Dean Bliss is a Lean Healthcare Coach for the Iowa Healthcare Collaborative (IHC). He assists Healthcare organizations in learning and applying continuous improvement activities and philosophy. He is an original member of the IHC’s Lean workgroup, which has conducted statewide Lean Healthcare conferences and Lean learning opportunities since 2005.
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Related Podcast: A Blissful discussion on Collaborative & Consortia
Transcription of the Podcast
Welcome everyone. This is Joe Dager, the host of the Business901 podcast. With me today is Dean Bliss. Dean is a Lean Healthcare coach for the Iowa Healthcare Collaborative. He assists Healthcare organizations in learning and applying continuous improvement activities and philosophy. He is an original member of the IHC’s Lean Workgroup, which is conducting its statewide Lean Healthcare Conferences and Lean Learning Opportunities since 2005. Dean, I would like to, of course, welcome you, and today I wanted to focus on the Iowa Healthcare Collaborative. Could you tell me a little about yourself and then lead into the collaborative and how it got started?
Dean: You bet Joe, a pleasure to be here. I’ve been at the Lean thing for quite a while. I worked for a company called Rockwell Collins in Cedar Rapids, Iowa, which got started with Lean back in 1999. I was there for 25 years. As I learned the tools and the techniques and the philosophy of Lean, we started to spread that information from the manufacturing world into other worlds. One of the things that happened was an organization called the Iowa Business Council which is made up of the CEOs of the largest companies in the state, and there are some very successful Lean companies around on that council, Vermeer, Pella, Rockwell Collins and others. They said, “Well, why don’t we teach these Healthcare people how to do this because we see our costs going up and all sorts of things going on? We think Lean could be some benefit.”
I was part of that activity back in 2004. In 2005, a hospital came to me and said, “Hey, could you help us get started doing this? We think there’s really some benefit here.” So that was the start of my Healthcare journey if you will. I’ve been at that since 2005, so that has been, about eight years. Holy cow, it’s been eight years.
Joe: That is a while.
Dean: It’s been quite a while, and we’ve really seen some nice things happen. That was kind of in the early days of Healthcare, the Thedacare, and Virginia Masons of the world started in 2002, 2003, some of the early 2000’s. We were still pretty early in the journey as far as Healthcare is concerned and there’s a lot of activity going on now across the country, which is really encouraging because Healthcare is obviously a big topic right now, and we need to take every step and every measure. We can make sure that we’re giving good quality care, that it’s affordable, that it’s safe and all those kind of things. Those are the things that we really focus on.
As far as the Healthcare collaborative, we’re kind of a combination of the hospital association and the medical society which is the doctors, so we’ve got kind of both sides of the coin if you will that are part of us. We’re working on a thing called the Hospital Engagement Network, or HAN, is kind of what the national reference is, and it’s a way to look at 10 different areas of potential harm that can come to patients in a hospital. We’re using the Lean activities; the Lean tools, various other tools as well, to look at how we deliver care in some of those areas and how things can go wrong. We’re looking at error proofing and some of those kinds of things within the Healthcare environment to make sure that our patients are safe. That’s kind of the activity going on right now.
In addition, we’ve got, in Iowa here we kind of think of ourselves as a hotbed of Lean in some areas. We’ve got a thing called the Iowa Lean Consortium that’s going on, which is across industries. So we’ve got Healthcare people and government people and retail people and manufacturing people, all kinds of working together, to present and share at training and activities and events. We’re really kind of digging into this, into the Lean thing, and we’ve been at it for quite some time.
Joe: Well, how does a collaborative start? Does one day a hospital says, “Let’s go get the guy across the street and let’s start something?” Or how does one start?
Dean: The way the Healthcare collaborative started was there was a clamoring for public reporting. We’re going to make all these hospital report things and report their safety and report their cost and all that kind of stuff and we had some people in the state of Iowa say, “Well, we’ll do that, but we want to do it in such a way that we’re not doing it because the government told us to, but we’re doing it to benefit what’s going on.” So that’s kind of how that Healthcare collaborative started.
That was about 2003, 2004, since then; we really branched out into the quality, the efficiency, the Lean, some of those things and really added to our toolkit if you will. If you were to go out on our website, you’d see a lot of tools out there for a lot of reasons and a lot of things that we can use. We can distribute to the 118 hospitals we have here in Iowa and really help even the smaller hospitals which most of our hospitals are 25 beds or less which is very small, really help them, the folks that don’t have a lot of resources be able to have some resources and be able to do some things that a larger system would be able to do, by hiring consultants and so forth.
Joe: The collaborative is more than just a Lean collaborative. The Lean Workgroup is a sub-group of it.
Dean: That’s correct. But we’ve got a lot of activities going on. One of the things that we have is that public reporting piece, again, engaging the hospitals in a variety of things we do. We do things called learning communities, which are ways to get people from certain types of Healthcare together in a group and have them share information with each other so that we can all get better.
One of the nice things about Healthcare is except for some of the bigger cities a lot of the smaller hospitals; there’s no competition. They’re willing to share; they’re willing to work with other organizations. We’ve got the ability to kind of take those best practices if you will, and kind of raise the level of care across the state.
Joe: In the work-group, was there an actual, let’s say a mission, and a value statement created for that sub-group, or maybe an outcome-based type of model developed?
Dean: We taught tools like 5S, Value Stream Mapping, Standard Work, A3 and a couple others and we do it one at a time, one per year and get some people together and we showed hundreds of thousands of dollars of savings each year just by that one tool. Now, obviously that’s not an in-depth thing that you’re going to be way down the Lean journey like a Toyota forever kind of thing, but it’s a way to introduce people to looking at their work a different way, and that’s really kind of the key for us was “Let’s teach people how to work differently. Let’s teach people the seven ways. Let’s teach people to observe and really see what’s going on, rather than just be immersed and the solution’s always more money and more people, really looking for those kind of different ways, different things that we can do to improve efficiency and to improve care.
Joe: Lean seems to be more of a driver in Healthcare than, Six Sigma. Is Lean the dominant way of thinking?
Dean: It’s really interesting. In the early days, it was Six Sigma. That was the more common thing at least that I saw, and I think some of that was because there was a belief that they could go hire a Six Sigma Black Belt, and everything would be wonderful. It’s easy to write a job description for that. There’s a national certification for Six Sigma, so they know that somebody’s a black belt. There really wasn’t a national certification necessarily for Lean back in those days. So it’s kind of interesting reading these job descriptions because I get stuff from recruiters all the time, and they say “You need to take a look at this job description.” Well, they want an RN with a Six Sigma Black Belt, been doing it for 10 years and knows Lean and knows this. I read this, and I think “Well, there are maybe five of those people in the country. You’re kind of excluding some people when you say stuff like that.” But to be fair to them, they didn’t really know what they were looking for. It was kind of like in the early days of manufacturing. Everybody starts going Lean; it’s like “Oh my God; I’ve God; I’ve got to go find a Lean person.” So there’s a little of a scramble going on really trying to figure out what they need and how that works. Six Sigma was little more definable back then and where some of that got started.
As those of us who do this for a living know, there’s value in Lean, there’s value in Six Sigma, but it’s just a matter of when to apply those various tools in the various situations. So it’s really, really helping people see “What’s the issue I’m trying to deal with? Is it a time issue? Is it a quality issue? Is it a variation issue?” What are the right things to apply at the right time and there are not a lot of people in Healthcare. There are a lot more now versus when I started back in 2005, but there’re not a whole lot of people in Healthcare that have been successful at doing this, so that’s one of the challenges. It’s really a different industry, and you have to learn the industry and learn the different things that are going on and kind of figure out how it works.
Joe: Can you give me some of the pitfalls that you’ve found in putting Lean into Healthcare?
Dean: Well, the biggest one was just learning the business itself. It’s a very different business. It’s a very different workforce. It’s a different dynamic as far as leadership is concerned. There’s a lot of power outside of a hospital, for example; that is held by physicians, which is kind of a different thing because a lot of physicians don’t work for the hospital. They work independently if they’re in a town that’s got more than one hospital they can kind of play them off each other. “We’d like you to do this.” “Well, the other guys don’t make me do that, so maybe I’ll take my business down the street.”
Learning all those dynamics and learning really what the big issues were, and also learning how the Center for Medicare and Medicaid Services, or CMS, applies the rules and how those rules need to be followed by the hospitals, the doctors, the insurance companies, and so forth. It’s learning a lot of the industry dynamics and then saying, “All right, let’s take a look at what are the two or three things that drive you crazy?” just like in a manufacturing business, whether it’s quality, whether it’s scrap, whether it’s time. One of the key things is that business is not getting paid by the insurance companies. Whatever it is, really trying to understand that whole business dynamic and then, coming back and saying, “All right, now we get it. How do we address some of these things?”
I’ve read a couple of the articles that say the Healthcare business is the more complex by a factor of; I forget the factor, then the automotive manufacturing business where this started because there’re so many things going on under that roof, because it’s not just taking care of patients, it’s doing laundry and it’s preparing meals and it’s doing all sorts of things beyond just the direct care of the patient, so really trying to figure out that whole system and how that system does not work together, which is what we find in a lot of areas.
Joe: Well, one of the things that you remind me of as you’re discussing there is I think the hospital is kind of an ecosystem in itself. In this little world that can evolve by itself with food and different people going in and out, but a lot of the control or I shouldn’t have said, control’s probably a bad word, but a lot of the influences are from outside sources, doctors coming in and so things are constantly evolving and control is constantly moving back and forth a little bit. It does seem a little complicated.
Dean: It really is and trying to figure out how, if we make a change in this area how it affects that area. It’s complicated on an assembly line, but it’s even more complicated in a system like this because there’re so many different dynamics, so there’s such a big web of things that go on, it’s like a spider web. You touch it on one side, and it affects the other side, but you’re not sure exactly how until you get over there.
So as we look at Value Stream Mapping and look at mapping those things out and really understanding all the different wrinkles that take place just simply from a visit to the emergency room by a patient. How many different departments get involved in that visit? Even if they’re only there for an hour, there’re six, eight, 10 different departments that are affected. How does all that fit together and then how do those departments that also serve other areas of the hospital, how is a change going to affect all that complexity goes on in there? And that’s really, to me, one of the biggest challenges.
The next one is really helping people see, I’ll tell you what, and you will never see a better workaround person than a nurse. Nurses are tremendous workaround people. They do anything they can to take care of those patients, but the problem is that it’s a workaround. It’s not solving the problem, and helping them see that they’re not solving a problem five times a day because if they were solving it five times a day, they’re not solving it. They’re just working around it. And helping them see that if we can eliminate that problem, “Oh, by the way, you’re going to get some more time in your day back. You’re not going to have to do that anymore.” So that’s another challenge, is really helping people see, again, seeing their work kind of a different way.
Joe: It is really a system thinking type concept that you have to use, as you mentioned because one change can affect so many different parts of the organization.
Dean: Absolutely, and that’s the trick is really trying to figure the system out, you know, as we’ve had all this debate about the Affordable Care Act over the years, nobody understands the system. A lot of people think they do, but nobody really does because we don’t know how payment reform’s going to change things; we don’t know how the different taxes or the different fees or the different things are going to affect things. We don’t really know until it happens, and we start to see the ripple effect of these things that kind of happen across the system.
So, as we look at, and people ask me all the time “What do you think of the Affordable Care Act?” my answer always is “It doesn’t matter what I think. It’s there. It’s the law of the land, so we need to really figure out how it works.” We need to figure out how it affects us and we need to figure out what we can do to be better prepared for some of those changes that are coming in 2014 and 2015 and some of that’s just taking the waste out of our system, just like we were taught back in Lean 101 in manufacturing. It’s the same kind of thing, but it’s just a different environment that we’re playing in.
Joe: Well it seems like that everybody should have a lesson in the red bead experiment and tampering a little?
Dean: Well, it does, and one of the things is helping people see that. From my perspective people ask me about the difference between manufacturing and hospitals. “Hospitals are about 20 years behind” because in the old days, they never worried about money. They didn’t really worry about being a business. It wasn’t an issue. Well now that the funding is different, it is a big deal and they have to start running like a business, they’re starting to catch up with some of the improvement techniques that we’ve had in manufacturing for years and years and years. So, we’re on a time lag. You can learn some lessons from what happened in manufacturing and apply them to Healthcare in such a way that we can kind of see what’s coming and see what the next step is. It’s not going to stop us from going through that step, but at least we’ll understand it as we go along, and that helps us progress.
Joe: Getting back to the collaborative, what are some of the things that have been difficult keeping the collaborative going and keeping the meetings and lesson going? Has that all worked like clockwork? Has it worked well or have there been some efforts required to keep that learning and that collaborative going?
Dean: Oh, there’re always wrinkles along the way. Think of it in terms of a Lean event. In a Lean event, everybody gets all excited, and you go in the event and you have a big old time and then you go back to work, and you’ve got work to do and you’re busy and you’re “Oh; we don’t have time to do that. We don’t have time to do this.”
Running a collaborative isn’t any different; because as we look at the collaborative, it’s funded, we get some funding from the government, we get some funding from some of our partners, suddenly times get tight “Well gee, maybe we shouldn’t give those guys so much money. Well, if we don’t give them any money, they won’t be able to do anything.” So those kinds of things, kind of the going-concern kind of things are critical.
Let me jump over to the Iowa Lean Consortium, which we just started about four years ago or three years ago, same kind of thing. Where we’ve got some sponsors, we’ve got some memberships, and we’ve got some of those kinds of things going. Are we providing enough value? And it all comes back to value just like we learned in Lean thinking. Value is what it’s about. So are we providing the value that our customers want? And if we’re not, what do we need to do differently?
There’s always that tension. There’s always that kind of constant back and forth as far as how we’re going to stay in business or should we stay in business? Are there things that we still need to do? The answer right now is yes that we should stay in business because we’re adding value to the Healthcare performance in Iowa. On the Lean Consortium side, we’re adding value to our members, so those kinds of things are always there. We have to be conscious of them. We’ve got to make sure that we’re paying attention to them. As long as we’re continuing to do good things and add value we want to, we believe we’ve got to keep going.
Joe: Initially, how many members were there in collaborative?
Dean: In the Healthcare collaborative we’ve got 118 hospitals and then we’ve also got a medical society which is all the doctors in the state. We’ve got now 5,000 doctors give or take, something like that. If you’re a member of the hospital association or a member of the medical society, you can use our services.
Right now, I spend a lot of time driving around the state of Iowa going from hospital to hospital kind of talking to them. It’s just kind of the Lean basics education, sometimes it’s strategic planning, sometimes it’s the application of a tool, and sometimes it is helping them run an event. So, all the different hospitals and clinics and so forth across the state can use our services.
Joe: What role does a consultant play in a collaborative?
Dean: Again, it’s one of those financial things we have to deal with. Right now, the way we’re funded and we’re not really charging anybody for anything other than just their memberships and their respective organizations. If they need deeper work, I kind of give them the basics and kind of help them get started, if they need to go deeper we’ve got a network or a group of people that I’ll refer a hospital too. “You know if you want to go deeper, go see this guy or that guy or this consulting group or that consulting group.” So they can get some more in-depth, and that’s at a fee.
So there’s kind of pluses and minuses if you’re an income independent consultant doing Healthcare in Iowa, one of the downsides is I’m stealing a little of your work, but on the other side if they need more work I’m giving it, I’m also giving it back to them. So we’ve got that kind of relationship, kind of between what I do and what the independent consultants do.
Joe: If someone was looking at starting a collaborative in any field, okay, Healthcare, manufacturing, give them a little of advice on where they might go or how they would start.
Dean: I wasn’t part of the beginning of the Iowa Healthcare Collaborative, so I can talk about the Lean Consortium a little that we did start several years ago, and one of the things that we got together and kind of had a “what should this be” session where we rounded up a bunch of the people we knew and had a consultant come in and help us conduct a session. So really, it’s kind of a 3P in a way because we were looking at “Well, what should we do and how should we structure it, and what kind of things should we offer?” and all those kind of things and we wanted to do that in advance and not just say “Let’s have a consortium. Let’s all get together and do some stuff.”
Well, let’s figure out what that stuff is. Let’s figure out what the value is. Let’s figure out what it would mean to be a member, what are the things if I was a member I would expect, what are the things that we can provide that are going to give value to those members? How are we going to deliver it? You know, what are the delivery methods? Is it live? Is it online? Is it podcast? Is it webcast? All those kind of things we wanted to work out in advance before we started taking people’s money essentially because we wanted to make sure that we were going to give something with value.
Again, back to our Lean thinking days; it all starts from value. From there, we said, “All right, should we be a single industry thing? Should we be a multi-industry thing? Is this something that beginners can be part of as well as experienced people can be part of?” We were really kind of setting the framework for what we wanted to be.
Around the country I know, there’re manufacturing-only ones, and there’re multi-industry ones and it really kind of depends on what their area is and what is available in their area. Make sure people don’t have to travel too far to get there, those kinds of things. So all those things were factors as we put the Lean Consortium together, really trying to understand how it’s going to be used, how it’s going to be deployed and what are the things that people are going to get out of it?
Joe: Well now four or five years later what would you have done different at the beginning?
Dean: I think we evolved in such a way that it worked. We got a lot of people to volunteer their services, several people, including myself; we’ve got educational material; we’ve got things that we had available to us and we said, “all right, we’re going to go talk about Value Stream Mapping.” So we rounded up some people that knew how to do Value Stream Mapping, and we put it on the website and it filled up.
Then we did one on a different subject, and it filled up, and then we did one on leadership, and it filled up. That told us “Well, something good’s happening here. We must have some good things going on.” We consciously put together a board of directors, and we made ourselves a nonprofit and all that kind of stuff so that we could operate, and then we said, “All right. Should we continue with this?” Every time we’d have a session we’d ask people “Was this valuable? What subjects would you like covered?” make sure we got the voice of the customer with us all the time so it’s not just us “Lean experts” trying to figure out what people should know. We want to give people what they want to know, those kinds of things, so really making sure that we understood our customers who, in a lot of cases were us, were ourselves as far as customers of the information, the customers of the experience, and helping those craft things around what the customers were telling us that they wanted.
Joe: Has the consortium developed into; it’s statewide, but are there regional pockets where meetings take place or do you do it online to track the outer perimeter or how do you do that?
Dean: What we’ve been trying to do is move things around. So everything’s, the center of our state’s Des Moines, that’s where I’m sitting right now, but there’re people that live in eastern Iowa, there’re people living in western Iowa, southwest, northwest, so it’s those kinds of things. What we’ve tried to do is move our events around to different places so everything’s not in the center of the state, everybody doesn’t have to drive two or three hours to get there, and looking for those different regions, looking for those different regional groups, there’re several regional groups in Iowa. Some of the community colleges have regional groups that they’ve put together, so we’re trying to tie all those folks in and bring them into the fold and really use their resources and look for their needs and so forth. Iowa’s not a huge state, but it’s a pretty decent-sized state. We’ve got 3 million people, and it’s 400 miles from one side of the state to the other, whatever it is, 300 miles
Joe: I was going to say, it’s like a six-hour drive across, isn’t it?
Dean: Yeah, it’s substantial. I mean, there’s some size there, so we do get into some issues with travel, so again, we try to move things to eastern Iowa or northern Iowa or central Iowa, western Iowa, whatever we can do just to kind of mix things up a little.
Joe: How often do you meet?
Dean: We get together, and again; I’m talking about the Lean Consortium again, we get together; we just had a board meeting yesterday. We get our board together once every six weeks or so. We’ve got committees. We’ve got a membership committee. We’ve got an events committee. We’ve got a marketing committee to address those specific issues, so they get together and talk about “How should we market our services?” The events’ committee is really responsible for getting events together, getting the instructors or speakers or whoever it is, getting the locations identified and those kinds of things. Membership, they’re just looking for ways to increase our membership, so we’ve got more revenue, so we can do more things, kind of building on what we have.
So, we do get together pretty regularly just to make sure we’re staying on top of things, and we try to offer things once a month. When you’re trying to offer something once a month that’s kind of a multi-industry thing it’s kind of a challenge sometimes. We really try to stay on top of things.
Joe: Is there an active interest in keeping it growing? I mean, is that what is required to sustain it? Do you need growth or is it pretty self-sustainable?
Dean: We kind of keep an eye on things. We’d like to grow into a situation where we’ve got a full-time director. Right now, we’ve got a part-time administrator, somebody that can kind of drive it. We work with, again; we’ve got people in government; we’ve got people in a variety of industries, so we want to make sure that what we do develop over time is sustainable. Those members are getting value out of it. We brought in John Shook recently, so that was kind of fun. We are going to bring in Jamie Flinchbaugh in the fall, Art Byrne we’re talking about bringing him in; we are trying to get some of the heavyweights. We are taking a look at that. We want to make sure that if we’re going to continue to do that, if people continue to like that, we’re getting real good, very good feedback on that, that we can keep this thing affordable. The way you keep it affordable is you keep your membership happy, for one thing, and then you continue to grow your membership. That gives you more revenue and more resources to go out and get those big name speakers, so we try and do that at least once a year, maybe twice, and then look for some kind of smaller events where we can teach a tool or talk about a specific technique or do a plant tour or something like that. We got a variety of different things that if I’m a Healthcare member, for example, I’ve got some opportunities to go see a manufacturing plant or go see how a city uses Lean in their processes and those kinds of things.
Joe: Dean, can you tell me a little more about yourself, of what roles you play? I mean, you’re instrumental in the Iowa Healthcare Collaborative; you’re instrumental in the Iowa Consortium. Is that the major part of what you’re doing?
Dean: It is today. I work full-time for the Iowa Healthcare Collaborative, as their Lean guy, and that’s my hospital work where I go around to the hospitals around the state.
Now, the Lean Consortium is the volunteer organization, for the most part. So there’s a variety of us that do it; we do it part time. Our employers give us the time and the ability to do those things, so that kind of multi-industry “Look; I’m on the board of directors for the Lean Consortium”, so that’s, I spend 90% of my time here at the Healthcare collaborative working with the hospitals and the clinics and so forth. I’ve done a couple; two or three training events for the Lean Consortium over time, and then we try to attend; all of us on the board try to attend all those events as they take place. So that’s kind of the relationship. Like I say, the Lean Consortium’s kind of a volunteer situation.
Joe: If someone wants to learn more about the consortium or the Iowa’s Healthcare Collaborative, what’s the best way to contact you?
Dean: The best way would be to go to the websites, and I can give you both websites. The Iowa Healthcare Collaborative is ihconline.org, and the Iowa Lean Consortium is iowaLean.org. So those are the two websites. That’s the best way to get in contact. Both of those have a lot of stuff on them, and it’s all free. We post it on the website; we do that on purpose, so we share with everyone.
The Lean Consortium area does have a members-only area that we’ve got more specific things to the Iowa folks and the people that do, are members of the consortium, but there’s a lot of information on those two sites as far as what we are and what we’re about and how we work. We also have some videos; we have some video links posted on both of those, so there’s some; I do a Lean 101 bit. I do a thing on Rapid Cycle Improvement. So there’s a couple of small webcasts that are out there on the ihconline.org site.
Joe: Is there anything you’d like to add that maybe I didn’t ask?
Dean: I guess the one thing I guess that I would say is as we get asked, and we do get asked every now and then “Should we set up a consortium? What should we do? How should we do it?” My advice is do what you think is going to serve the people in your area the best.” That’s what you’re looking for. It’s not for you; it’s really for the people around you, and helping your industries improve, helping your hospitals improve, helping your governmental entities improve, those kinds of things. It’s really about continuing to learn. That’s something Toyota taught us, is if you’re not learning you’re falling behind. You should be learning every single day, not just whenever you go to class, so really looking at your work in such a way that “How can we do it better tomorrow than we did today? How can we do it better today than we did yesterday?”
Don’t be limited to your own industry. Don’t be limited to your own city. Don’t be limited to your own state, for that matter. There’re all sorts of people out there that are using continuous improvement tools, whether you call them Lean, whether it’s Six Sigma, whether it’s Theory of Constraints, whether it’s ISO9000, who cares, Baldridge, you know; all those things are improvement, ways to get better. Use them all. Use the ones that work.
If you’re using one now and it’s working, keep using it, because it’s about getting better, and that’s something I talk about a lot when I teach is it’s not about getting perfect. It’s about getting better. You can get better every single day. Even if you’re the best in the world, you always work on getting better. You look at athletes that are the best in the world, and they continue to improve. They continue to work on their game. It’s the same thing for us. If you’re just kind of sitting back saying, “Well, we’ll get better six months from now,” well, you may not be around six months from now. So let’s work on getting better now. Really look for those opportunities. There’re ways to do these things. Sometimes they’re frustrating, sometimes they’re hard, but you’ve got to do them. You’ve got to keep getting better. That’s kind of what it’s about.
Joe: I would like to thank you very much. I appreciate it. This podcast will be available on the Business901 website, and also the Business901 iTunes Store. So, thanks again Dean.
Dean: Thank you.
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