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But achieving shifts in healthcare is more complex than in any other industry. One of these reasons is that despite private healthcare funding much of the care, US healthcare organizations such as hospitals and clinics are considered part of the public sector. Within the total number of healthcare organizations in the US , over half are non-profit, and profit organizations run about one quarter.
As a result, healthcare change management models must resolve more complex issues. Given this complex matrix of factors, achieving change in healthcare can feel like a daunting, almost impossible task. However, our guide to change management theories in healthcare will equip you with a clear vision and the tools needed to achieve change with the support of all your staff to benefit patient care and customer satisfaction. The reasons for transformation in healthcare are vast, and the scope is broader than in conventional office environments.
The two main reasons for any change in healthcare are research and technology. Technology is needed not just to stay competitive with other healthcare organizations but to save lives most effectively and to diagnose illnesses as early as possible. Just as in any other industry, technology is constantly evolving. The difference in healthcare is that equipment involves higher-cost one-off expenses, and investing in research is a higher-cost ongoing process than research in other fields.
A financial company may commission software developers to make a customer banking app and update it monthly. However, healthcare research requires more significant investment over a more extended period as new information is being harvested by researchers, requiring specialized staff.
New care practices are the research outcomes and must be implemented by change leaders immediately, mainly where cultural shifts brought on by Covid are concerned. But these practices are constantly changing as research discovers new findings.
The relentlessly dynamic impact of research on care makes it challenging for healthcare staff to keep up, creating negative feelings toward change and increasing the need for change management models. Employees in healthcare are a unique group.
Unlike other industries, healthcare practice enflames staff opinions and values, leading to value-based care practice. This dynamic is very different from rules in other industries because, in healthcare, people look after vulnerable people who depend on them. When it comes to vulnerable people, there are a lot of very fixed opinions on specific care practices, cultural attitudes, and differing standards. This reason is why the change process is challenging due to limiting beliefs.
Individual change leads to organizational change. Within a different healthcare organization, there are smaller sub-cultures in departments and wards within an overarching organizational culture. Change managers need to identify the different cultures in other areas and be aware of why staff resists change to facilitate change effectively. Such issues often stem from group dynamics, resulting in negative feelings about change.
These common issues must be known by change leaders and identified in specific individuals and groups to help staff understand and support the change. The change leader can tackle this issue by engaging in shared decision-making as a part of successful change processes to overcome resistance and sustain change. The ever-pressing progress of technology is unavoidable in any industry, especially the healthcare industry.
One example is that hospitals and clinics have adopted electronic medical records EMR in the United States. Moving to digital medical records has required many healthcare organizations to rework their entire medical records systems, but it also equips them for the future, increasing productivity and efficiency. Technology adoption and change management in healthcare are fraught with similar challenges to technology adoption in any other industry.
But in many ways, healthcare staff face more complex challenges to successful digital adoption than other industries. Healthcare staff needs to understand the drawbacks as well as the benefits of any technology adoption. Suppose the team is given training before and during technology adoption. In that case, staff can help reduce losses, and when staff feels more confident with technology, they will be more open to embracing future technology adoption.
Staff is often motivated by opportunities or threats. One way to reduce resistance is to promote the opportunities of technology rather than its potential threats. In healthcare settings, there are several ways to communicate these benefits.
EMRs are more easily shared, and patient history is more straightforward for clerical and medical staff to move from one healthcare setting to the next. Additionally, convenience and efficiency are improved, leading to improved quality of care. Although managing change is more complex and challenging in health care than in other industries, the process is made more accessible and effective by choosing the most suitable change management methods.
In healthcare, leading change successfully is frequently achieved via change management methods, including According to research in conducted by Harrison et al. The other two models have been included for balance against more soft, person-centered approaches, as this is a large part of healthcare practice. Part of their value to healthcare is that some of these included models, such as the ADKAR model, focus less on tasks and do not make staff implement changes before they can understand them.
The ADKAR model focuses more on human psychology, helping staff to understand the need for change to support healthcare change management, making it more suitable and effective in healthcare organizations.
It helps manage change within short-term, intensive change initiatives due to the aggressive top-down approach to achieving change through three stages. The preparation stage. Look at how things operate to see the resources needed for the desired results. Communication is essential in this phase, as healthcare staff must be aware of what changes need to happen to prepare them for the subsequent steps. The implementation stage. Project leaders set changes into motion, and communication is again of very high significance as change is a complex process to handle for team members.
Support must be available via communication channels at this critical phase. Implement required skills of staff needed for change to take place.
The refreeze stage is part of an ongoing process to achieve success. This stage involves developing a strategy to ensure change sticks. Analyze the effect of the new changes and measure how close you are to achieving goals set at the unfreeze phase. Healthcare managers and change leadership should use this theory alongside a softer model for longer-term change management strategies.
Leaders must bear in mind that without a softer model monitoring employee experience to some level alongside the Lewin Model, adverse effects on employee retention and performance may occur due to burnout. This model supports change leaders with implementing change initiatives in healthcare organizations as it is task-oriented, and healthcare organizations are often driven by completing tasks to a schedule.
The model includes eight steps:. Motivate the team by creating an environment filled with a sense of urgency. Build a guiding coalition, including all the right staff to plan, coordinate and carry out the change. Establish a clear vision and each accompanying change initiative. Break goals into bite-size chunks and communicate successes little and often. Maintain momentum, and push harder after every successful implementation. The sense of urgency for short-term wins could lead to high rates of staff burnout.
Something healthcare staff are already at risk of before the change leader implements a change plan. Over a few months, short-period change management strategies in health care work well with this model. One example could be a move to paperless patient onboarding in an ER unit, which is a high-pressure, task-oriented environment.
Although burnout due to this change could potentially be high, staff may be more pragmatic and see improvements quickly, reducing staff stress and increasing patient care quality over the time taken to implement the change. Paperless onboarding would primarily involve getting used to new technology and simple employee training , and the sense of urgency, the first step of the model, is innate in ER staff due to the nature of the work.
ADKAR Awareness, Desire, Knowledge, Ability, Reinforcement analysis is vastly different from the first two models as it focuses on understanding the emotions and thoughts of the people affected by the change.
In healthcare, many stakeholders are affected by changes with different ways of gaining or losing. There are five steps to achieving an ADKAR analysis; the first is creating awareness for healthcare staff. Show healthcare staff what changes are necessary and why.
Detail is needed when explaining changes, and change leaders should define training schedules. Face-to-face announcements and training are preferred so staff can ask questions to enable them to participate early in the process.
Create a desire to be supportive of the change to create an environment in which employee engagement increases so much that attitudes toward change become positive organically. Ensure adequate support is available for employees. Training, coaching, and checklists provided by the business are some types of support. Ensure employees, relatives, and patients can give feedback about their change journey. Leaders of change, such as project leaders or healthcare managers, record and action this to provide the best opportunity for learning and development.
At this point, the change leader can make further adjustments to the plan based on the feedback. Use rewards and cash or holiday incentives to employees and other means such as championing staff who embody shared values.
Also, HR could implement an internal advertising campaign to remind everyone that the change leader adjusted the plan based on their feedback. These actions ensure the new status quo is maintained for ongoing performance improvement. Of all the change management tools in this list, the ADKAR model is the model most focused on human experience and supporting staff to engage with new ways of fulfilling their role naturally. For this reason, the ADKAR model can be effective for long-term change strategies within large or small teams.
It can be beneficial in healthcare environments due to the many stakeholders of different professions with competing goals. The ADKAR model is great for many healthcare contexts but particularly for departments caring for high vulnerability patients needing sensitive communication with patients and relatives, like an intensive care unit.
Change is an ongoing process in any organizations. Over years, healthcare organizations have been exposed to multiple external stimuli to change eg, ageing population, increasing incidence of chronic diseases, ongoing Sars-Cov-2 pandemic that pointed out the need to convert the current healthcare organizational model.
Nowadays, the topic is extremely relevant, rendering organizational change an urgency. The work is structured on a double level of analysis. In the beginning, the paper collects the overall literature on the topic of organisational change in order to identify, on the basis of the citation network, the main existing theoretical approaches.
Secondly, the analysis attempts to isolate the scientific production related to the healthcare context, by analysing the body of literature outside the identified citation network, divided by clusters of related studies.
This review adopted a quantitative-based method that employs jointly systematic literature review and bibliographic network analysis.
Specifically, the study applied a citation network analysis CNA and a co-occurrence keywords analysis. The CNA allowed detecting the most relevant papers published over time, identifying the research streams in literature.
The study showed four main findings. Fourth, interestingly, contributions have been limited within the healthcare context.
Human dimension is the primary criticality to be managed to impede failure of the re-organizational path. Individuals are not passive recipients of change: individual change acceptance has been found a key input. In this view, individual acceptance of change within the healthcare context resulted being undeveloped and offers rooms for further analyses. Healthcare organizations are in an ongoing state of change forcing to convert themselves incrementally or in radical ways.
Organizational change constitutes a complex phenomenon that develops in any sector. Accordingly, the paper is built upon two sequentially levels of analysis. First, the paper collects the overall scientific production concerning organizational change topic basis on the citations network. This allows for outlining main ongoing theoretical developments and detecting emerging research strands.
This preliminary step is critical to gaining an insight into the depth of scientific production in the healthcare context. Second, the work groups additional contributions extant in the literature but not included in the citation network.
The analysis is accomplished by selecting papers based on the occurrence of author keywords within the original set of retrieved papers.
Thereby, this stage of analysis draws further conclusions on the existing body of knowledge concerning to organizational change in the healthcare context.
The dynamic perspective, which the method provides, eases the detection even of literature gaps not considered to date in the existing body of research production, due to the heterogeneous contributions. Thereby, medical professionals can manage their patients without considering their peers throughout their activities.
Hence, professional bureaucracy has developed drawing upon a bottom-up decision-making arrangement. Consistent with Mintzberg , 40 managing such an organizational configuration implies facing three distinct managerial issues.
To this respect, what should be considered is the role of the professional community in healthcare organizations. At the beginning, related to the topic, the set of chosen keywords does not include specific terms. The query was performed as displayed below in Figure 1. SLNA method contains the analysis of bibliometric networks based on the paper retrieved, such as citations and keywords analysis, as one of its components Strozzi et al, Vos Viewer was adopted for the preliminary analysis, in terms of network visualization, for creating the input file for Pajek, and for implementing the analysis of the keywords.
CNA is a method based on citations, which are the links between papers nodes in a citation network. The isolated nodes cannot be involved in the analysis, and the citation analysis can be performed only when components are connected. The first step in performing network analysis is extracting the isolated nodes, uploaded in VOS Viewer software.
The bibliometric network showed only documents out of that received at least one citation, displayed in the Pajek tool. Firstly, the bibliometric network was adjusted by changing the direction of knowledge flow ie, inverting the direction of arrows from cited to citing papers, that is, from the oldest paper to the most recent one.
Secondarily, the analysis revealed that only out of documents were connected. CNA connected components in this network were 4. The first component included papers, whilst the remaining components were composed of 26, 10 and 4 papers, respectively.
Given the small size of the last identified components ie, 26, 10 and 4 compared with the first one ie, papers , only the component with nodes was analysed. Figure 2 shows the first biggest connected component. The quantification of the transversal weight of the citation was executed.
A cut-off value of 0. Figure 3 depicts the main path for the biggest connected component. To outline a framework as comprehensive as possible on the subject, only the use of citations to trace the coordinates can be limiting. Some papers are not included in the analysis because other ones did not cite them, despite their contents were significant or they may not be selected since they were published recently, therefore they did not still receive a sufficient number of citations.
This suggests that the CNA should be combined with other tools such as the Global Citation Score analysis and keyword analysis. In the following, the citation network analysis is designed to trace the active research streams on the topic of organizational change and to have a preliminary assessment of the extent to which these patterns are present even among the studies dealing with organizational change in the healthcare field. In this view, a first-order analysis based on the main path associated with the biggest connected component may be useful to detect general streams and gain an overall picture.
The main path sheds light on the articles that refer to prior papers, which act as hubs concerning later works. Global Citation Network Score Analysis is a tool to detect seminal or recent breakthrough studies 51 that were not selected in the citation network but received a significant amount of citations in the whole Scopus Database.
In that sense, these works are however relevant in the field. VOSviewer maps the position of items by applying a function to be minimized which depends on a similarity measure between items defined as follows:. The measures the co-occurrence of keywords and in the same document; and express the expected number of co-occurrences of and , on the hypothesis that the co-occurrences of and are statistically independent. Therefore, this stage contributes to a complete preliminary understanding of which literature strands are being developed on organizational change topic within the healthcare field.
A first research stream dwells on the factors enabling individuals to be prepared for specific change initiatives. Normative-reeducative change strategies and work environment steering towards learning culture demonstrate to be facilitators.
A second literature flow deepens personal beliefs that individuals develop about change initiatives. The third flow of literature proposes the adoption of a multi-level approach to organizational change and places emphasis on the change outcomes.
Merging the individual-focused micro perspective and the organizational-oriented macro perspective, with inflows from meso-level theory 68 may contribute to obtaining a comprehensive vision on organizational change. Change type and change method should be converging to attain the intended change outcome. Consistent with past studies, this step of literature review through CNA shows that works emphasized the need to give emphasis on individual perceptions towards change.
The research trajectory appeared to be unexplored in healthcare. Interestingly, a comprehensive framework involving micro-meso and macro perspective to evaluate change actions and the importance of change outcome was found to be emerging trends only in the general literature on organisational change.
The use of keyword analysis is intended to confirm or to extend this initial finding on existing research streams related to the topic of organisational change in healthcare.
The first cluster includes approaches to manage change organization within the production context, 91 by illustrating applications in terms of product development 85 and impact on supply chain management. The third cluster enlarges supportive and boosting tools of organizational change, containing IT applications such as a monitoring system for organizational development activities, 96 team-based simulations improving readiness for change in university setting, 73 and as a means for gaining business-IT alignment.
The fourth cluster encompasses the key role of participation for learning within change, even debating a mix of learning styles to sustain successfully organizational change initiative in the healthcare context.
The fifth cluster copes with the performance management issue, by soliciting a change in organizational values to enhance a successful performance management reform. This is consistent with the result debated in the citation network analysis. The cluster is mainly composed of 6 papers. The sixth cluster focuses on sustainability change initiatives in Higher Education Institutions. The cluster is mainly composed of 9 papers.
The relationship between innovation and change in the healthcare context should be explored. Both external and internal factors trigger the need for change in healthcare organizations. This is leading to a compulsory changing in the healthcare organizational framework. Likewise, the need to make health processes more efficient, for instance, forms another triggering factor, the inside one, for organizational change.
Therefore, the organizational change issue should be investigated by bearing in mind these multiple boosts to changing. This supports the need to investigate deeply the concept of change and innovation in a healthcare setting, by seeking to outline the boundaries of organizational change and innovation.
In particular, the analysis should start investigating the issue by emphasizing on the fact that micro-context should not be assumed simply as a backcloth to action. The resistance to organizational change initiative arises when professional logic comes into contrast with the management one. Thus, it becomes a priority to seek a new concept of leadership where the recipients of the change can themselves be those who manage the leaders with the possibility to hinder or sustain proactively their leadership.
As the work by Augl 76 pointed out in cluster number 5 of keyword analysis, the health system might be regarded as a set of social systems where organizations may be considered as communication systems. In this regard, the author suggested a new approach to change management by modifying the current communication paths to contextual collaboration.
The manufacturing context and the healthcare context. The former analyses the issue of organisational change also concerning supply chain management; the latter pays attention to the attitude of the clinician towards change initiatives linked to the introduction of new technology.
Of the remaining clusters, some of them relate the topic of change to the adoption of support systems IT applications — cluster 3 or support strategies formal and informal communication — cluster 2; participation — cluster 4 for the implementation of change; further clusters tackle the topic of change as a tool to improve performance management cluster 5 or combine it with sustainable change initiatives and the concept of innovation.
With the analysis carried out so far, a growing interest in the most recent literature on the individual-change relationship emerges ie, The subject is developed by scholars from different perspectives. The contributions discussed in this paper clearly define the need to deal with acceptance of change from the perspective of the individual. The extensive analysis reported on the topic allows contextualizing the organizational change initiatives in the healthcare world, where the individual-change relationship is central and can offer additional ideas on the profile of change recipients.
The research line takes a position on change recipients, by paying attention to the effects that organizational change causes on persons or, in other words, on the psychological aspects of the organizational change.
Change outcome and organizational performance in change initiative appear to be not adequately explored. The work see 58 illustrates only conceptual models. Studies aimed at identifying and testing empirically specific performance measures in the organizational change context appear to be missing.
A summary of the results is provided in the table number 4 Table 4. Cluster 8 provides some insights on the state of art in the healthcare research field. Beyond case studies, the topic becomes relevant only relative to the spreading of digital services in the care system. Other studies eg, 62 , retrieved in the previous step, describe a potential stream of organizational change issues in the healthcare context.
Notably, these works address change management only concerning the negative health impact for the individual, without paying attention to the individual behaviour change. Moreover, the papers available do not point out change management in the specific context of professionalized organizations.
Therefore, studies aimed at investigating the nature of change that characterizes the healthcare professionalized organizations are needed. In summary, the literature reviewed informed us that three potential streams were not yet fully explored.
Change management in the context of healthcare organizations, performance evaluations and innovation-organizational change relationship was the most evident gaps found out. Nevertheless, the present work debates individual-level perspective on the change as a prominent dimension to tackle in designing change initiatives, albeit individual and organizational issues related to change should not be viewed as detached. This stimulates to set aside a polarized perspective on organizational change.
The performed review traces a clear step in the production research on the subject. Especially in the healthcare context, the literature reviewed highlighted an evident imbalance of scientific production in favour of individual effects of changing.
Technology and organization appear to be a double face of the change, being strictly related, but there is not a common perspective in defining the role of enabler for those variables. In this respect, further research should address the above-mentioned issue in the organizational change context.
Likewise, a specific investigation on organizational change and the healthcare field is encouraged. Healthcare organizations ought to adopt change models fitting their specific needs of change. Overall literature stream traces a systemic perspective, whereby an individual, organizational and expected outcome of change should be milestones of any organizational change action.
New technologies are speeding up the demographic changeover and are increasing the economic burden for the NHS. The converging outcome lies on strengthen the equity, the value and the sustainability of healthcare. Exploratory studies may be useful.
Research on change management is gaining momentum and offering many stimuli. Therefore, the development of research lines to deepen the topic is important, especially in the healthcare field. Clinicoecon Outcomes Res. Published online May Author information Article notes Copyright and License information Disclaimer. Received Jan 9; Accepted Apr This work is published and licensed by Dove Medical Press Limited. By accessing the work you hereby accept the Terms.
Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4. Abstract Background Change is an ongoing process in any organizations. Methodology This review adopted a quantitative-based method that employs jointly systematic literature review and bibliographic network analysis.
Results The study showed four main findings. Conclusion Human dimension is the primary criticality to be managed to impede failure of the re-organizational path.
Keywords: change management, organizational change, literature review, Systematic Literature Network Analysis, healthcare. Introduction Healthcare organizations are in an ongoing state of change forcing to convert themselves incrementally or in radical ways.
RQ2: What is the state-of-the-art of change management in the healthcare field? Open in a separate window. Figure 1. Figure 2. Figure 3. Keywords Analysis Global Citation Network Score Analysis is a tool to detect seminal or recent breakthrough studies 51 that were not selected in the citation network but received a significant amount of citations in the whole Scopus Database.
Figure 4. Clusters from Keywords Analysis The first cluster includes approaches to manage change organization within the production context, 91 by illustrating applications in terms of product development 85 and impact on supply chain management.
The Importance of Individuals in Organizational Change With the analysis carried out so far, a growing interest in the most recent literature on the individual-change relationship emerges ie, Discussion The research line takes a position on change recipients, by paying attention to the effects that organizational change causes on persons or, in other words, on the psychological aspects of the organizational change. Conclusion The performed review traces a clear step in the production research on the subject.
Healthcare organizations receive multiple external and internal stimuli of change. Disclosure The authors report no conflicts of interest in this work. References 1. American Medical Association. AMA principles for physician employment. Accessed May7, Nord J Work Life Stud. Creating readiness for organizational change. Hum Relat. Berlin J, Kastberg G. Stockholm: Liber; The emergence of organizational change. The Routledge Companion to Organizational Change. Routledge; — Brizzi L, Cava F.
Roma: Carocci; Burnes B. Kurt Lewin and the planned approach to change: a re-appraisal. J Manag Stud. Collaborative networked organizations — concepts and practice in manufacturing enterprises. Comput Ind Eng. Comerio N, Strozzi F. Tourism and its economic impact: a literature review using bibliometric tools.
Tour Econ. Croce D, Mazzone A. Ital J Med. Exploratory Social Network Analysis with Pajek. Cambridge: Cambridge University Press; Future of medical engagement. Aust Health Rev. Are we nearly there yet? A study of the English National Health Service as professional bureaucracies.
J Health Organ Manag. Bibliometric cartography of information retrieval research by using co-word analysis. Inf Process Manag. Understanding change and innovation in healthcare settings: reconceptualizing the active role of context. J Chang Manag. Elston T, MacCarthaigh M. Sharing services, saving money?
While change theories can help provide best practices for change leadership and implementation, their use cannot guarantee success. The process of change is vulnerable to many internal and external influences.
Using change champions from all shifts, force field analyses, and regular supportive communication can help increase the chances of success . Knowing how each departmental staff member will likely respond to change based on the diffusion of innovation phases can also indicate the types of conversations leaders should have with staff to shift departmental processes.
You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Change Management Jennifer M. Affiliations 1 McNeese State University. Confirmation staff recognize the value and benefits of the change and continue to use changed processes. Issues of Concern All change initiatives, no matter how big or small, unfold in three major stages: pre-change, change, and post-change.
He further qualified those change acceptance categories with the following descriptions: Innovator: passionate about change and technology; frequently suggest new ideas for departmental change.
Early majority: Prefer the status quo; willing to follow early adopters when notified of upcoming changes. Late majority: Skeptical of change but will eventually accept the change once the majority has accepted; susceptible to increased departmental social pressure. Laggard: High levels of skepticism; openly resist change .
Clinical Significance Change is inevitable, yet slow to accomplish. Review Questions Access free multiple choice questions on this topic. Comment on this article. References 1. Leading change: a concept analysis. J Adv Nurs. Shirey MR. Lewin's Theory of Planned Change as a strategic resource.
J Nurs Adm. Mitchell G. Selecting the best theory to implement planned change. Nurs Manag Harrow. Using Diffusion of Innovations Theory to implement the confusion assessment method for the intensive care unit. J Nurs Care Qual. Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. Change Management. In: StatPearls [Internet].
In this Page. Bulk Download. Related information. PubMed Links to PubMed. Similar articles in PubMed. Ann Clin Lab Sci. The patient experience of patient-centered communication with nurses in the hospital setting: a qualitative systematic review protocol. Newell S, Jordan Z. Recent Activity. Standard use of health maintenance forms and morning huddle meetings were instituted. In addition, the chief executive officer said that after POE implementation, salary structure adjustments were made so that all staff positions were paid from the same wage scale.
These adjustments broke down the informal hierarchy that previously placed care coordinators in a lower position than clinical support staff members. This case study examined implementation of an intervention dedicated to closing preventive care gaps between recommended best practices and care actually delivered. Although our evaluation had strengths, it also had limitations.
Leadership and staff members did not use the model proactively during the POE implementation planning process, and we did not assess validity and reliability of the model before using it in our case study. However, we found a strong connection between steps 1 through 7 of the change model and the implementation steps taken by White House Clinics.
In addition, the findings of the case study might not be generalizable to other FQHCs or similar clinical settings. Despite these limitations, application of such organizational change frameworks could be particularly useful for clinical settings, such as FQHCs, that historically do not have the same resources as large health care organizations and that serve a substantial proportion of medically underserved patients.
Use of change-management approaches can help guide these organizations through strategic implementation and sustainability of an evidence-based intervention such as POE.
Thus, the change-management approach not only serves to improve clinical workflows of the organization but also serves to improve patient outcomes and subsequently population health. The authors thank Dr Aasha Hoogland, Ms Stephanie Moore, and the federally qualified health center staff members for their contributions to this project.
This article is a product of a Health Promotion and Disease Prevention Research Center supported by cooperative agreement no.
No copyrighted material, surveys, instruments, or tools were used in this article. Corresponding Author: Angela L. Email: angela. The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U. These cookies allow us to count visits and traffic sources so we can measure and improve the performance of our site. They help us to know which pages are the most and least popular and see how visitors move around the site. All information these cookies collect is aggregated and therefore anonymous.
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