减少病人手术待术时间（）课件.ppt

1、1台州医院台州医院 梁军波梁军波2Define业务案例业务案例 提高病人满意度提高病人满意度 增加医院收入增加医院收入项目组织项目组织倡导者：倡导者：陈院长陈院长项目组长：项目组长：梁军波梁军波项目成员：项目成员：郎云琴郎云琴 洪碧君洪碧君 林学正林学正 吴海令吴海令MBB：曹洁曹洁项目范围项目范围 骨科骨科 疑难病症除外疑难病症除外项目陈述项目陈述 2002年，年，病人的术前等候时间很长，很多要病人的术前等候时间很长，很多要 等等 100小时以上，造成病人的平均住院日增加小时以上，造成病人的平均住院日增加 费用增加，满意度下降费用增加，满意度下降 此项目将把病人平均术前等候时间降到此项目将把

2、病人平均术前等候时间降到72小时小时项目时间表项目时间表定义定义 测量测量 控制控制 分析分析 改善改善2002/3 2002/6 2002/8 2002/11 2003/1团队章程团队章程台台 州州 医医 院院3Define流流 程程 图图Y1Y2Y3从流程图看时间段从流程图看时间段 台台 州州 医医 院院病人入院病人入院术前准备术前准备承诺手术承诺手术准备好？准备好？安排手术？安排手术？手术手术否否是是是是否否病人入院病人入院术前准备术前准备承诺手术承诺手术手术手术4Measure数据采集规则：数据采集规则：随机随机客观记录客观记录同一各石英钟同一各石英钟最初由最初由GEBB协助协助护士长

3、每天检查数据真实性护士长每天检查数据真实性次数据表与病历检查单一同使用次数据表与病历检查单一同使用数据的真实性是项目成功的基石数据的真实性是项目成功的基石 数据采集计划数据采集计划病案号:病案号:姓名：姓名：Y待术时间Y待术时间麻醉开始时间_月_日 ,_:_Y1术前准备及时性1术前准备及时性Y2承诺手术及时性承诺手术及时性Y3手术安排及时性手术安排及时性辅检完成时间辅检完成时间_月_日,_:_承诺手术时间承诺手术时间_月_日_:_开始手术室时开始手术室时间间_月_日_:所需时间：所需时间：_ 所需时间：所需时间：_所需时间：所需时间：_X5医生是否够X5医生是否够X6手术台是否够X6手术台是否

4、够X7是否有急诊插入X7是否有急诊插入X8是否非手术日X8是否非手术日 1-是 0-否 1-是 0-否 1-是 0-否 1-是 0-否主管医生_责任护士_关于“术前待术日”课题数据采集表入院日期：-月-日 -:-入院日期：-月-日 -:-Y=麻醉师签名_台台 州州 医医 院院5515253550150250O bservationYN um ber of runs about m edian:E xpected num ber of runs:Longest run about m edian:Approx P-Value for C lustering:Approx P-Value for

5、M ixtures:N um ber of runs up or down:E xpected num ber of runs:Longest run up or down:Approx P-Value for T rends:Approx P-Value for O scillation:15.000019.4865 8.0000 0.0672 0.932824.000024.3333 5.0000 0.4470 0.5530R un C hart for YAnalyze4个个p 0.05,数据为随机数据数据为随机数据平均待术时间平均待术时间99.6小时小时,标准偏差标准偏差37分钟分钟,

6、非正态数据非正态数据 台台 州州 医医 院院408012016020024095%C onfidence Interv al for M u859510511595%C onfidence Interv al for M edianV ariable:YA-Squared:P-Value:M eanStD evVarianceSkew nessKurtosisNM inim um1st Q uartileM edian3rd Q uartileM axim um 87.141 30.276 90.6010.9490.01599.554137.23051386.111.531035.190073

7、7 41.000 73.750 99.500117.000243.000111.967 48.361113.744Anderson-D arling N orm ality T est95%C onfidence Interv al for M u95%C onfidence Interv al for Sigm a95%C onfidence Interv al for M edianD escriptive S tatistics非正态非正态随机数据随机数据运行图运行图总等待时间总等待时间6去除无法确诊的病症后的等待时间去除无法确诊的病症后的等待时间Analyze台台 州州 医医 院院40

8、608010012014016095%Confidence Interv al for Mu9010011095%Confidence Interv al for MedianVariable:C11A-Squared:P-Value:MeanStDevVarianceSkewnessKurtosisNMinimum1st QuartileMedian3rd QuartileMaximum 85.872 23.247 89.9710.4140.31995.569428.6614821.4740.1091140.25813936 41.000 73.125 97.500116.000170.50

9、0105.267 37.387108.985Anderson-Darling Normality Test95%Confidence Interv al for Mu95%Confidence Interv al for Sigma95%Confidence Interv al for MedianDescriptive Statistics正态正态Y1Y2Y3-50050100 1 51020304050607080909599DataPercentN orm al Probability Plot for Y1.Y3从分布看，从分布看，Y1、Y3非正态，非正态，Y2正态，正态，Y1所用时间

10、较长，所用时间较长，Y2的偏差很大，的偏差很大，Y3有明显双峰有明显双峰各子时间的正态测试各子时间的正态测试7AnalyzeActual(LT)Potential(ST)0100200Process PerformanceUSLActual(LT)Potential(ST)110100100010,000100,0001,000,000010203040Actual(LT)Potential(ST)PPMSigma(Z.Bench)Process Benchmarks-0.82797410-0.83794559Process DemographicsDate:Reported by:Proje

11、ct:Department:Process:Characteristic:Units:Upper Spec:Lower Spec:Nominal:Opportunity:72Report 1:Executive Summary现在现在 Z值值=0，急需提高！，急需提高！台台 州州 医医 院院流程报告流程报告8Analyze术前待术前待术时间术时间环境环境人人方法方法材料材料机器机器医生医生护士护士病人病人家属家属病人病人经济经济诊断诊断通知机制通知机制检查方法检查方法时间限定时间限定手术准备手术准备麻醉机麻醉机检查准备检查准备电梯电梯时间段时间段手术台手术台手术器械手术器械鱼骨图鱼骨图台台 州

12、州 医医 院院9010020030040095%Confidence Intervals for Sigmas1050100150YF-TestTest Statistic:21.482P-Value :0.339Levenes TestTest Statistic:2.078P-Value :0.159Factor Levels01Homogeneity of Variance Test for YAnalyze05010095%Confidence Intervals for Sigmas1050100150YF-TestTest Statistic:5.164P-Value :0.350

13、Levenes TestTest Statistic:1.715P-Value :0.199Factor Levels01Homogeneity of Variance Test for Y01020304050607095%Confidence Intervals for Sigmas1050100150YF-TestTest Statistic:773.173P-Value :0.057Levenes TestTest Statistic:3.029P-Value :0.091Factor Levels01Homogeneity of Variance Test for Y10203040

14、5095%Confidence Intervals for Sigmas1050100150YF-TestTest Statistic:2.222P-Value :0.323Levenes TestTest Statistic:2.587P-Value :0.117Factor Levels01Homogeneity of Variance Test for Y从偏差看，从偏差看，4个个X对总体时间都没有影响对总体时间都没有影响 台台 州州 医医 院院F检验检验1001020304050607095%Confidence Intervals for Sigmas1020304050607080

15、90100Y1F-TestTest Statistic:187.102P-Value :0.116Levenes TestTest Statistic:1.443P-Value :0.238Factor Levels01Homogeneity of Variance Test for Y10102030405060708095%Confidence Intervals for Sigmas102030405060708090100Y1F-TestTest Statistic:2.810P-Value :0.593Levenes TestTest Statistic:0.484P-Value :

16、0.491Factor Levels01Homogeneity of Variance Test for Y110203095%Confidence Intervals for Sigmas102030405060708090100Y1F-TestTest Statistic:1.337P-Value :0.768Levenes TestTest Statistic:0.034P-Value :0.855Factor Levels01Homogeneity of Variance Test for Y1Analyze从偏差看，从偏差看，X对对Y1都没有影响都没有影响 台台 州州 医医 院院F检

17、验检验11010020030040095%Confidence Intervals for Sigmas10050100Y2F-TestTest Statistic:23.285P-Value :0.326Levenes TestTest Statistic:2.005P-Value :0.166Factor Levels01Homogeneity of Variance Test for Y2010020095%Confidence Intervals for Sigmas10050100Y2F-TestTest Statistic:1.917P-Value :0.803Levenes Te

18、stTest Statistic:0.789P-Value :0.381Factor Levels01Homogeneity of Variance Test for Y201020304095%Confidence Intervals for Sigmas10050100Y2F-TestTest Statistic:7279.239P-Value :0.019Levenes TestTest Statistic:3.902P-Value :0.056Factor Levels01Homogeneity of Variance Test for Y215253545556595%Confide

19、nce Intervals for Sigmas10050100Y2F-TestTest Statistic:1.501P-Value :0.645Levenes TestTest Statistic:0.321P-Value :0.575Factor Levels01Homogeneity of Variance Test for Y2Analyze从偏差看，是否有急诊插入对从偏差看，是否有急诊插入对Y2有影响有影响 台台 州州 医医 院院F检验检验120102030405095%Confidence Intervals for Sigmas102025303540455055Y3F-Tes

20、tTest Statistic:188.637P-Value :0.115Levenes TestTest Statistic:0.727P-Value :0.400Factor Levels01Homogeneity of Variance Test for Y305101595%Confidence Intervals for Sigmas102025303540455055Y3F-TestTest Statistic:1564.653P-Value :0.001Levenes TestTest Statistic:1.450P-Value :0.237Factor Levels01Hom

21、ogeneity of Variance Test for Y30102030405095%Confidence Intervals for Sigmas102025303540455055Y3F-TestTest Statistic:253.398P-Value :0.099Levenes TestTest Statistic:0.867P-Value :0.358Factor Levels01Homogeneity of Variance Test for Y312395%Confidence Intervals for Sigmas102025303540455055Y3F-TestTe

22、st Statistic:3.299P-Value :0.140Levenes TestTest Statistic:4.836P-Value :0.035Factor Levels01Homogeneity of Variance Test for Y3Analyze从偏差看，手术台是否够对从偏差看，手术台是否够对Y3有影响有影响 台台 州州 医医 院院F检验检验13x4医 生 人 手x5手 术 台 数x6是 否 有 急 诊x7是 否 非 手 术0101010195100105110115YMain Effects Plot-Data Means for YAnalyzeGeneral Li

23、near ModelAnalysis of Variance for Y1,use Adjusted SS for TestsSource DF Seq SS Adj SS Adj MS F Px4医生人 1 233.5 460.3 460.3 2.18 0.150X5手术台 1 35.8 105.1 105.1 0.50 0.486x6是否有 1 70.2 53.6 53.6 0.25 0.618x7是否非 1 288.2 288.2 288.2 1.36 0.252Error 31 6553.0 6553.0 211.4Total 35 7180.7 台台 州州 医医 院院General

24、Linear ModelAnalysis of Variance for Y2,use Adjusted SS for TestsSource DF Seq SS Adj SS Adj MS F Px4医生人 1 2244.4 1939.9 1939.9 2.38 0.132X5手术台 1 1633.2 1722.7 1722.7 2.12 0.155x7是否非 1 122.6 122.6 122.6 0.15 0.700Error 32 26039.4 26039.4 813.7Total 35 30039.6 General Linear ModelAnalysis of Variance

25、 for Y3,using Adjusted SS for TestsSource DF Seq SS Adj SS Adj MS F Px4医生人 1 1070.7 2.8 2.8 0.68 0.416X6是否有 1 0.2 37.4 37.4 9.07 0.005x7是否非 1 2980.9 2980.9 2980.9 722.96 0.000Error 32 131.9 131.9 4.1Total 35 4183.7 对总的时间来说，对总的时间来说，手术台是否够及是否非手术日手术台是否够及是否非手术日 有一定作用有一定作用对对Y3来说来说,除手术台数除手术台数,是否有急诊插入是否有急诊

26、插入,及是否非手术日也有影响及是否非手术日也有影响 主因影响图主因影响图/F检验检验14Analyze是否非手术日的影响力度达是否非手术日的影响力度达71%，其它可忽略不计，其它可忽略不计 台台 州州 医医 院院 对于时间最长的对于时间最长的Y1-对一些简单的病人，可在门诊进行常对一些简单的病人，可在门诊进行常 规化验，无禁忌症的，直接入院手术规化验，无禁忌症的，直接入院手术-每天下午每天下午3点以前入院的病人，当天行点以前入院的病人，当天行 X线、线、ECG检查检查-将化验检查结果放到网上全员分享将化验检查结果放到网上全员分享 对于偏差较大的对于偏差较大的Y2-将择期病人的术前待术时间将择期

27、病人的术前待术时间72小时小时 计入每组工作指标计入每组工作指标 手术台不够手术台不够-开放手术室手术时间开放手术室手术时间是否非手术日是否非手术日(2981,71.3%)医生人手医生人手(1071,25.6%)其它其它(132,3.2%)改进措施改进措施原因分布的饼图原因分布的饼图15Control1020304032425262728292O bservationYnewN um ber of runs about m edian:E xpected num ber of runs:Longest run about m edian:Approx P-Value for C lusteri

28、ng:Approx P-Value for M ixtures:N um ber of runs up or down:E xpected num ber of runs:Longest run up or down:Approx P-Value for T rends:Approx P-Value for O scillation:25.000021.0000 3.0000 0.9000 0.100028.000026.3333 3.0000 0.7388 0.2612R un C hart for Ynew台台 州州 医医 院院Av erage:56.575StD ev:15.2973N:

29、40Anderson-D arling N orm ality T estA-Squared:0.859P-Value:0.02532425262728292.001.01.05.20.50.80.95.99.999ProbabilityYnewN orm al Probability Plotp0.05,随机数据随机数据运行图运行图改进后总等待时间正态测试改进后总等待时间正态测试16C haracteristic1T otalD efs66U nits40O pps1T otO pps4040D P U0.150D P O0.1500000.150000P P M150000150000ZS

30、 hift1.5001.500ZB ench2.5362.536R eport 7:P roduct P erform anceControlZ值从值从0上升到上升到2.536，有所改进，有所改进,并具有统计上的差别并具有统计上的差别!台台 州州 医医 院院1 02 03 04 09 5%C o n fid e n ce In te rv a ls fo r S ig m a s215 01 0 01 5 0C 2 2F-TestTest S tatistic:3.510P-V alue :0.000Levenes TestTest S tatistic:9.075P-V alue :0.00

31、4F a cto r L e v e ls12H o m o ge ne ity o f V a ria nce T e st fo r C 2 2产品报告产品报告F检验检验17Control收益计算收益计算病人：病人：每个病人节省每个病人节省2天住院天住院400元，元，400 X2400个病人个病人/年年.骨科骨科=96万万我的医疗组我的医疗组：（提前（提前2天新收病人收费天新收病人收费 1200元元 老病人提前出院的损失老病人提前出院的损失400元）元）X500个病人个病人/年年=40万万每年增收每年增收=40万万*21%=8.4万万骨科骨科：（提前（提前2天新收病人收费天新收病人收费 1

32、200元元 老病人提前出院的损失老病人提前出院的损失400元）元）X2400病人病人/年年192万万每年增收每年增收=216万万*21%=40.3万万台台 州州 医医 院院推广应用至全院的潜在效益推广应用至全院的潜在效益:每年增收每年增收=30000*800*21%=504万万18aE)rUdH0uXhK4x!kO7A&nRaE)rUeH1uXhK4x!kO7B&oRaE)rUeH1uYhL4x!kO7B&oRbE-rUeH1uYhL4y!lO8B&oRbE-rVeI1vYhL4y!lO8B*oSbE-rVeI1vYiL5y!lO8B*oSbF-sVeI1vYiL5y$lP8B*oSbF-sV

33、fI2vYiL5y$lP8C*pSbF-sVfI2vZfI2vZiM5z$mP8C*pScF+sWfJ2vZiM5z$mP9C(pScF+sWfJ2wZjM5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jM6z%mQ9D(qTdG+tWgJ3w#jN6A%nQ9D(qTdG0tXgK3w#jN6A%nQaD)qTdG0tXgK3x#kN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kN7A&nRaE)rUeH0uXhK4x!kO7B

34、&oRaE)rUeH1uYhL4x!kO7B&oRbE-rUeH1uYhL4y!lO7B&oRbE-rVeI1uYhL4y!lO8B*oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVfI1vYiL5y$lP8C*oSbF-sVfI2vZiM5y$lP8C*pScF+sVfI2vZiM5z$mP8C*pScF+sWfJ2vZiM5z$mP9C(pScF+sWfJ2wZjM5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jN6z%mQ9D(qTdG0tWgJ3w#j

35、N6A%nQ9D(qTdG0tXgK3w#jN6A%nQaD)qTdG0tXgK3x#kN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kN7A&nRaE)rUeH1uXhK4x!kO7B&oRaE)rUeH1uYhL4x!kO7B&oRbE-rUeH1uYhL4y!lO7B&oRbE-rVeI1uYhL4y!lO8B*oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVfI2vYiL5y$lP8C*pSbF-sVfI2vZiM5y$lP8C*pScF+sVfI2

36、vZiM5z$mP8C*pScF+sWfJ2vZiM5z$mP9C(pScF+sWfJ2wZjM5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(qTcG+tWgJ3w#jN6z%mQ9D(qTdG0tWgJ3w#jN6A%nQ9D(qTdG0tXgK3w#jN6A%nQaD)qTdG0tXgK3x#kN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)rUdH0uXhK4x!kO7A&nRaE)rUeH1uXhK4x!kO7B&oRaE)rUeH1uYhL4x!kO7B&oRbE-rU

37、eH1uYhL4y!lO7B&oRbE-rVeI1uYhL4y!lO8B*oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lP8B*oSbF-sVfI2vYiL5y$lP8C*pSbF-sVfI2vZiM5y$lP8C*pScF+sVfI2vZiM5z$mP8C*pScF+sWfJ2sWfJ2wZiM5z$mP9C(pTcF+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jM6z%mQ9D(qTdG+tWgJ3w#jN6A%mQ9D(qTdG0tXgJ3w#jN6A%nQaD(qTdG0tXgK3x#jN6A

38、%nQaD)qUdG0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kN7A&nRaE)rUeH0uXhK4x!kO7B&nRaE)rUeH1uYhK4x!kO7B&oRbE)rUeH1uYhL4y!kO7B&oRbE-rVeH1uYhL4y!lO8B&oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVfI1vYiL5y$lP8C*oSbF-sVfI2vZiL5y$lP8C*pScF-sVfI2vZiM5z$lP8C*pScF+sWfI2vZiM5z$mP9C*pScF+sWfJ2wZj

39、M5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jM6z%mQ9D(qTdG+tWgJ3w#jN6A%mQ9D(qTdG0tXgJ3w#jN6A%nQaD(qTdG0tXgK3x#jN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kN7A&nRaE)rUeH0uXhK4uXhK4x!kO7B&oRaE)rUeH1uYhL4x!kO7B&oRbE-rVeH1uYhL4y!lO8B&oRbE-rVeI1vYhL4y!lO8B*oSbE-

40、rVeI1vYiL5y!lO8B*oSbF-sVeI1vYiL5y$lP8B*oSbF-sVfI2vYiL5y$lP8C*pSbF-sVfI2vZiM5y$lP8C*pScF+sWfI2vZiM5z$mP9C*pScF+sWfJ2wZiM5z$mP9C(pTcF+sWfJ2wZjM6z$mP9C(pTcG+tWfJ2wZjM6z%mQ9C(pTcG+tWgJ3wZjM6z%mQ9D(qTcG+tWgJ3w#jN6z%mQ9D(qTdG0tWgJ3w#jN6A%nQaD(qTdG0tXgK3x#jN6A%nQaD)qUdG0tXgK3x#kN7A%nQaD)qUdH0uXgK3x#kN7A&nR

41、aD)qUdH0uXhK4x#kN7A&nRaE)rUdH0uXhK4x!kO7A&nRaE)rUeH1uXhK4x!kO7B&oRbE)rUeH1uYhL4y!kO7B&oRbE-rVeH1uYhL4y!lO8B&oRbE-rVeI1vYhL4y!lO8B*oSbE-rVeI1vYiL5y!lO8B*oSbF-sVeI1vYiL5y$lP8B*oSbF-sVfI2vYiL5y$lP8C*pSbF-sVfI2vZiM5z$lP8C*pScF+sWfI2vZiM5z$mP9C*pScF+sWfJ2wZiM5z$mP9C(pTcF+sWfJ2wZjM6z$mP9C(pTcG+tWfJ2wZjM6z

42、%mQ9C(pTcG+tWgJ3wZjM6z%mQ9D(qTcG+tWgJ3w#jN6A%jN6A%nQ9D(qTdG0tXgK3w#jN6A%nQaD)qTdG0tXgK3x#kN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kO7A&nRaE)rUeH1uXhK4x!kO7B&oRaE)rUeH1uYhL4x!kO7B&oRbE-rUeH1uYhL4y!lO7B&oRbE-rVeI1uYhL4y!lO8B*oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVf

43、I2vYiL5y$lP8C*pSbF-sVfI2vZiM5y$lP8C*pScF+sVfI2vZiM5z$mP8C*pScF+sWfJ2vZiM5z$mP9C(pScF+sWfJ2wZjM5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ3wZjM6z%mQ9D(qTcG+tWgJ3w#jN6z%mQ9D(qTdG0tWgJ3w#jN6A%nQ9D(qTdG0tXgK3w#jN6A%nQaD)qTdG0tXgK3x#kN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)rUdH0uXhK4x!kO7A&nRaE)

44、rUeH1uXhK4x!kO7B&oRaE)rUeH1uYhL4x!kO7B&oRbE&oRbE-rVeH1uYhL4y!lO8B&oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVfI1vYiL5y$lP8C*oSbF-sVfI2vZiL5y$lP8C*pScF-sVfI2vZiM5z$lP8C*pScF+sWfI2vZiM5z$mP9C*pScF+sWfJ2wZiM5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jM6z%mQ9D(qTdG+tWgJ3w#jN

45、6A%mQ9D(qTdG0tXgJ3w#jN6A%nQaD(qTdG0tXgK3x#jN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kN7A&nRaE)rUeH0uXhK4x!kO7B&nRaE)rUeH1uYhK4x!kO7B&oRbE)rUeH1uYhL4y!kO7B&oRbE-rVeH1uYhL4y!lO8B*oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVfI1vYiL5y$lP5y$lP8C*pSbF-sVfI2vZiM5y$lP8C*pScF+s

46、VfI2vZiM5z$mP9C*pScF+sWfJ2wZiM5z$mP9C(pTcF+sWfJ2wZjM6z$mP9C(pTcG+tWfJ2wZjM6z%mQ9C(pTcG+tWgJ3wZjM6z%mQ9D(qTcG+tWgJ3w#jN6z%mQ9D(qTdG0tWgJ3w#jN6A%nQaD(qTdG0tXgK3x#jN6A%nQaD)qUdG0tXgK3x#kN7A%nQaD)qUdH0uXgK3x#kN7A&nRaD)qUdH0uXhK4x#kN7A&nRaE)rUdH0uXhK4x!kO7A&nRaE)rUeH1uXhK4x!kO7B&oRaE)rUeH1uYhL4y!kO7B&oRb

47、E-rVeH1uYhL4y!lO8B&oRbE-rVeI1vYhL4y!lO8B*oSbE-rVeI1vYiL5y!lO8B*oSbF-sVeI1vYiL5y$lP8B*oSbF-sVfI2vYiL5y$lP8C*pSbF-pScF+sVfI2vZiM5z$mP8C*pScF+sWfJ2vZiM5z$mP9C(pScF+sWfJ2wZjM5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jN6z%mQ9D(qTdG0tWgJ3w#jN6A%nQ9D(qTdG0tXgK3w#jN6A%nQaD)qTdG0tXgK3x#

48、kN6A%nQaD)qUdH0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kN7A&nRaE)rUeH1uXhK4x!kO7B&oRaE)rUeH1uYhL4x!kO7B&oRbE-rUeH1uYhL4y!lO7B&oRbE-rVeI1uYhL4y!lO8B*oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVfI2vYiL5y$lL5y$lP8C*pScF-sVfI2vZiM5z$lP8C*pScF+sWfI2vZiM5z$mP9C*pScF+sWfJ2wZiM5z$mP9C(pTcF

49、+sWfJ2wZjM6z$mP9C(pTcG+tWgJ2wZjM6z%mQ9D(p19+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jM6z%mQ9D(qTdG+tWgJ3w#jN6A%mQ9D(qTdG0tXgJ3w#jN6A%nQaD(qTdG0tXgK3x#jN6A%nQaD)qUdG0tXgK3x#kN7A&nQaD)qUdH0uXhK3x#kN7A&nRaE)qUdH0uXhK4x!kN7A&nRaE)rUeH0uXhK4x!kO7B&nRaE)rUeH1uYhK4x!kO7B&oRbE)rUeH1uYhL4y!kO7B&oR

50、bE-rVeH1uYhL4y!lO8B*oRbE-rVeI1vYiL4y!lO8B*oSbF-rVeI1vYiL5y$lO8B*oSbF-sVfI1vYiL5y$lP8C*oSbF-sVfI2vZiL5y$lP8C*pScF-sVfI2vZiM5z$lP8C*pScF+sWfI2vZiM5z$mP9C*pScF+sWfJ2wZjM5z$mP9C(pTcG+sWfJ2wZjM6z%mP9C(pTcG+tWgJ2wZjM6z%mQ9D(pTcG+tWgJ3w#jM6z%mQ9D(qTdG+tWgJ3w#jN6A%mQ9D(qTdG0tXgJ3w#jN6A%nQaD(qTdG0tXgK3x#kN6A