Plymouth Hospitals

NHS Trust

Five Year ICT Strategy

2012 - 2017

“Technology alone cannot transform healthcare but healthcare

cannot be transformed without it”
 Contents

Contents

1. FOREWORD ........................................................................................................................3
2. INTRODUCTION ..................................................................................................................3
3. TRUST STRATEGIC CHALLENGES ...........................................................................................4
4. ICT STRATEGIC CHALLENGE..................................................................................................4
5. ICT GOVERNANCE ...............................................................................................................7
6. INVESTMENT PLANNING .....................................................................................................8
ANNEX A – ICT STRATEGY EXECUTIVE SUMMARY .........................................................................9
ANNEX B – ASSURANCE MATRIX ................................................................................................ 10
ANNEX C – STRATEGIC ROADMAP ............................................................................................. 12
ANNEX D – INVESTMENT SUMMARY ......................................................................................... 13
ANNEX E – ICT GOVERNANCE REPORTING STRUCTURE ............................................................... 14

Page 2 of 14
 Foreword

1. Foreword
“To be a major university teaching
This strategy sets outs the strategic direction of hospital and healthcare provider,
Plymouth Hospitals NHS Trust Information and recognised as one of the best in the
Communications Technology (ICT) and the key
country. We will lead with excellence
components of its strategic ICT vision of a paperless
hospital. and care with compassion.”

The scope of the vision is such that an iterative Plymouth Hospitals NHS Trust
approach will be adopted aiming towards “paper
light” functions in key areas of the hospital within the first five years. This will demand significant
process change together with a coordinated programme of legacy rationalisation and integration.

The approach will focus on four key themes:

 Standardised technologies and methodologies.

 Effective systems and services.
 Exploitation of leading edge developments in technology.
 Innovative solutions to operational challenges.

2. Introduction “Technology alone cannot

Well implemented and supported ICT is no longer a back transform healthcare but
office function and is critical for the effective delivery of healthcare cannot be
healthcare services and a key enabler of the transformation transformed without it”
agenda underway within the NHS.
Plymouth ICT Shared Service
The Trust ICT service is provided by Plymouth ICT Shared
Service (PICTS) as part of an integrated community-wide approach to technology implementation
and support.

The strategy describes how we will use information technology to improve clinical outcomes and the
quality of our care and how the paperless vision will be realised by a single electronic health record
for every patient, accessible from any location, at any time, with appropriate levels of security to
respect and preserve patient confidentiality.

A key element of the strategy is to exploit “best of breed” clinical and business applications and,
through the use of system interoperability, to make the complexity transparent to the user by
providing access via a single clinical portal accessed by a single log on. This will enable
contemporaneous data capture at the point of care, provide real time information to support clinical
decision making and enhance the quality of care we provide through the support of our education
and research strategies.

The national ICT programme is now about local choice and local delivery; the Trust’s strategy will
however, support integration across the wider healthcare community as data sharing between
health and social care organisations will be an essential element of service transformation. We will
work closely with our local health and social care partners to achieve this.

The strategy will also make on-line communication between patients and our clinicians much easier.

Page 3 of 14
 Trust Strategic Challenges

The strategy is focused on driving real change and sets out how the Trust will use ICT to deliver its
strategic aims. ICT will be central to the Trust’s transformation programme ensuring investment in
technology brings the maximum return in expected benefits.

A summary of the ICT Strategy is provided at Annex A.

3. Trust Strategic Challenges

It is clear from the Trust’s overall Strategy that the organisation faces three major challenges in the
years ahead. Technology will have a lead role in supporting the Trust to successfully respond to
these challenges.

Changing settings of care

The Trust has committed to working across the health community to redefine pathways of care to
ensure patients are cared for in the most appropriate setting. From the quantitative work done to
date it is clear that there are a large number of patients currently cared for in the hospital who could
be cared for in a less specialist setting if there was appropriate provision made within the
community.

In the future there may be fewer patients seen in the hospital, with more work undertaken closer to
a patient’s home. As more creative packages of care are defined, there will be greater need to share
information between organisations and individual clinicians, as well as supporting new and
innovative methods of delivering services and interacting with patients.

At the same time, we are likely to see further rationalisation of specialist services into fewer centres.
This may see additional services undertaken from PHNT, with the organisation acting as the ‘hub’ for
clinical systems across Devon and Cornwall. This cross organisational working will again require
greater sharing of information and support for new ways of working.

Productivity and Patient Value

Reduced income through deflated tariff and significant unfunded cost pressures will result in a
challenging productivity requirement for the Trust. To meet this challenge the Trust will need to
focus on providing value to the patient by reducing waste and increasing patient involvement in
decision making. It will require more patients to be seen and treated per outpatient clinic and
theatre lists.

It will require better patient flow through and out of hospital. Technology will have a major role to
play in terms of ease of use of technology, maximising the benefit from the technology we have,
developing or buying innovative solutions and providing excellent support to front line services.

Continuous Quality Improvement

Quality remains central to everything we do and will need to continuously improve even when faced
with the challenges outlined above. Technology has a lead role to play across all three dimensions
of quality (Safe, Effective and Personal), whether it is through applied technologies, such as bar
codes and radio tags, or through information provision to support clinical audit, or supporting
solutions that allow us to gain greater insight into the patient’s experience.

4. ICT Strategic Challenge

The ICT challenge is to support the short and medium term Trust objectives whilst still realising the
overall long term vision of a paperless hospital.

Page 4 of 14
 ICT Strategic Challenge

The overall strategic approach that will allow short and medium term priorities to be addressed
whilst maintaining a focus on the longer term aim can be summarised as:

Standardised architecture enabling effective services which exploit technology and

support the development of innovative solutions

Key investments and developments will need to underpin this strategic approach. The individual
elements are described below:

Standardised architecture
Over the period of this strategy demands upon the local technology architecture will increase
significantly, with greater reliance on business critical solutions on a 24/7 basis. To meet the
increasing demands over the next five years, the Trust will need to:

 Replace and/or refresh the core infrastructure for servers, storage, networking, telephony
and interoperability
 Deliver a comprehensive rolling replacement programme that ensures all end user client
devices are capable of supporting the latest innovations to the user.

A further challenge is the need to reduce the variation and total number of disparate technologies
being supported and to standardise wherever possible. These core requirements will be central to
every system review undertaken and investment decision made.

To ensure that the core infrastructure provides the lowest total cost of ownership (TCO), detailed
investment plans have been produced which closely align each investment scheme with the Trusts
key objectives and provide an expectation of benefits to be realised (summarised at Annex D).

Effective services
Many areas of the Trust will be expected to deliver significant efficiency benefits through IT enabled
process change and the introduction of “smart” solutions commensurate with a large and complex
organisation. A number of key projects are already underway to facilitate the transformation and
efficiency agendas including:

 Digital dictation and voice recognition will enable new working practices and the delivery of
significant savings in administrative time and effort. Pilots are live with procurement of a
hospital wide solution planned for Summer 20012.
 Managed print services will reduce overall costs and improve the overall printing function.
The roll out across the entire hospital will be complete by the end of 2012/13.
 Development of the Trust’s order communications solution into a unified clinical portal for
access to all diagnostic requests, results and clinical documentation. A key development is
the GP ordering solution which has been piloted in 2 practices and will be rolled out across
all Plymouth GPs by the end of 2012/2013.

Alongside technical enablers to change, the organisation expects ICT support services to become
increasingly more responsive to its needs and resolve as many issues as possible at the first point of
contact with the ICT technical team. A key factor in the delivery of all these objectives is the need to
make IT solutions easier to use and support with minimal training. Many emergent mobile devices
have gained popularity largely due to their highly intuitive and simple to use end user interface and
these devices will play a key role in the delivery of effective ICT services moving forward.

Page 5 of 14
 ICT Strategic Challenge

Exploit technology
The exploitation of technology is a key area where ICT adds value to the business through bringing
together the needs of the business, an understanding of the market offerings and provision of
professional procurement and implementation skills. To be effective, the ICT service must:

 Lead the implementation of creative solutions that meet the clinical and business needs of
the organisation. This is ensured through active involvement of clinicians in the setting of
the strategy, agreeing of annual priorities and oversight of the programme delivery.
 Ensure excellent horizon scanning and market intelligence capability. A dedicated team
provide the focus to ensure there is a clear understanding of technology developments and
effective upgrades undertaken to ensure more effective and reliable solutions for users.
 Deliver effective programme management. The trust has a dedicated team of project
managers, with considerable experience of delivering major systems.

Some examples of new technologies in the pipeline would include:

 Streamlining theatre and outpatient management to improve patient flow. New systems in
these areas will improve productivity and the patient experience through better access to
information and improved system functionality.
 Scheduling resources across the Trust in support of new pathways of care.
 Providing positive patient identification systemically at all points of care, such as through the
use of bar coded wrist bands, bar coded blood products and so on.
 Providing mobile access to systems and services, whether to support clinicians in delivering
care, such as the use of iPhones to request another consultant review of a patient, or iPads
to audit our quality delivery and to collect the opinion of our customers.

Innovative solutions
Innovation is at the heart of everything the ICT service does and therefore must make a major
contribution to this aspect of the Trust’s strategic vision. Innovation and exploitation work
together, with innovative solutions often arising from realising the full potential of an existing
technology, or developing solutions that fulfil an unmet need.

The ICT service provides innovation across all technical disciplines including:

 Presence and availability using converged data and voice telecoms technology to improve
communications, through for instance the use of ‘soft phones’ to allow a phone number to
move between office phones and mobiles seamlessly.
 Tracking patients and resources using RFID and associated technologies in order to maximise
the use of expensive/scarce assets.
 Enabling “bring your own devices (BYOD)” to permit personal technologies to be used for
business use in a controlled manner. For instance, the use of iPhones would improve the
user experience, through not having to carry more than one device and also reduce the cost
to the organisation of providing the ‘works’ device.

In particular, the software development and integration function is developing innovative solutions
in the following areas:

 A patient care management solution to meet the challenge of real time bed management
integrated with ward whiteboards and providing visible real time alerts and real time clinical
data capture. This would fundamentally change the way the hospital could manage its bed
base.

Page 6 of 14
 ICT Governance

 Integrated multi-resource scheduling in support of new pathways of care.

 The ability to identify abnormal results systemically, alert the appropriate clinician and
record actions taken.
 The ability to capture patient vital signs electronically and therefore supports early
intervention and potentially reduces harm and save lives.
 A single sign on (SSO) capability for clinical staff to reduce the time wasted logging on to
systems and to facilitate context switching between disparate systems.

A consistent objective across all four themes is to remove the organisations reliance on the paper
casenote in line with the primary ICT long term objective of becoming paperless. An assurance
matrix is provided at Annex B which cross references the key planned programme developments
with the Trusts primary objectives and the four main strategic themes. Annex C provides a
diagrammatic representation of how these developments will enable a paper light function at the
five year point as a stepping stone towards being fully paperless at some point thereafter
(indicatively April 2022).

5. ICT Governance
The ICT governance reporting structure is outlined at Annex E.

Programme
ICT programme management, in conjunction with the Trust programme management, will be
governed by the OGC methodologies:

 PRINCE2 – For project management.

 Managing Successful Programmes (MSP) – For programme management.

All ICT developments are managed using the project and programme management principles
identified which can be summarised as:

 New developments must be supported by a business case that is signed off by the
appropriate steering group/programme board.
 Projects must have a senior responsible officer who is accountable for the delivery of the
project to the executive.
 Projects must have a Business Change Manager (project lead or clinical lead) responsible for
delivering the necessary change within their business or clinical area.
 Projects must have an ICT Project Manager who leads the planning, delivery, monitoring and
post implementation review of the project.
 The Project Manager and Business Change Manager will ensure benefits are identified,
monitored and realised.
 Where more than one project requires managing together, a suitable Programme Manager
must be identified to ensure interdependencies are appropriately coordinated.

All Projects are required to report progress, against the aims, objectives, benefits, budgets and plans
set out in the Project Initiation Document, to the steering group / programme board.

Information Governance
The Information Governance (IG) agenda continues to be a high profile area and the Trust has a well-
established service which strives to ensure the confidentiality, integrity and availability of the
information used during the provision of healthcare. High-profile data losses from the public sector,
including the NHS, have brought Information Governance issues into the public spotlight in the last

Page 7 of 14
 Investment Planning

two years. The Trust must ensure that there are robust systems and processes in place for the
handling of personal data in a manner that meets the needs of the service and provides public
confidence.

The Department of Health's Information Governance Assurance Framework is supported by the

Information Governance Toolkit (IG Toolkit). The IG Toolkit is a self-assessment and reporting tool
that all organisations must use to assess local performance in line with the requirements set out in
the NHS Informatics Guidance and Operating Framework 2010/2011. It is expected that the Trust
will achieve level 2 on all of the 45 requirements at the 31st March 2012 submission. It is also
recognised that achieving level 2 in each requirement is a significant challenge and assurance against
this objective is monitored by the Trust Audit Committee.

Clinical Systems Training

The Clinical Systems Training team provide blended learning solutions to ensure staff are competent
in the use of the key EPR systems. This includes the primary systems for patient administration and
order communications as well as other local EPR systems such as eDischarge and RAPA. The team
also provides comprehensive Information Governance training. Training is increasingly required to
be evidenced in order to comply with national Initiatives such as the Information Governance
Toolkit, Care Quality Commission and NHSLA Standards.

Service Performance
The ICT service has well developed metrics to report and measure efficiency, quality, accuracy and
timeliness of service delivery. This has been further enhanced with the development of key
performance indicators to form part of routine customer performance reporting via the quarterly
PICTS Dashboard Report. The service is also an active member of the National Benchmarking Club
which utilises its Benchmarking Information Pack (BIP) and the nationally defined NIMM framework
to provide quantitative and qualitative indicators of performance benchmarked against appropriate
peer groups.

The Director of Strategic Planning & Information and Director of Financial Services & Performance
hold quarterly reviews with the Director of Plymouth ICT Shared Service to formally review and
assess ICT service performance.

6. Investment Planning
A summary of the five year investment plan which outlines investment and expected benefit is
included at Annex D. The costs and benefits are draft and will be worked up in more detail as each
project is developed and prior to investment decisions being made.

Page 8 of 14
 Annex A – ICT Strategy Executive Summary

Annex A – ICT Strategy Executive Summary

Standardised architecture enabling effective services which exploit technology and support the development of innovative solutions

Standardised Architecture Effective Services Exploit Technology Innovative Solutions

We will have a standardised architecture We will support the business in delivering We will exploit new technologies in support We will research, develop and implement
capable of meeting the demands of our greater value through the provision of high of service transformation and business innovative solutions to business problems
customers quality technology services change
Our key objectives are to: Our key objectives are to: Our key objectives are to: Our key objectives are to:
 Ensure that our core infrastructure is robust,  Enable greater service efficiency in the  Lead the implementation of creative solutions to  Identify where developmental opportunities exist.
resilient and extensible. management of Theatres, Beds and Clinics. meet the Trust’s clinical and business needs.  Develop and implement high quality, safe and
 Ensure that we are capable of providing highly  Provide access to clinical information at all points of  Understand the systems and services available in effective solutions.
interoperable systems. care. the marketplace and have excellent R&D capability.  Exploit commercial opportunities.
 Ensure that we provide the lowest total cost of  Make technology easier to use.  Provide a framework for the rapid procurement and  Protect intellectual property and investment.
ownership (TCO).  Remove reliance upon the paper casenote. deployment of systems and services.  Remove reliance on the paper casenote.
 Remove reliance on the paper casenote.  Remove reliance on the paper casenote.
We will do this by: We will do this by: We will do this by: We will do this by:
 Reviewing key architecture strategies for value and  Introducing “smart” solutions commensurate with  Actively engaging clinicians in setting the strategy,  Understanding the needs of both our clinical and
effectiveness. an organisation of our size and complexity: agreeing annual priorities and overseeing non-clinical staff.
 Providing investment plans to enable longevity of o Digital dictation and voice recognition programme delivery.  Having strategic developmental partnerships with
service provision and assure lowest TCO. o Managed print services  Leveraging existing relationships with the commercial suppliers.
 Planning the replacement programme to maintain  Extending the functionality within the order commercial supplier marketplace.  Investing in local developmental expertise and
service levels and minimise service disruption. communications solution to provide a true “clinical  Investing time and resource into new and emergent software tools.
 Working closely with standards agencies to inform portal” technologies.  Developing solutions using open standards and
and utilise emergent interoperability standards.  Implementing electronic document and records  Having a robust ICT Programme governance methodologies.
 Actively managing our ICT estate to reduce variation management. framework closely aligned to investment planning  Developing the “commerciality” of the service.
and the number of supported technologies.  Having the right people with the right skills available and benefits realisation.
when required.
We will measure our success by: We will measure our success by: We will measure our success by: We will measure our success by:
 Compliance to service KPIs and metrics.  The delivery of solutions and realisation of service  The ICT survey (clinical satisfaction).  The delivery of project objectives and benefits.
 Delivery of financial targets. benefits.  Reviewing supplier performance.  Reviewing the effectiveness of partnership
 National recognition as a key player in the  The ICT survey (clinical satisfaction).  Reviewing the efficacy of ICT programme arrangements.
interoperability agenda.  The percentage of “first point of contact” fixes governance  Reviewing service capacity and capability.
 Qualitative and quantitative benchmarking (HIBC undertaken.  Delivery of quantifiable benefits.  Externally reviewing our compliance to standards.
and NIMM).  A reduction in the reliance on paper records.  A reduction in the reliance on paper records.  Income generation capability.
 A reduction in the reliance on paper records.  A reduction in the reliance on paper records.

Page 9 of 14
 Annex B – Assurance Matrix

Annex B – Assurance Matrix

Quality

Settings Of Care
Effective Care

Personal Care

Productivity
Safe Care
Code Theme Planned Programme Development Complete By

ST01 Standardised Rolling replacement programme for client devices    31/03/2017
ST02 Standardised Core server and storage infrastructure    31/03/2017
Use of the Microsoft software product suite for all
computer desktop and server application
ST03 Standardised
requirements including desktop management and    31/03/2017
automation services.

ST04 Standardised Integration and Interoperability – Core Integration  31/03/2017

Mitel Internet Protocol (IP) Telephony and

ST05 Standardised
associated communication application suites    31/03/2017

Application Virtualisation - An innovative way to

EF01 Effective
deliver applications to the user    31/03/2015
EF02 Effective Patient reminders to reduce DNA rates   31/03/2013
Digital Dictation/Voice Recognition - Streamline the
EF03 Effective
production of clinical documentation     31/03/2014

eDRMS - Document management for Trust policies

EF04 Effective
and procedures    31/03/2013

eDRMS - Clinical Letters (Discharge summaries,

EF05 Effective
clinic and Accident and Emergency letters)    31/03/2015
EF06 Effective Order Communications - iSOFT iCM  31/03/2017
Managed print service project providing a
rationalised managed print estate with multi-
EF07 Effective
function devices replacing the majority of old Trust     31/03/2013
legacy printers

Virtual Desktop Infrastucture - Cloud type

EF08 Effective
computing     31/03/2015

Secure wireless connectivity to support mobility

EX01 Exploited
within healthcare premises  31/03/2017
Chemotherapy Prescribing - Project underway to
EX02 Exploited
procure and implement a new system     31/03/2013
Webex type facilities and greater use of telecoms
EX03 Exploited
"presence and availability"   31/03/2015
EX04 Exploited ePrescribing (including ‘To Take Out’ medicines)  31/03/2015

Page 10 of 14
 Annex B – Assurance Matrix

Quality

Settings Of Care
Effective Care

Personal Care

Productivity
Safe Care
Code Theme Planned Programme Development Complete By

GP Order Communications - Sunquest iCE being

EX05 Exploited
rolled out across the community    31/03/2013
Mobile end user device strategy - Laptops,
EX06 Exploited
notebooks, PDAs, smartphones etc.  31/03/2017
Check In Screens and Room Allocation Software in
EX07 Exploited
the Main Outpatients Department     31/03/2014
EX08 Exploited PACS/CRIS - Currently procuring new systems     30/06/2013
Patient access to information - Linked to Integration
EX09 Exploited
initiatives    31/03/2013

EX10 Exploited Positive Patient ID - Wristbands and NHS Number    31/03/2017
Patient and resource tracking - Ekahau pilots with
EX11 Exploited MEMS and strategic forum in place to review    31/03/2017
potential

Theatre Efficiency - Planned to procure new theatre

EX12 Exploited
system in 2012/13    31/03/2014
Maternity Efficiency - Planned to procure new
EX13 Exploited
Maternity system in 2012/13    31/03/2014
Consultant Patient List - To become a component of
IN01 Innovative
SALUS     31/03/2013
IN02 Innovative eDischarge - To become a component of SALUS    31/03/2015
IN03 Innovative eWard - To become a component of SALUS    31/03/2014
Patient Care Manager - SALUS module providing
IN04 Innovative
real time bed management and patient information.    31/03/2017
Risk of Admission Patient Alert (RAPA) - To become
IN05 Innovative
a component of SALUS  31/03/2013
SALUS - Replaces Corporate Services and provides
IN06 Innovative
patient context, uses PBAC  31/03/2014
IN07 Innovative Scheduling (for beds, tests, theatres, etc)     31/03/2017
IN08 Innovative Single Sign On to clinical applications (via Salus)     31/03/2017
Vital Signs Monitoring - Possibilities for
IN09 Innovative
procurement or development     31/03/2015

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 Annex C – Strategic Roadmap

Annex C – Strategic Roadmap

Page 12 of 14
 Annex D – Investment Summary

Annex D – Investment Summary

Year 2012/13 2013/14 2014/15 2015/16 2016/17 2012-17 Sub-Totals 2017-2022 Totals

Cash Cash Saving

Invest Benefit Invest Benefit Invest Benefit Invest Benefit Invest Benefit Invest Invest Non Cash Benefit
Standardised Architecture Benefit Benefit pa

Server & Storage Infrastructure 250 0 820 0 750 0 700 0 700 0 3,220 0 3,000 0 Effective ICT support 0

Rolling Replacement Programme 300 40 340 40 250 40 100 40 2,500 40 3,490 200 4,000 200 Effective ICT support 0

Communications 245 0 230 20 260 20 400 20 320 20 1,455 80 750 100 Effective ICT support 0

Integration & Interoperability 0 0 115 0 0 0 0 0 0 0 115 0 0 0 Effective ICT support 0

Sub-Tot 8,280 280 7,750 300 0
Effective Services
"Smart" solutions 600 148 995 364 300 364 0 364 0 364 1,895 1,604 0 1,820 General staff efficiency 1,000

Order Comms (Requests & Results) 120 400 0 250 0 250 0 250 0 250 120 1,400 0 1,250 Safe and effective care 2,000

Electronic Document and Records Mgt 130 0 150 125 250 250 250 250 250 250 1,030 875 0 1,250 Information access 500
Sub-Tot 3,045 3,879 0 4,320 3,500
Exploited Technology
Theatre Management 100 40 140 40 0 40 0 40 0 40 240 200 0 200 Improved utilisation 500

Outpatient Booking and Patient Flow 10 0 120 50 0 50 100 50 0 50 230 200 0 250 Improved utilisation 0

Electronic Prescribing 250 0 500 200 500 400 0 400 0 400 1,250 1,400 0 2,000 Safe and effective care 300

Departmental Clinical Systems 340 0 380 0 200 0 200 0 200 0 1,320 0 0 0 Improved utilisation 1,200

PACS & RIS 100 0 1,000 0 500 0 0 0 0 0 1,600 0 0 0 Safe and effective care 0

Positive Identification 100 0 0 0 0 0 0 0 0 0 100 0 0 0 Safe and effective care 0

Mobility 40 0 200 0 0 0 0 0 0 0 240 0 250 0 Clinical staff efficiency 0

Sub-Tot 4,980 1,800 250 2,450 2,000
Innovative Solutions
Patient Care Management 390 0 100 65 40 65 40 65 40 65 610 585 0 325 Improved utilisation 2,550

Multi-Resource Scheduling 0 0 50 0 50 0 0 0 0 0 100 0 0 0 Improved utilisation 0

Results Acknowledgement & Alerting 50 0 0 0 0 0 0 0 0 0 50 0 0 0 Safe and effective care 0

Vital Signs Monitoring 0 0 250 0 250 0 0 0 0 0 500 0 0 0 Effective Patient Care 0

Single Sign On 10 0 120 0 90 0 40 0 40 0 300 0 0 0 Clinical staff efficiency 700

Patient & Resource Tracking 25 0 25 50 50 50 0 50 0 50 100 450 0 250 Safe and effective care 0
Sub-Tot 1,660 1,035 0 575 3,250

Totals 3,060 628 5,535 1,204 3,490 1,529 1,830 1,529 4,050 1,529 17,965 6,994 8,000 7,645 +Non-cash Saving pa 8,750

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 Annex E – ICT Governance Reporting Structure

Annex E – ICT Governance Reporting Structure

Page 14 of 14