38 Bibiliography Feitelberg, Sam uel B. (1966). Basic considerations o f a jo b description. Phys. Ther. 46, 383-386. 386. Lister, M arilyn J. (1966). P erform ance evaluation o f the new staff mem ber. Phys. Ther. 46, 387-390. 387-390. JUNIE 1980 R ochelle, D o n n a (1966). H ow to answ er questions. Phys. Ther. 46, 428. T odd, J. W . (1977). T h e use o f hospitals. 6 Analyses. Update, A pril, 935-938. K enly, Judith D. (1972). A supervisor’s view of staff evaluation. S. Af r. J. Physiother. 28, 2-4. W hitfield, A. G. (1978). C hair a com m ittee. Br. M ed. J. 2, 936-937. F I S I O T E R A P I E PRELIMINARY THOUGHTS ON AUDITING T H E EFFIC IEN C Y OF A PHYSIOTHERAPY SERVICE USING A COMPUTER PROGRAMME M. J. R U N N A L L S , Dip. Physio., C .T.P. (Cape Town)* A B S T R A C T T h e initiation o f a docum entation audit o f the efficiency o f physiotherapy services provided in a large general teaching hospital is discussed. R esults and trends o f behaviour as analysed by com puter program m es are show n. I N T R O D U C T I O N T h e T ygerberg H ospital is n o t only a large general teaching hospital b u t also p a r t of a large provincial hospital (state controlled) organisation. Thus, because of its very size (1 750 beds) and the hierarchy in the m anagerial system th ere will naturally be certain in trin ­ sic problem s. T o be confident th a t there is an adequate physiotherapy service in both out-patient departm ent an d w ards is n o t easy. I t is also well nigh im possible fo r the senior physiotherapy staff to keep track of all th a t occurs. T h e fact th a t a ju n io r o r even a senior m em ber o f staff, is unhappy, o r perhaps in adequate as regards their w ork p o ten tial and capacity can go u n ­ noticed. I t is also difficult to defend th e departm ent against ju s t o r unjust criticism from higher authorities, th e m edical profession, nursing profession, o ther allied health services an d peers unless its effectiveness (the case) can be substantiated very clearly. F urth erm ore, it should be rem em bered th a t litigation w ill inevitably become m ore prevalent an d substantiative evidence again will be essential to defend th e case. M E T H O D W ith these p roblem s in m ind a docum entation audit has been instituted based on th e w ork o f K h an and H ow royd (1976) w ho posed th e follow ing questions: 1. Is an acceptable stan d ard o f care being provided? 2. Does th e present stan d ard o f care show any im ­ provem ent over previous years? 3. Is the staff com petent? 4. Is full use of resources being m ade? A uditing o f docum entation becomes a way o f assess­ ing th e efficiency o f th e departm ent. F u lly realizing that this is purely a “docum entation” au d it it can, however, b e regarded as a relevant an d reasonable m easurem ent o f efficiency o f th e services provided. Such an au d it can * Senior L ectu rer and H ead o f D ep artm en t of Physio­ therapy, U niversity of Stellenbosch and T ygerberg H ospital. Received 30 A pril 1980. O P S O M M IN G D ie instelling van ’n dokum entasie-oudit van die doel- treffendheid van fisioterapie-dienste wat in ’n groot op- leidingshospitaal voorsien word, w ord bespreek. R esul- tate e n gedragspatrone soos deur rekenaar-program me ontleed, w ord aangedui. be evolved around two focal points, and the Problem O riented M edical R ecord approach propagated by W eed (1968, 1971). T h e tw o focal p oints are: 1. T h e physiotherapist viz. the m easurem ent o f p ro ­ fessional com petency and 2. th e system viz. the identification o f problem s which lim it th e system and thus th e com petency of the physiotherapist. W ith regard to the physiotherapist th ere a re fo u r characteristics o f professional com petency which can be analysed: 1. C om pleteness: A re all the data fully re c o rd e d ' A re all th e problem s identified? A re there plans pertaining to all the problem s? 2 R eliability: A re the data accurate? A re all the d ata kept up to date? A re all the plans instituted? Is there evidence th a t th e latest treatm ent m o d ali­ ties are being im plem ented? ^ 3. S ound analytical sense: Is there evidence th a t tq d ata obtained are used to solve th e problem s? 1_ the plan th a t has been developed relevant to the d ata? D oes the plan tak e cognisance, o f th e latest treatm ent techniques? A re all the plans realistic? 4. Efficiency: A re the problem s solved within a rea­ sonable am ount of time? A re alternative treatm ent m ethods im plem ented when necessary and as soon as possible? A docum entation audit th a t w ould fulfil all th e above- m entioned factors w ith certain m easurable criteria had to be established. F o r this p u rpose au d it form s fo r long­ term patients (hospitalization o f m ore th an 14 days) and an d short-term patients (hospitalization of less th an 14 days) w ere evolved. T hese form s were draw n up so th a t th e results could be com puterized an d w ere based on th e form proposed by K h an and H ow royd (1976). (Figs. 1 an d 2): A sh o rt com puter p ro g ram m e was w ritten to calculate th e percentages fo r each sub-section o f the au d it form . T hese percentages w ere then used fo r fur- there analyses. By m eans of th e B M D P 9D program m e of the B M D program m e package a m onthly analysis of efficiency was possible. F u rth e r com puter program m es w ere set up to show th e trends of behaviour in the v arious sub-sections o f the established criteria fo r effi­ ciency as well as to establish auditor bias. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE 1980 P H Y S I O T H E R A P Y 39 F o ld er No. □ □ □ □ □ □ □ □ D ate o f D M Y reference □ □ □ □ □ □ TYG ERBERG HOSPITAL D EPA R T M E N T OF PH Y SIO TH ER APY A U D IT OF SHORT-TERM TREA TM EN T N /A = 8 o r 88 1. Referral *1.1 A uthorized referral 1.2 P atient seen w ithin 24 hours *1.3 R eferral has p rim ary diagnosis/requires evalu­ ation to help diagnose 1.4 C ondition fo r which treatm ent is required is specified 1.5 R eferral has sufficient relevant inform ation *1.6 C ontra-indication (if any) m entioned Yes 6 6 3. Treatment 3.1 T reatm ent p lan outlined 3.2 R e p o rt to /o r discussion w ith th e referring doctor *3.3 Safety measures in adm inistration of treatm ent noted 3.4 T reatm en t noted on each visit 3.5 F requency o f treatm en t sufficient Department Audited Perhaps N o 3 0 1 0 Assessment 2.1 H istory 2.2 O bjective findings 2.3 Subjective findings 2.4 H om e/w ork situation noted 2.5 X -ray an d la b o rato ry findings noted 0 0 0 0 2 1 0 10 5 0 4 2 0 2 1 0 2 1 0 2 1 0 6 3 0 6 3 0 2 1 0 2 1 0 Code Points □□ □ □ U□□□□ □□ □ □ 4. Progression *4.1 Im provem ent n o ted a t least once a week 6 3 0 □4.2 T reatm en t plan changed to suit p a tie n t’s c u r­ re n t condition and reasons given 6 3 0 □ 5. Discharge and follow-up procedures 5.1 Present condition noted 2 1 0 n 5.2 T o tal discharge o r fu tu re treatm ent noted 2 1 0 n 5.3 H om ecare and follow -up noted w here necessary 2 1 0 n 6. General 6.1 A ll entries dated and signed 2 1 0 n 6.2 A p p ro p riate utilization o f professional time 2 1 0 n 6.3 G eneral neatness 2 1 0 □ Sub Audited by □ □□ Team N o. on D ate o f A udit □ □ D M Y □ □ □ □ □ □ S I 4 I 1 I 0 I 1 I Fig. 1 A n auditing com m ittee o f five representatives o f the m ost senior to th e m ost ju n io r m em bers o f staff were appointed on a th ree m onthly basis. In this w ay it was hoped th a t any a u d ito r bias could be countered. The auditors and th e various departm ental areas w ere as­ signed num erical values. E ach a u d ito r was responsible to r certain departm ental areas and drew a treatm ent to rm fo r auditing p e r week from each departm ent. F o r departm ents w here m ore than one physiotherapist was w orking a form p e r week per physiotherapist was drawn. were forw arded ̂ o r a 7 a K s . th e C° mPleted aUdh f° rmS DISCUSSION "Hie Institution o f this system initially m et w ith som e resistance by th e physiotherapists w ho regarded it as a nuisance to be 100% accurate both w ith docum entation o f th e treatm en t and when auditing the treatm ent form s. T h e latter form s are rejected by the com puter centre if they a re not com pleted accurately! T h e im plications and function o f th e docum entation a re now understood an d valued by the physiotherapists. T he aim s o f docu­ m entation are thus: 1. to assess th e standard of care being provided R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 40 F I S I O T E ' R A P I E JUNIE 1980 T Y G E R B E R G H O S P IT A L D E P A R T M E N T O F P H Y S IO T H E R A P Y A U D IT O F L O N G -T E R M T R E A T M E N T F o ld er N o. □ □ □ □ □ □ □ □ D ate of D M Y reference □ □ □ □ □ □ N /A = 8 o r 88 1. R eferral Yes Perhaps N o Points *1.1 A uthorized referral 6 3 0 □ 1.2 P atien t seen within 24 hours 2 1 0 □ *1.3 R eferral has p rim ary diagnosis/requires evalu­ ■ atio n to help diagnose 6 3 0 □ 1.4 C ondition fo r which treatm ent is required is specified 2 1 0 □ 1.5 R eferral has sufficient relevant inform ation 2 1 0 □ *1.6 C ontra-indication Of any) m entioned 6 3 0 □ 2. A ssessm ent 2.1 H istory 2 1 0 n *2.2 O bjective findings 10 5 0 o n *2.3 Subjective findings 4 2 0 □ 2.4 H om e/w ork situation noted 2 1 0 □ 2.5 X -ray and la b o rato ry findings noted 2 1 0 □ 2.6 Sum m ary o f problem s 2 1 0 □ 2:7 P atien t seen as a w hole 2 1 0 □ 3. T re a tm e n t 3.1 T reatm en t p lan outlined 2 1 0 □ 3.2 T reatm ent p lan evident of stated problem /s 6 3 0 □ 3.3 R ep o rt to or discussion w ith the referring doctor 6 3 0 □ 3.4 A dditional treatm ent noted 2 1 0 □ *3.5 Safety m easures in adm inistration of treatm ent noted 6 3 0 3.6 T reatm en t noted on each visit 2 1 0 3.7 F requency of treatm en t sufficient 2 1 0 _ 4. P rogression *4.1 Im provem ent noted once p e r m onth *4.2 T reatm ent plan changed to suit p atien t’s condi­ tion/changed within a week if not effective 4.3 Changes and reasons fo r noted □ □ n D ischarge an d F ollow -up P rocedures 5.1 P resent condition noted 5.2 T otal discharge or fu tu re treatm ent noted 5.3 H o m ecare and follow -up noted w here neces­ sary D e p a rtm e n t A udited A udited by D ate of A udit □□ □ G en eral 6.1 A ll entries dated an d signed 2 1 0 □ 6.2 A p propriate utilization o f professional time 2 1 0 □ 6.3 G eneral neatness 2 1 0 □ C ode Q H Sub n Team N o. □ □ D M Y onnnen S I 4 I 1 I 0 I 1 Fig. 2 2. to assess im provem ent in the standard o f care provided 3. to assess th e com petency o f the staff 4. to identify any problem s within the system which prevent treatm en t being effected com petently 5. to provide continuity o f p atien t care betw een p h y ­ siotherapists 6. to pro v id e continuity and . co-operation between m em bers of the health team 7. to provide clinical records fo r research purposes 8. to provide evidence in the case o f possible litiga­ tion. / T h e im m ediate effect of instituting the auditing p ro ­ gram m e was the pin-pointing o f problem s in several R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) JUNE 1980 P H Y S I O T H E R A P Y 41 T YG ERBERG H O SPIT A L /H O SPIT A A L D E PA R T E M EN T FISIOTERAPIE : D EPA R T M E N T O F PH Y SIO TH ER APY F ISIO T E R A P IE -B E H A N D EL IN G /T R E A T M E N T B Y PH Y SIO T H ER A P Y 15- 2 D O K T O R SE V E R W Y S IN G D O C T O R ’S R E F E R E N C E Behandeling voorgestel t r e a t m e n t suggested .......................... T 'een -in d ik asie en a n d e r opm erkings C ontra-indication an d o th er rem arks G eneesheer D o cto r .............................................. V an en V oorletters S urnam e and initials L eer nr. F o ld er N o ................... R as/G eslag R ace/Sex ... G eb. D atum ...Date o f Birth Saal/A fdeling ..W ard/D epartm ent Adres A ddress F oonnom m er ..Phone N o ...... D iagnose D iagnosis D atum D a t e ... D atu m v an O pvolgkliniek ..D ate of next C linic ...... F IS 1O T E R A P IE -0 E H A N D E L IN G / T R E A T M E N T BY P H Y S IO T H E R A P Y Fisioterapeut-in-bevel Physiotherapist-in-charge Vir voltooing deur Fisioterapeut by Ontslag: For completion by Physiotherapist on Dischaige: Datum van Ontslag: D ate o f Discharge: R ehabilitasie voltooid Ja/N ee R ehabilitation com pleted Y es/N o Verwys na: Referred to: 1. G eneesheer, N aam D octor, N am e 2. F isioterapie B uitepasient D epartem ent P hysiotherapy O ut-patient D epartm ent 3. M aatskaplike W erker, N aam » Social W orker, N am e A rbeidsterapeut, N aam O ccupational T herapist, N am e 5. 5. D aghospitaalorganisasie, N aam D ay H ospital O rganisation, N am e 6. R ehabilitasie-kliniek (TBH) R ehabilitation Clinic (TBH) 7. A nder O ther H andtekening van F isioterapeut: Signature o f P hysiotherapist: ....................... Tuisoefeningprogram Ja/N ee H om e Exercise P rogram m e Y es/N o G eskik vir werk Ja/N ee F it fo r w ork Y es/N o D atum van verwysing D ate of referral D atum van eerste afspraak •Date of first appointm ent D atum van verwysing D ate of referral D atum van verwysing D a te o f referral ■ D atu m van verwysing D ate o f referral D atum van verwysing D ate of referral Fig. 3 areas w here there were no fixed data bases fo r clinical assessments. This resulted in the form ulation of several new specific evaluation form s, e.g. fo r am putation and intensive care patients. F urtherm ore, the aud it dem anded a global sum m ary of each patient. This resulted in the form ation o f a new departm ental reference form (Fig. 3) which was to precede each specific evaluation. This form em braces a t a glance a precis o f th e p a tie n t’s particulars, the medical referral and the total rehabilita­ tion program m e, and indicates the physiotherapists responsible fo r the treatm ent program m e. F rom th e table, Fig. 4, it can be seen th a t initially the efficiency of treatm ent of the short-term patients lagged som ew hat behind th a t of th e long-term patients. Because this system was in its initial stages it was decided to place the average totals for the short-term and long­ term patients in large figures on th e staff tearoom notice board each m onth. L ittle was discussed but weaknesses were po inted o u t individually to th e physiotherapists. It is possible to draw th e aud it form and po in t o u t specific problem s and discuss them . As can be seen there was an overall im provem ent in the percentage efficiency from R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 42 F I S I O T E R A P I E JUNIE 1980 Analysis of some pertinent results from April-December 1979 1. T o tal percentage efficiency S H O R T -T E R M R ESU L TS M onth A pril M ay Ju n e July A ugust Septem ber O ctober N ovem ber D ecem ber L ong an d short-term 76,1 70.3 64.7 75.7 80,9 76.4 76.4 81.4 82.7 Fig. 4 Long-term 80,1 76.2 74.3 82.5 84.5 80,8 80.3 81.5 85,1 Short-term 70,0 65,9 58.6 71.6 78.3 72.8 73.8 81.4 81.4 A pril-D ecem ber, 1979. F u rth e r analysis o f th e short-term audits show ed th a t th e w eakest areas w ere th e sub-sections fo r evaluation an d treatm ent. T his was n o t p articu larly gratifying but an in-depth analysis reveals th a t th e areas w hich needed m ore attention were: 2.4 H om e/w ork situation noted 2.5 X -ray an d lab o rato ry findings noted 3.1 T reatm en t p la n outlined 3.2 R ep o rt o r discussion w ith the d o cto r w ho referred th e p atien t 3.3 Safety m easures in th e adm inistration o f treatm ent noted. A general tren d o f im provem ent in these sections was noted over th e n in e m onths of th e audit. (See Fig. 5) System changes envisaged: 1. M any weak points have been identified and im ­ proved. Some sections have, how ever, still n o t im proved lis much as hoped. Because o ther factors have rem ained it constantly high values an d show little change it would seem w o rth w eighting th e areas requiring m ore im provem ent m ore heavily. B efore taking this step, however, the present system will be continued fo r A pril M ay June July A ugust Septem ber O ctober N ovem ber D ecem ber E valuation T reatm ent 69,5 55,5 56,2 38,4 49,8 32,9 59,9 51,9 69,7 65,1 64,1 52,3 68,8 54,1 80,7 60,5 74,5 66,5 Fig. 5 an o th e r 3 m onths because o f a large change in staffing a n d m any new ju n io r staff mem bers. 2. T o issue m onthly a simple com puterized plan o f the sub-sections on evaluation an d treatm en t fo r each specific d ep artm en t to facilitate im provem ent o f th e sp - areas by th e individual physiotherapists. Fig. 6 shov^ J a breakdow n o f the unit on treatm ent planning in the sub-section. C are m ust be given to docum enting the treatm en t plan in all the cases falling to th e left o f the M value. 3. P ractice au d it sessions w here the auditing com m it­ tee will au d it th e sam e form independently and then discuss the points allocated. I t has been show n statis­ tically th a t som e auditors are very strict and others a re very lenient. H opefully practice au d it sessions will bring a b o u t a m o re uniform strictness in marking. CONCLUSION T h ere is still m uch th a t needs to b e learned a b o u t th e validity an d im plication o f such a docum entation audit. I t is nevertheless very interesting to see th e efficiency of th e physiotherapy services num erically evaluated. It is also felt th a t th e w hole system serves to rem ind physiotherapists o f th e global approach necessary to T reatm en t p la n stated: M ean 1,0274 St Dv. ,912 Cell S S M S S 1 A (frequency of 1 0 + ) 2 A 3 4 65 4 6 3 7 o 4 8 8 9 4 10 3 11 12 913 I 14 « 15 1 16 1 17 418 4 Cells 1-18 = V arious departm ents e.g. paediatrics, out-patient neurology. M = 1,0274 = M ean of to tal points scored. F requency o f form s audited = o th er num erical values. Yes 2 Perhaps 1 N o 0 Points R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p atien t care which so o ften tends to fall by th e w ay in this busy w orld o f ours. R eferences K han, A ., H ow royd, H . A . (1976). P hysiotherapy care audit and peer review. Physiother. Can. 28, 163. Weed, L. (1968). M edical records th a t guide and teach. JUNE 1980 43 N e w Eng. Jnl. M ed. 278, 593. Weed, L. (1971). Q uality control an d the m edical record. A rch. Int. M ed. 127, 101. A cknow ledgem ents D r. D. J. van Schalkwyk, D ep artm en t fo r B iostatis­ tics, S outh A frican M edical R esearch C ouncil. p h y s i o t h e r a p y PRACTICE MANAGEMENT P A U L SULCAS, B.Com., B.A. (Hons.), T h is article is based on a presentation by the author at the A n n u a l General M eeting o f the Private Practi­ tioners Association o f the So u th A frica n Society o f Physiotherapy held in Cape T ow n during February 1979. V arious aspects o f practice m anagem ent are dealt with, and suggestionsjrecom m endations m ade as to pos­ sible courses o f action w hich could overcom e actual (or potential) areas o f concern. IN T R O D U C T IO N F o r m any years I have h ad dealings w ith physiothera­ pists. A s to professional com petence in preventative and rem edial treatm en t there can be no doubt. H owever, when it comes to general adm inistrative m atters there can be n o do u b t th a t m uch can be im proved. W ith this fu ndam ental prem ise in m ind the aspects w hich follow are intended to provide guidelines in two directions, viz. potential areas of im provem ent, a n d /o r confirm ation th a t (if you believe it) y o u r practice is well m anaged and controlled. A SPEC T S O F C O N C E R N 8^ # T h e w aiting room reflects the im age o f y o u r prac- ce. T ry to ensure th a t it is easily accessible an d well laid out; fu rn itu re to be fun ctionally co m fortable and in good condition; the walls, curtains and carpets colourful and m atching; p o tted plants a re always eye­ catching; periodicals should be o f interest to patients an d up-to-date; and d o be punctual w ith y o u r ap p o in t­ ments! # ‘A dm inistrative’ activities are relatively easy to h an d le provided you do n o t perm it a backlog to build up. C onsiderable attention should be given to th e size, content, durability and layout o f th e p atien t record card which, in m any instances, also functions as p atien t’s account card. E n su re th a t all patients are charged, and a t th e correct ra te — double check all additions and subtractions. Rules fo r alphabetical filing of these cards should be devised in o rder to facilitate easy location. T h e handling of paym ents from patients is always a potential problem area and m ust be closely m onitored. T ry to p rep are y o u r m o nthly accounts to patients tim eously to reach the patient, if possible, as near to A ssociate P rofessor, D epartm ent of A ccounting U n i­ versity o f C ape Town. Received 12 F e b ru a ry 1980. M .C om ., D .C om ., C.A.(S.A.), A .C.I.S., A .T .D .P.M .* O P S O M M IN G D ie artikel is gebaseer op ’n voordrag deur die skryw er tydens die A lgem ene Jaarvergadering van die Privaat Praktisynsassosiasie van die Suid-A frikaanse Fisioterapie Vereniging gehou te K aapstad gedurende Februarie 1979. A sp ekte van p ra ktyksb estu u r word bes- preek en voorstellelaanbevelings w ord gem aak ten op- sigte van aksie w at w erklike (o f potensiele) probleem areas kan bemeester. m onth-end as possible (Sulcas, 1976). D elin q u en t payers can b e encouraged to pay by using stickers on accounts, o r th ro u g h personal telephonic contact, o r by w riting a letter. R em em ber th a t if y o u r inflow o f cash is bad because of lack o f y o u r attention/interest, you could have problem s in settling your own outstanding accounts as well as keeping th e Receiver o f R evenue satisfied! # Security considerations are frequently overlooked. H e re specific reference is m ade to keeping y o u r records locked u p in a fire-proof safe during h o u rs when the practice is closed. In addition, equipm ent can be stolen relatively easily and you should have serial num bers readily available fo r th e police. Finally, check the phy­ sical security o f your prem ises fo r ease of unauthorised entry, o r fo r p o ten tial fire h a z a rd circum stances, e.g. your air-conditioning unit. # T h e m ethod o f financing equipm ent acquisition can be problem atic when faced w ith alternative p ro p o ­ sals fo r purchasing, leasing, o r renting. I t is suggested th a t you seek advice fro m som eone w ho n o t only un d er­ stands th e im plications o f these choices, b u t also fully understands y o u r personal circumstances. Y o u r accoun­ ta n t/a u d ito r w ould n o rm ally be ideal. # I f a p artn ersh ip is operational, o r contem plated, ensure th a t a legally d ra fte d agreem ent exists setting o u t th e rights an d obligations o f all parties. Included should be, in te r alia, procedures on dissolution o r adm ission o f a new p a rtn e r, an d on w h at happens if o n e p a rtn e r dies. D espite the friendship of partners, surprising things can (and do!) take place when problem s involving m oney affairs arise. # W ith th e bulk o f y o u r patients being direct referrals from m edical practitioners, it sho u ld be a stan d ard p ro ­ cedure to re p o rt back — this can be done telephonically, b u t it is recom m ended th a t a w ell w ritten re p o rt should be subm itted. N o t only is a p erm an en t reco rd m ade fo r the d o cto r’s files, b u t th e professionalism o f y o u r atti­ tude can n o t fail to create a good im pression. M arketing professionals w ould call this a sound m arketing strategy! # Y o u r p erso n al financial affairs should n o t be neg­ lected, p articu larly when looking to th e future. H ere R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )