged from broad topics such as understanding how healthcare organisations develop QIPS priorities to more discrete topics such as quality measurement. Graduates discussed gaining practical knowledge such as how to build an accountable team, barriers to improvement work, and understanding and navigating the gap between leadership and the front line. The research training component of both fellowship programmes was perceived as an asset that afforded graduates the ability to move back and forth between quality and research or combine them in their careers.
…having it helped me bridge the gap now in my current role between quality improvement people and those clinicians who tend to be more familiar with research approaches, and so I see myself as a translator between those two disciplines and having had that background … is really helpful for that. (Participant 0208)
Similarly, graduates who pursued careers in research reported that they use their QI knowledge and skill as a toolkit for addressing problems.
…learning some of these methodologies are useful because doing different types of research often involves scrutinising it or developing a plan or trying to find a root cause of a problem. So, I'm able to apply those skills in a different area of my career right now and I do think…if I want to take a more administrative role, having this experience will be an asset… (Participant 0319)
Commenting on the fellows’ knowledge, mentors noted that they brought a scientific approach to problems that made people feel comfortable exposing risk and encouraged dialogue. Mentors felt confident that fellows knew how to test the effectiveness of interventions and understood how to work with people, even dissenters, on improvement activities.
Graduates consistently differentiated between ‘soft’ and ‘hard’ skills learned in their fellowship and found both to be transferrable to their current workplace (table 2). The capstone project and other hands-on experiences were seen as particularly helpful for ‘soft’ skills development.
(the importance in the capstone experience was that)…everything that could potentially happen in the real life actually happens during the capstone project, because it is real life. (Participant 0219)
Finally, several graduates described changes in their attitudes towards quality and safety as a result of the training programme.
There were several aspects of training that were viewed less positively. Graduates from both programmes reported wanting more training in data analytics specifically statistical process control charts and principles. They also desired more training in leadership, healthcare finance, cost, value and how to recruit executive sponsors for QIPS work. Graduates reported wanting more realistic expectations when beginning the job search and ideas for how to get started in a career in QIPS. Finally, graduates sought more opportunities to connect with fellows from other years in the programme and within national QIPS organisations.
Impact of fellowship training programmes on results
Upon fellowship completion, graduates secured a range of leadership positions (table 1) and 68% (n=19/28) were hired by their training institution. Some had specific QIPS roles created for them in a division or department. One graduate is the first medical director of QIPS at a large healthcare institute and several are building QIPS programmes from scratch. Graduates without QIPS administrative positions have part of their effort supported for QIPS research and/or education.
Graduates ubiquitously agreed that the fellowship brought value and prepared them for their QIPS careers. Some described it as career-defining. The fellowship gave graduates academic credibility, differentiated them in the eyes of senior leadership, made them interesting to employers and colleagues, and provided them with access to leadership and organisation-wide quality work.
(The fellowship has) prepared me in a thousand different ways…I understand quality. I understand safety. I understand leadership. I understand organisations. I understand a ton of stuff and I'm literally applying everything that I have learnt on a weekly basis. (Participant 0213B)
Interviewer: So looking back on this training experience and where you are now, do you believe that the program brought value to your career?
Graduate: No question. It totally changed my life. (Participant 0306)
The fellowship was often referred to as legitimising their knowledge and skills and opening doors to job opportunities.
I think having a formal credential in (quality and safety) is a big help, especially in a field like mine where there's very few people who have had formal training in it. (Participant 0215A)
Some graduates reported arriving in their new workplaces as the expert that people turn to when they want to do improvement work.
… whenever different situations occur in the hospital setting that are related to patient safety or quality, I'm immediately identified as the person to help with or support those initiatives. (Participant 0219)
The mentors agreed that the fellowship helped launch careers but offered some cautionary advice, noting that it can be difficult to find QIPS roles, recognising that there are a finite number of them. Additionally, graduates will be junior faculty at their institution and need to accrue credibility by working clinically.
Among the 25 graduates who were asked about the institutional impact of their QIPS capstone project on patient care and the healthcare delivery system, 13/25 (52%) believed it had an institutional impact, 3/25 (12%) a departmental impact and 9/25 (36%) a divisional impact. Twenty of 25 (80%) graduates self-reported that their fellowship QI work was still having an impact several years later, while 3/25 (13%) were not and 1/25 (4%) was unknown.
Mentors were asked about the impact of the fellows and the fellowship programmes on the institution in which they performed their improvement work. They shared that fellows improved patient care quality and in many cases directly affected outcomes. Examples included reducing mortality for a group of high-risk infants, reducing the rate of venous thromboembolism and reducing the bloodborne pathogen exposure rate for employees. Some fellows were able to build new programmes, such as an infectious disease transition service that has benefited thousands of patients in one health system.21 Several fellows’ projects contributed to building local infrastructure for quality and safety. For example, in one case, eight full-time staff positions are now dedicated towards a project started by a QIPS fellow. While some fellows’ contributions were at the division or department level, others had institutional impact, and a few even informed national guidelines in the field.
All of the work that she's (a fellow) done really has been presented either locally, regionally, or nationally, with significant results when you look at the statistical process control, so her work has improved the healthcare of hundreds, if not thousands, of children. (Mentor 0517)
Mentors described that the fellows’ QI work often became the new standard of care and was no longer seen as a ‘project’. They also commented on the cultural shifts that accompanied the practice change related to the fellows’ projects. Fellows created dialogue, provided a sense of urgency and momentum for action, shifted the conversations from blame to curiosity, and raised awareness of improvement science. Mentors recognised that while some projects might not last, local culture change often does. Reflecting on the impact of the training programme on the acceptability of the field of QIPS overall, one mentor stated:
(The fellowship) helps raise awareness that there is a science around this. It's not just people mucking around out there. There's actually some real expertise. (Mentor 0430A)
Other mentors thought that the impact of the fellows’ work was less significant for a variety of reasons ranging from a short time frame of fellow involvement to fellows being unable to effectively engage their audience to a lack of institutional improvement culture to sustain the changes made.
Many mentors described their mentees in the programme as role models, paving a career pathway in specialties where QIPS work was less familiar. Another mentor expressed the sentiment that QIPS is at the heart of medicine, and therefore their training is consistent with the desire to provide the best care possible. By demonstrating how to merge QI work with clinical work, mentors described how the fellows increased the acceptability of the field as a whole.
Other mentors described how the fellowship created value by producing a pipeline of future leaders and researchers in quality and safety.
I think that it's a domain that involves specialised expertise…and so giving people the protected time for that content training and experiential learning with mentorship, is essential to creating people that are competent to hold key, high profile roles in their institutions. Namely chief quality officers or chief patient safety officers. That's a big agenda for most hospitals now and it's a complex field, so there's definitely a need for that role. I think that these training programmesare well designed to help fill that role. (Mentor 0622)
This is the first study that includes mixed-methods to describe the value of postgraduate physician fellowship programmes in QIPS from the perspective of graduates and institutional mentors. The study provides a window into their perspectives on why they selected these programmes, how they divide their clinical and non-clinical work time, and their insights, retrospectively, on the value of the training. As the quality and safety academic career pathway, first described by Shojania and Levinson in 2009, becomes more visible and tangible to physicians-in-training, an increasing number of them are drawn to the work and seek to pursue it as a career.7 This early realisation caused some of the graduates that we interviewed to grapple with whether to pursue the accrual of knowledge and skills in QIPS through progressive experience versus pursuing a 2-year fellowship that included explicit training in QIPS.
The rationale, input, activities and outcomes related to creating a QIPS fellowship programme are illustrated in figure 2. Both of our institutions created a QIPS fellowship to begin to close the gap between the number of trained QIPS physician leaders and the number needed, both locally and nationally. This required a supply of interested trainees and an institutional investment. The educational activities to support the QIPS fellowship programmes included curriculum development, integration with an existing masters’ degree programme and mentored experiences leading QIPS work. Both of our institutions benefited from the outcomes of the programmes which included a cadre of physicians formally trained in QIPS and institutional gains related to organisational performance and improvements in patient care quality related to the graduates’ work. Mentors frequently commented that the presence of QIPS fellows and a fellowship programme helped increase the acceptability of QIPS as a distinct field requiring expertise. Further demonstrating this acceptability is the development of formal academic promotion criteria for QIPS activities in several academic medical centres, medical student and resident concentrations and training pathways in QIPS, and standardised reporting guidelines for the publication of QI.14 22–24
The results of this study demonstrate that the development of a QIPS fellowship is one way for healthcare organisations to build internal physician expertise and leadership capacity in QIPS. Sixty-eight per cent of the graduates from our two programmes combined were hired by the health system where they trained. In a national study of 75 US Veterans Affairs National Quality Scholars Fellowship Programme (VAQS) graduates, 44% obtained faculty positions within the Veterans Affairs (VA) site network where they trained similarly demonstrating the local capacity-building nature of these training programmes.25 It is possible that the local retention rate for QIPS fellowship graduates may decrease as capacity is reached and the number of QIPS positions is finite. In order to be sustainable, therefore, we assert that QIPS fellowship programmes must continuously work to demonstrate value by tracking local improvements in organisational and patient care outcomes. While the outcomes and impact of specific institutional capstone projects is one way to demonstrate value, it is important to recognise that there are other, longer-term impacts of these educational programmes that may be harder to measure such as the acceptability of the career path, the institutional culture related to QIPS and the development of mentors and educators in the field.
A notable aspect of these programmes was the provision of instruction in both QIPS and research methods which provided our graduates with the skills to study and disseminate their improvement work. Our QIPS fellowships are not the first to have an emphasis on scholarship. Developed in 1999, the VAQS fellowship programme and the VA chief residency in quality and safety programmes have been training physicians in quality, safety and the scholarship of improvement for two decades.25–27 A study of 75 VAQS graduates found that 80% were employed and actively engaged in improvement work or research and 66% were in academic faculty positions.25 While these numbers are lower than our findings (96% engaged in QIPS work and 96% in academic positions), they are a testament to the growth of compensated roles for QIPS work and the growth of the QIPS academic career pathway—whether concentrated in operations, education or research.
The earlier stage at which most physicians in our study were seeking out skills in QIPS sets them apart in important ways from mid-to-late career physicians who are looking for the same skills. From a practical perspective, our graduates had the flexibility to complete a 2-year, in-person training programme on a largely full-time basis, while continuing to work clinically either as a fellow or junior faculty member at a highly reduced effort. Most mid-career to late-career physicians are not afforded that luxury due to job demands. From an educational perspective, when mid-career to late-career physicians pursue training in QIPS, their goal is to train-up quickly for a new or existing job that requires this skill set. In contrast, the physicians in this study were mostly early career and still exploring their interests and career paths within QIPS broadly. These differences suggest that physicians who are seeking QIPS training early in their career may benefit from different educational programming and experiences when compared with more experienced physicians.
Our study has several limitations. We studied the graduates of two QIPS physician fellowship programmes embedded within academic medical centres. The majority of trainees in these programmes completed residency and/or clinical fellowship at the same institution, enrolling during or immediately following their clinical training. The demographics, career outcomes and perspectives of physicians and other healthcare professionals who complete masters or certificate programmes in QIPS later in their career or while working full-time may be different and therefore should not be extrapolated. Because participants were asked to self-identify mentors who could speak to the value of their work, it is possible that this prompted interviewees to name mentors who already held specific, positive views about their work and the fellowship programme. We asked and reported on graduates’ self-perceptions of whether or not the impact of their work was ongoing; this has inherent bias. While we informed graduates and mentors that their transcripts would not be available to the programme directors and that all of the interviews would be deidentified, it is possible that response bias still occurred.
For institutions seeking to develop or build similar programmes, our experience and research has resulted in several lessons learnt. Selection of and collaboration with mentors is critical to ensure an immersive project experience that hones QI and leadership skills. Mentors should be well positioned to sponsor fellow work in a way that it can become part of the fabric of the institution. Explicit conversations with fellows throughout the programme are essential to help them develop and describe their QI work in a way that supports eventual dissemination and publication. Finally, creating and sustaining a community of alumni from these programmes can allow prior graduates to enrich the experience of current fellows. Future directions for both of our programmes will include additional training in healthcare finance and strategy as many of our graduates pursued careers that included a QIPS administrative role. Similarly, incorporation of more opportunities for interprofessional training and leadership will be pursued.
In summary, graduates from two QIPS fellowship programmes and their mentors perceive programmatic benefits related to the attainment of their career goals and institutional impact. The results and conceptual framework presented here may be useful to other academic medical centres seeking to develop fellowships for postgraduate physician training programmes in QIPS.
The authors thank the Laffey-McHugh Foundation and CRICO, the Controlled Risk Insurance Company, for grant support of the CHIPS Fellowship and the HMS Fellowship, respectively. In addition, we thank all of our graduates, supporters, and steering committee members, especially: Patrick J. Brennan, MD, Ron Keren MD MPH, Michael Parmacek MD, Joseph St. Geme MD, Richard Shannon MD, Joshua P Metlay MD PhD, Judith Long MD, Rachel Werner MD PhD, Judy Shea PhD, Susan Abookire MD, Tejal Gandhi MD MPH, Joseph Jacobson MD, Allen Kachalia MD JD, Carole Keohane RN MHP, Elizabeth Mort, MD MPH, Marc Pimental MD, Lauge Sokol-Hessner MD, Saul Weingart MD PhD and Ms. Grace Bommarito.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval Institutional review boards of Beth Israel Deaconess Medical Center and the University of Pennsylvania.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
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