Assignment 1: Executive Memo
You are the CEO of a Healthcare organization. The patient satisfaction data, as measured by
the Press-Ganey survey, shows most patients who have received care at your hospital would
not recommend the facility to friends and family, and the patients’ overall rating of the
organization is mediocre at best. Your top focus as CEO is to build a superior patient
Your Assignment:
Based on your reading of the Service Fanatics textbook, including the best practices shared in
the book, draft a 2-to-3-page Executive Memo, to be distributed to all staff and members of your
Be sure your memo includes the following:
1. Clear and concise outline of the strategy for improving the patient experience
2. Tactics to be used to drive the strategy
3. Description of how all staff can participate in putting “Patients First”
4. Call to Action, with a Statement about how success will be measured
Your assignment must follow these formatting requirements:
• Typed, double-spaced, using Times New Roman font (size 12) with one-inch margins on
all sides.
• In place of a Cover page, provide the following Headings on Page 1 of your memo:
· TO: Insert Professor’s Name
· FROM: Insert Your Name
· DATE: Insert Assignment’s Due Date
· RE: It’s All About the Patient, Assignment 1
Note: The Headings page is not included in the required assignment page length.

Praise for Service Fanatics
“Service Fanatics will become the gold standard on patient-
centered care. Cleveland Clinic in all its glory, like many of
the rest of us in healthcare, had lost its way with
compassion and empathy. Dr. James Merlino in his role as
the Clinic’s Chief Experience Officer, along with CEO Toby
Cosgrove and the rest of the healers at Cleveland Clinic,
changed that by putting Patients First. Merlino’s description
of this journey is at times painful, raw, and brutally honest.
Service Fanatics and its author exude passion, humility,
integrity, and caring. It will make any organization better
and is a must-read for everyone in healthcare.”
—David T. Feinberg, MD, president of
UCLA Health System and
CEO of UCLA Hospital System
“Merlino gives a behind-the-scenes account of how
Cleveland Clinic, traditionally known for medical excellence,
transformed itself to put equal focus on the patient
experience. It’s a fascinating story on its own merits, but it’s
also the story of the future of healthcare. For all healthcare
leaders who are (or those who soon will be) leading a similar
transformation, this book will be an indispensable guide to
the journey ahead.”
—Dan Heath, coauthor of the
New York Times bestsellers
Made to Stick, Switch, and Decisive
“This book is a candid recounting of Cleveland Clinic’s rocky,
flawed journey toward creating world-class patient
experience. James Merlino is painfully honest about the
failures and mistakes along the way, even as he lays out a
practical road map for change. This combination of candor,
pragmatism, and hope is why Merlino has emerged as one
of the most respected healthcare leaders in the country.
Service Fanatics is invaluable for any hospital administrator
determined to transform patient experience.”
—Leah Binder, president and CEO
of The Leapfrog Group
“Driven by his experience as a family member, patient, and
physician, Jim’s passion has created a movement to refocus
the healthcare system’s design, process, and culture on the
patient. With his colleagues at Cleveland Clinic, he has
championed the effort to once again center care around the
patient and has engaged healthcare leaders across the
industry to embrace transparency in the spirit of
improvement. Jim’s commitment to his patients and
empathy for their journey resonates on every page of this
book. When we reflect on the major transformation of the
industry, history will show that Jim Merlino and Cleveland
Clinic were at the forefront of returning our healthcare
system to the patient and helping us return to the noble
cause that drew us all to careers in healthcare.”
—Pat Ryan, CEO of Press Ganey
“It’s an important work by the leading voice in patient
experience. It’s also a gripping personal narrative that
changed my perspective on every doctor-patient interaction
I’ve had in my life. … Service Fanatics is upfront about just
how hard it is to change a culture so that it becomes truly
customer-centric—then tells you how you can do it anyway.
Merlino describes the challenges at Cleveland Clinic with an
unsentimental eye, and he also provides detailed
descriptions of what the leadership team did to overcome
those challenges. … All in all, Service Fanatics is a great
read that’s also making me smarter about patient
experience. If only all business books could bring those two
elements together.”
—Harley Manning,
“It is one thing for a leader to establish an organization-wide
priority and quite another to achieve it. To many, Cleveland
Clinic’s rapid improvement in patient satisfaction scores
appears nearly miraculous. Dr. Merlino’s book offers a
compelling and candid tale of how an already great hospital
engaged its 43,000 employees to become even better. By
detailing every step with candor and eloquence, this book
explains precisely how the hospital achieved its gains—and,
in so doing, offers invaluable lessons not only for healthcare
leaders but also for anyone interested in how to achieve
meaningful progress across any organization.”
—Barbara R. Snyder, president of
Case Western Reserve University
“Anyone involved in healthcare will treasure Dr. Jim Merlino’s
book because it provides a candid, poignant look at patient
care from both provider and patient perspectives. The
stories and lessons around empathy and compassion are
inspirational and help us think more clearly about the
importance of the overall patient experience.”
—Kurt Newman, MD, president and CEO
of Children’s National Health System
“In this warts-and-all account, Jim Merlino describes how he
and his Cleveland Clinic colleagues transformed a culture
focused almost exclusively on clinical excellence into one
that fully embraced the need to deliver a caring and
empathic experience for people. In so doing, Merlino has
created a comprehensive and methodical playbook for other


healthcare organizations seeking to fulfill the same
paramount objective: putting patients first.”
—Susan Dentzer, senior policy adviser to
the Robert Wood Johnson Foundation
“The art and science of caring for others is remarkably
highlighted in Dr. Merlino’s splendid Service Fanatics. This is
a must-read for all leaders or aspiring leaders in the
business of delivering professional services. Dr. Merlino and
his Cleveland Clinic colleagues get i t!”
—Marc Byrnes, chairman
of Oswald Companies
“Cleveland Clinic is a great example of what healthcare
should embody—full service to each and every patient. I’ve
seen what their work and commitment have done, with a
very important member of my family, my brother, and it’s
fantastic. Every medical venue should emulate their
facilities as well as their superb and comprehensive
services. Keep up the great work.”
—Donald J. Trump
Copyright © 2015 by James Merlino. All rights reserved.
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For my father, who showed me the other side
To Amy, for her unwavering support
To Toby and Joe, for never saying no and never doubting
Chapter 1
Transformed by the Patient Experience
Chapter 2
Patients First as True North
Chapter 3
Leading for Change
Chapter 4
Describing the Elephant: Defining the Patient
Experience and Strategy
Chapter 5
Culture Is Critical
Chapter 6
Cultural Alignment: The Cleveland Clinic
Chapter 7
Physician Involvement Is Vital
Chapter 8
Want to Know What Patients Think? Ask!
Chapter 9
Execution Is Everything
Chapter 10
Healthcare Requires Service Excellence
Chapter 11
Doctors Need to Communicate Better
Chapter 12
Making Patients Our Partners
Chapter 13
Getting It Done Has Defined Our Success
Epilogue: We Have a Responsibility to Lead
I’ve learned that people will forget what you
said, people will forget what you did, but people
will never forget how you made them feel.
n 2004, acclaimed heart surgeon Dr. Delos “Toby” M.
Cosgrove became the CEO of Cleveland Clinic, an
institution known for innovation and excellence in patient
outcomes. As he transitioned from surgery to strategy, he
was invited to speak to Harvard Business School students
about the Cleveland Clinic model of care. During that
address, he was challenged by a student who asked
whether he taught empathy for patients at Cleveland Clinic.
It is a story that Toby has shared over the years as a
defining moment in his strategic thinking. Patients go home
from the Clinic “well,” but do they feel well cared for? The
seed and the stake were planted for Patients First, Cleveland
Clinic’s defining purpose.
I am on the board of the Clinic, and Toby asked me to
translate my business credentials in customer experience to
help the Clinic with the patient experience by chairing a
board-level committee on patient safety, quality, and
experience and to work with the new chief experience
officer, Dr. Jim Merlino. In my role as then vice chairman of
community banking at KeyBank, I had embarked on a
similar journey—to differentiate through the customer
experience by putting the customer at the center of
everything we do.
Jim Merlino is a rising star, whose passion for the patient
is rooted in an experience with his ailing father, where he
found himself on the “other side” of medical practices and
outcomes. In the early days, Jim and I would meet to discuss
ways to institutionalize the Clinic’s nascent efforts in patient
experience. The principles I had developed in banking on
how to drive change and customer experience were
relevant, but being involved in Cleveland Clinic’s
transformation around the patient opened my eyes and
upped my game as well. And in the process of working
together, Jim and I became friends.
Jim had no clear starting point and no clear definition of
success. There were no playbooks or manuals on what to
do. He launched a methodical internal and external process
to learn best practices from a variety of industries, as well
as understand and determine what success would look like
for Cleveland Clinic.
It takes leadership to set the tone and to set aspirational
goals for an institution. Together, Toby and Jim created the
processes for organizational change and required and
empowered all the employees of the Clinic—from physicians
to service workers—to become caregivers. With no
guidebook on how to take Patients First from aspirational
goal to operational reality, the Clinic embarked on a journey
of trial and error, success and failure, until the aspiration
became a strategy and tactics were developed that allowed
the Clinic to implement world-class patient experience.
Service Fanatics is a testament to Jim’s passion and work,
but also to Toby Cosgrove and Cleveland Clinic.
A senior leader of another hospital once said, “We can’t
all be Cleveland Clinic.” To which Jim responds, “Yes, you
Service Fanatics shows you how. It is the road map, rich
with stories and examples, as well as tools and insights to
operationalize the patient experience. Improving the patient
experience is not only the right thing to do; it is an
imperative in the changing world of regulation and law in
American healthcare. But its message and content
transcend healthcare. Service Fanatics provides pragmatic
lessons and actionable takeaways for business professionals
in many industries—mine included. In an era of content
overload, it is a compelling and valuable read.
Beth E. Mooney
Chairman and CEO
ana Bernstein is a smart, energetic, beautiful 25-
year-old woman out to conquer the world. She
enchants everyone she meets. Dana is also an expert in
understanding the world of healthcare: expert not because
she’s on the provider or delivery side of healthcare, but
expert because she’s lived on the patient side since she was
three. In the past 22 years, Dana has had more interactions
with doctors and nurses, more admissions to hospitals, and
more procedures than most people have in a lifetime.
What gives Dana her expert credentials is a battle with
Crohn’s disease,
one of the two major bowel diseases
characterized by inflammation, or in layman’s terms,
significant irritation and erosion of the bowel lining and
walls. It’s a disease in which the body’s immune system
essentially attacks its own organs. An estimated 1.4 million
in the United States suffer from inflammatory bowel
Not many are familiar with it, and there is no
known cause or cure.
Crohn’s disease represents a terrifying spectrum of
possibilities. Some can live their entire lives with only very
minor manifestations of it, while others develop significant,
frequently recurrent, episodes involving the constant use of
medications, multiple surgical procedures, and potential loss
of the entire intestine, necessitating a small bowel
transplant. Crohn’s can affect any part of the intestinal tract
and can lead to significant problems in just about every
major organ system.
Dana lives at the extreme end of the spectrum. Since her
diagnosis, she’s had multiple operations and innumerable
hospital admissions and procedures. If you sat and talked
with her, you’d believe she’s no different from anyone else
her age. But if she shared her struggle with Crohn’s, you’d
learn that she has little of her intestines left, uses an
ostomy, and receives daily nutritional support through a
catheter threaded into her chest. Dana also struggles with
managing chronic pain caused by extensive inflammation
and the significant scarring from multiple surgeries. She’s
facing the possibility of a small bowel transplant, which is a
daunting procedure. It will put her life in jeopardy, and she’ll
need more than just expert medical care to get through it.
By her own admission, Dana is not an undemanding
patient. Aside from the complexities of her disease, she is
very much the captain of her body. She and her mother, Cari
Marshall, probably know as much about Crohn’s disease as
many of the physicians who’ve provided Dana’s care, and
Cari has dedicated her life to helping Dana fight her disease.
Dana is an activated patient who’s not afraid to be her own
advocate. She and her mother don’t just want information to
make a decision; they want to be involved in how and why
decisions are made.
But Dana also wants something more, and that’s the
reason she travels 2,000 miles for healthcare, while there
may be experts who could treat her closer to home in Las
Vegas. Dana wants her physician to be someone not only
who is at the top of his field, but who brings compassion and
humility to his work. She found that combination in Dr. Feza
Remzi, chair of the Department of Colorectal Surgery at
Cleveland Clinic.
In Dana’s words, “I know I’m a tough patient, but I’ve
been through a lot and know what works for me and what
doesn’t. I often feel when I challenge doctors, they don’t
want to engage and have a serious conversation with me
about what’s going on.” She believes that Remzi cares for
her as a patient, but also treats her like a friend. “He cares
for me—I can feel it in the way he talks to me and the way
he treats me,” she says. “He actually yells at me
sometimes, but that shows he cares.”
Does considering a patient a friend cloud a doctor’s
judgment and objectivity? “Absolutely not!” explains Remzi.
“I’m her physician and surgeon first, but is it too much for
me to care for her as a person?” Remzi explains how this
brings more to the table: “If caregivers feel personally
engaged, they will be sharper and more in the moment.” As
a physician, he knows the boundaries. “I’ll never
compromise what’s right for her care, but I’ll always see
myself as her partner and advocate in helping her to
conquer this terrible disease. We are friends in the foxhole
together. I have her back, and she helps me be a better
doctor—she keeps me sharp.”
Remzi provides Dana with medical advice and treatment,
but he also helps guide her and her family through the right
decisions. Dana’s mother describes Remzi as one of the
most compassionate and caring people she has ever met,
saying, “His empathy is real!” The family’s trust and
confidence in Remzi’s medical ability is bolstered by his
concern for Dana as a person, not just as a patient.
Is it truly possible to expect both high professional
competency and compassionate care with a human
connection? I had the honor of being a guest speaker at an
advanced executive leadership course at Harvard Business
School when we discussed this very question as part of a
Cleveland Clinic case study. We were considering the patient
experience, how it factored into the treatment of patients
and whether there could be a financial return on investment
to help drive these concepts across an organization. I posed
a dilemma to the students: You’re a patient needing heart
surgery and have the choice of two surgeons. One is
absolutely the best in the world by every measurable
objective outcome, but she is mean and doesn’t
communicate well with patients or their families. She’s a
true technocrat who has no empathy or humanism. Your
other choice is a surgeon renowned for compassion and
empathy, but his outcomes, while within the standard of
care, by reputation are not quite as good as the other
surgeon’s. Whom would you want to do your surgery?
Interestingly, the students were about equally divided in
their choice. Some said they didn’t care whether the
surgeon ever talked to them, as long as the operation was a
success with a great outcome. Others took what I call the
more “humanistic” perspective: they wanted someone to
care for them as a person as well as perform a competent
operation, arguing that if the compassionate surgeon’s
outcomes were within the standard of care, that was good
As a surgeon who has seen excellent, marginal, and poor
surgeons up close, I used to believe that technical
proficiency was the most important element of surgical care
and that if I ever needed an operation, I would surely choose
technical prowess over everything else, including whether
the doctor talked to me. I have seen very nice and
empathetic but technically challenged surgeons navigate
terrible complications and avert liability by building strong
connections with patients and families. This illustrates a fact
that’s often revealed in malpractice litigation: Doctors don’t
get sued because they are incompetent. They get sued
because they don’t communicate or build relationships with
patients and families.
I wonder how the Harvard students would have
responded if my colleague Shannon Philips, Cleveland
Clinic’s quality and safety officer, had first educated them
about the culture of safety. Technically proficient but
disruptive physicians actually create an environment that is
unsafe and stifle other caregivers from stepping forward to
protect patients. These physicians can actually have worse
outcomes because they foster a culture of fear. I suspect the
students who favored the technocrat might have
Being on the other side of healthcare, both as a patient
and as a family member of a patient, changed my beliefs
about what I want from a physician. Patients deserve—and
should demand—a physician who is medically competent as
well as empathetic and compassionate. I also believe that
as healthcare leaders responsible for safeguarding quality
medical delivery, we should work hard to ensure that we
provide both.
Brian Bolwell, chair of Cleveland Clinic Taussig Cancer
Institute, is, like Remzi, among the smartest physicians I
know, and also a caring and compassionate human being. I
was in his office one day, and he seemed subdued. I asked
what was wrong, and he said, “A young woman I took care
of for a long time just died. It’s impossible not to be sad.”
She was not merely a patient to him; he knew about her life,
shared a journey with her, and cared about her. If I am ever
diagnosed with a terrible disease, I want physicians like
Remzi and Bolwell to care for me. I want to have a
connection with the persons treating me. I want to know
that they care about me personally, that they are as
invested in my recovery as I am. Yes, I demand that they be
competent and objective, but I want to know that they will
be there with me and for me. I don’t want some brilliant
technocrat to just perform a procedure and walk away
without an afterthought as to how I will get back to my life. I
want my doctors to know something about me as a person,
listen to what I think, and understand that outside the
hospital I have a life, a family, and friends. Why is this
important? I want my doctors and other caregivers invested
personally in my outcome.
Empathetic care that transcends the human condition is
what I aim to provide to my patients and is the standard we
should all expect for ourselves as patients. A personal
investment in empathy and compassion by all caregivers is
the foundation of the future for healthcare. We must align
our organizations and people around patients and how we
deliver care to them.
A focus on the patient experience has become a
differentiator for Cleveland Clinic. Dana travels 2,000 miles
for high-quality care and high-quality caring at our
institution. Our alignment around the patient impacts
everything we do, not only improving patient satisfaction,
but ultimately enhancing our delivery of safe, high-quality
care and high value. Any healthcare system in the world can
and should adopt putting patients first as its primary
When we began our patient experience journey, there
was no textbook or playbook telling us how to start. The
healthcare scholarship doesn’t often consider the
competency of how to deliver care. Trial and error became
our modus operandi. We created our own strategies and
tactics, adopted some from others, and applied lessons from
businesses outside healthcare. Our approach has been
based on living the challenges at the front lines of a
diversified and heterogeneous healthcare system with
incredible patient needs and demands. Our physician
champions, including me, still see patients. Our nurse
champions are at the patients’ bedside. This frontline
involvement and commitment is one of the reasons we’ve
been successful. You cannot fix the patient experience from
a 50,000-foot strategic perspective; most of the work must
be operationalized at the patient touch points and carried
out by frontline caregivers.
From a practical standpoint, improvement required us to
frame a strategy concisely and then focus on key elements
that allowed us to implement it. Everything patients—and
their families—see, do, and touch is considered by us as the
patient experience.
This book focuses on how to think about the patient
experience, how to define it, and the factors we feel are
critical to enhance it. Improving patient-centeredness also
impacts how we deliver safety and quality. These are
important not just for patients, but for caregivers as well.
In the subsequent chapters, I describe how Cleveland
Clinic’s leadership determined to make the patient
experience a priority, defined it, and set a strategy for
improving it. I discuss the foundational elements of culture,
physician involvement, and understanding patients. I share
our execution successes and failures, including how we
organize, recruit, train, and measure for service excellence;
how Cleveland Clinic has evolved its culture and aligned its
workforce around Patients First; and how we improved the
critical element of physician communication. I convey my
beliefs and experiences regarding cutting-edge issues such
as making patients our partners in ensuring a quality
experience and sharing approaches with caregivers
worldwide so that patients everywhere can hope to receive
better care.
I have written about Cleveland Clinic’s journey because
we have made a difference and our approach is working. It
is just one of many possible approaches, and you may find
that it can help your organization. And just as we have
learned from a variety of different businesses outside of
healthcare, I believe that our strategy and many tactics hold
lessons for other businesses as well. Aligning a workforce
around the customer is applicable to any business that has
customers, which is every business.
No doubt some reading this book will look at parts of our
organization and say that our approach is not functioning as
well as we think. Improving the patient experience is hard
work, and we still have a lot to do. But just as Cleveland
Clinic historically has had relentless focus on medical
excellence, there’s no question that we now pair that with a
relentless focus on improving the patient experience. We
have gone from being among the lowest-rated hospitals in
the country for patient experience metrics to among the
This book is not meant to be a comprehensive resource
for every patient experience tool available or a technical
manual of all that we do. I discuss our strategy and many of
our tactics, and I describe some of the roadblocks we
encountered. If you peer under the hood of our organization,
we look like most other healthcare systems—perhaps even
like yours. We have the same needs and challenges, and we
all face an uncertain future.
There are some elements unique to our journey that
have granted us unusual success. Cleveland Clinic’s
appetite for innovation allowed this program to gain hold
and flourish, giving us a head start. But at the time we
began, external pressures were not as intense. Today, the
forces pushing hospitals to get better are much stronger, so
this should help others gain the foothold they need to climb
the path of improvement.
It’s my hope that you will find something in this book that
can help your organization. Perhaps the book will reinforce
that you are on the right path and provide you with a
reassuring pat on the back. My goal is simple. If you deliver
healthcare, you must think about how to align your
organization around the patient. In such an environment,
Remzi, Bolwell, and millions of other caregivers throughout
the world can deliver high professional competency and
compassionate care with a human connection. It is what
patients like Dana Bernstein …
Assignment 1: Executive Memo
Due Sunday, midnight of Week 3
You are the CEO of a Healthcare organization. The patient satisfaction data, as measured by
the Press-Ganey survey, shows most patients who have received care at your hospital would
not recommend the facility to friends and family, and the patients’ overall rating of the
organization is mediocre at best. Your top focus as CEO is to build a superior patient
Your Assignment:
Based on your reading of the Service Fanatics textbook, including the best practices shared in
the book, draft a 2-to-3-page Executive Memo, to be distributed to all staff and members of your
Be sure your memo includes the following:
1. Clear and concise outline of the strategy for improving the patient experience
2. Tactics to be used to drive the strategy
3. Description of how all staff can participate in putting “Patients First”
4. Call to Action, with a Statement about how success will be measured
Your assignment must follow these formatting requirements:
• Typed, double-spaced, using Times New Roman font (size 12) with one-inch margins on
all sides.
• In place of a Cover page, provide the following Headings on Page 1 of your memo:
· TO: Insert Professor’s Name
· FROM: Insert Your Name
· DATE: Insert Assignment’s Due Date
· RE: It’s All About the Patient, Assignment 1
Note: The Headings page is not included in the required assignment page length.
RUBRIC – Assignment 1: Executive Memo



Low Pass


High Pass


1. Articulate a clear and concise strategy for improving the patient experience.
Weight: 20%

Does not articulate a strategy for improving patient experience. Does not justify the strategy. Not at all clear and concise.

Partially articulates a strategy for improving patient experience. Partially justified the strategy. Not fully clear and concise.

Satisfactorily articulates a strategy for improving patient experience. Satisfactorily justified the strategy. Clear and concise.

Presents a well-articulated strategy for improving patient experience. Justifies the strategy. Very clear and concise.

Thoroughly articulates a strategy for improving patient experience and thoroughly justifies the strategy. Excellent level of clarity and conciseness.

2. Describe strategic tactics for improving the patient experience. Weight: 20%

Does not describe the strategic tactics for improving the patient experience.

Partially describes the strategic tactics for improving the patient experience.

Satisfactorily describes the strategic tactics for improving the patient experience.

Describes well the strategic tactics for improving the patient experience. Clear and concise.

Thoroughly and succinctly describes the strategic tactics for improving the patient experience. Clear and concise

3. Provide a statement about how all staff can participate in putting “Patients First”. Weight: 20%

Does not provide a statement of how all staff can participate in putting “Patients First”.

Partially provides a statement of how all staff can participate in putting “Patients First”.

Satisfactorily provides a statement of how all staff can participate in putting “Patients First”.

Well-formulated statement of how all staff can participate in putting “Patients First”. Clear and concise statement.

Thoroughly and completely formulated statement of how all staff can participate in putting “Patients First”. Clear, concise, and actionable.

4. Provide a call to action, and state how success will be measured. Weight: 20%

Does not provide a call to action. Missing or incomplete statement of how success will be measured.

Partially provides a call to action. Partially provides a statement of how success will be measured.

Satisfactorily provides a call to action. Short statement as to how success will be measured.

Well-expressed call to action. Clear and concise statement about how success will be measured.

Thoroughly and completely provides a call to action. Clear and concise statement of how success will be measured.

5. Clarity, Logic, Writing Mechanics, Grammar, and Formatting. Weight: 20%

Multiple mechanical errors: much of the text is difficult to understand or the text does not flow; memo fails to follow formatting instructions.

Mechanical errors make the text difficult for the reader to understand; text does not flow; memo includes unsupported conclusions and assertions.

Some mechanical errors: text flow is satisfactory; memo is mostly clear; assertions and conclusions are generally justified and explained.

Few mechanical errors; text flows well; memo clearly expresses the student’s position in a manner that logically develops the topics.

Minimal minor mechanical errors; text flows very well; memo clearly expresses the student’s position in an exemplary manner that logically develops the topics.

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