Norton Brownsboro Hospital

healing with nature, healing by design to create a healing environment


Creating a nurturing, healing, health care environment doesn't just happen by chance; it takes a concerted effort, discarding the traditional ways of thinking about patient care to develop something that is unique and appealing to today's savvy patient.

In the past, patients typically selected a hospital based on its location, reputation, or perhaps their physician's recommendation. Now, patients consider factors such as the comfort of the patient rooms, overall general appearance of the hospital, how convenient processes are for the patient and the friendliness of the staff, among others. This creates a new paradigm and thus new challenges for the teams charged with building a hospital that meets these new expectations.

Patient satisfaction is a major factor that drives the success (or failure) of a hospital. To create a hospital that is focused on the patient first requires that teams think about service delivery and take total ownership in the plan to create an environment that is integrative in nature versus a silo mentality. A new model of care was needed that would impact all aspects of the project from the design of the facility, to construction, to creation of the optimum processes.


Every project manager feels that if his or her project doesn't go well, then it will be a “disaster.” In health care, however, a project that delivers a malfunctioning piece of medical equipment, processes that are not streamlined, improperly tested software, or poorly trained clinical staff can truly mean the difference between life and death for the patients. Norton Healthcare is serious about making sure all projects are completed on schedule, on or under budget, and with a high degree of quality. Failure is not an option in health care.

The creation of Norton Brownsboro Hospital presented many unique challenges not found in your typical project or construction project. This was the first new hospital built in Louisville, Kentucky, in 25 years and it attracted the attention of the entire community, adding even more pressure to deliver the best.

Design and construction of the hospital had their share of challenges, but to achieve the desired facility that would meet the service expectations of the patient population, the people, processes, and technology had to be the best. This goal created a new set of nontraditional challenges that the project team wasn't expecting. For example:

  • How do you recruit, hire, and train almost 600 employees in less than one year? Especially considering the majority of employees are nurses and technical clinicians (e.g., laboratory, pharmacy, diagnostics).
  • How do you design dozens of processes when the owners of those processes haven't been hired and the technology on which those processes depend hasn't been purchased and/or installed?
  • How do you ensure changes are made correctly to dozens of existing information systems and all new technologies are selected, purchased, tested, and implemented, according to strict requirements, many of which had to interface with one another for the first time?

All of these challenges had to be resolved with a budget that could not be exceeded and an opening date that could not move.

About Norton Healthcare – Setting the Stage

For more than a century, Norton Healthcare's faith heritage has guided its mission to provide quality health care to all those it serves. Today, Norton Healthcare is the Louisville area's leading hospital and health care system (44% market share) and third largest private employer, providing care at more than 100 locations throughout Greater Louisville and Southern Indiana. The not-for-profit system includes five Louisville hospitals, 11 Norton Immediate Care Centers, 10,900 employees, nearly 400 employed medical providers, and more than 2300 physicians on its medical staff. For five consecutive years, Norton Healthcare has been recognized as one of the “Best Places to Work” in Kentucky. The health care system serves patients in the Greater Louisville area, including Southern Indiana, and throughout Kentucky.

How It All Started – From Sod Farm to Health Care

There used to be a sod farm located near the intersection of I-71 and the Gene Snyder Freeway in northeastern Jefferson County, Kentucky; as time passed, more and more families began moving in that direction. Because these people needed places to shop and eat, a large retail center was planned for on the west side of the freeway. This area became one of the fastest growing areas in eastern Jefferson County.

When Stephen A. Williams, president and CEO of Norton Healthcare, observed the growth taking place in that part of the Louisville Metropolitan area, he advised Russell F. Cox, then vice president in charge of facilities and facility planning, that he should check it out. Within a few days, Norton Healthcare executives were having serious discussions with the developer of the adjacent property.

Norton Healthcare's first property was a four-story, 86,000-square-foot medical office building that opened on 10 July 2006. Norton Medical Plaza—Brownsboro was a success even before it opened; immediately, people began asking, “How soon can we build a hospital there?”

Everyone felt strongly that there was a need for an access point for health care in that part of the community. After extensive research, the decision was made to build a new hospital.

Norton Brownsboro Hospital was a major goal on Norton Healthcare's strategic plan and one of the largest undertakings in Norton Healthcare's history. To commit to building NBH was a huge risk because it was a significant investment in capital—$146 million —and had to be completed on a rapid implementation schedule, with a not-to-exceed budget, and meeting all major stakeholder expectations.

Norton Brownsboro – Not Your Typical Hospital

From the beginning, everyone said Norton Brownsboro Hospital would not be a typical hospital. The hospital would address the need for critical health care services within this growing region and provide quality care in a patient-centered environment with a connection between nature, health, and well-being.

The Goal

The goal was not to build a new “old” hospital. Norton Brownsboro Hospital had to be different. What made this situation unique was that the team was able to start with a clean slate, a “green field,” and use the most up-to-date practices to build a hospital that would offer a truly different experience for patients, their families, employees, and physicians. It wasn't just about providing health care services; it was about providing the best environment of care for our patients.

The space program and design relied on national best practices for health care. Significant improvement in patient care has been attributed to the functionality of a hospital through the architectural design, which required unconventional and very attractive solutions to overall facility design. The hospital would feature an open, airy design using abundant natural light; an earth-tone color scheme; wood accents; quieter carpeted nursing areas; and numerous windows overlooking hospital gardens, including large roof-top meditation gardens, to promote a healing environment.

The hospital design, patient care model, and services were developed with valuable input from a wide variety of constituents, including Norton Healthcare physicians, nurses, staff, patients, community leaders, area residents, and others. A thorough review of best practices nationally, including site visits to new hospitals across the country, was also an important part of the planning process.

Everyone was excited about the new hospital and being a part of its creation. As a result of their feedback, a holistic environment would be created with pleasing aesthetics and innovative features. Staff would focus on the needs of the patient first. Stress would be reduced for patients and staff. There would be easy access to service and tools for clinicians to provide safe and effective care.

The patient units would be designed using a unique layout. Patient rooms would be spacious, private, and filled with natural light. Families could relax and take a break in resource centers with complimentary refreshments on each nursing unit. Visitors and family members would have comfortable surroundings in the patient room.

The noise level would be reduced, creating a quiet, calm environment. Noise in health care facilities is a major cause of stress for patients and a distraction for caregivers, especially in the emergency department. Noise is the number one complaint in hospitals today, so there would be no overhead paging; instead, staff would carry mobile devices to communicate with one another. Patients would use the nurse call system to talk with their assigned nurse. Hallways would be carpeted and other acoustical solutions would be incorporated into the hospital. Patients would be able to concentrate on getting well without distractions and frustrations.

Patient Room Layout

Exhibit 1 – Patient Room Layout

Even the interior furnishings of the hospital were designed with the patient in mind. The goal was to create a warm feeling in the facility. Furniture needed to be functional and durable, yet in keeping with the design of the building.

For example, the overbed table is more than just a table. It's the second most used piece of equipment in the patient room. The overbed tables serve as the patient's personal storage, dining space, and as a work surface for the caregiver. Choosing the right style was very important (Exhibit 1).

Equipment is the cornerstone of the space planning process. Clinicians need easy access to the tools that enable them to provide safe and effective care to their patients. The headwall, which contains those tools, needed to provide a careful balance between clinical efficiency and the emerging demand for hospital design. Patients and families desire surroundings that provide comfort yet create a hotel-like atmosphere. The flexible headwall system used at NBH combines a sophisticated design with the clinical flexibility.

Green Guide for Health Care™

Health care facilities present a challenge and an opportunity in the development and implementation of sustainable design, construction, and operations practices. Issues such as 24/7 operations, energy and water use intensity, chemical use, infection control requirements, and formidable regulatory requirements can pose significant obstacles to the implementation of currently accepted sustainability protocols.

Sustainable design and the creation of healthy healing environments aren't new ideas. They actually began by the imperative in the Hippocratic Oath in which physicians are asked to “first, do no harm.” Creating environments that promote healing complements the development and practice of treatments that heal.

It is difficult to design and operate hospitals sustainably due to the complexity and high cost of designing and building health care facilities today. Due to the expanded use of natural lighting throughout the facility, energy consumption was reduced.

Norton Brownsboro Hospital used the Green Guide for Health Care™ (the Guide), the health care industry's best practices design toolkit, integrating enhanced environmental and health principles into the planning, design, construction, operations, and maintenance of new hospitals and other health care facilities. The Guide allows health care organizations to evaluate their progress toward establishing environmentally friendly, healing environments. It includes tips for adding healing design features, incorporating energy and water efficiency strategies, and using safer materials, among others.

The hospital was built with the liberal use of open spaces and “green” building materials. This included an 8700-square-foot courtyard in the interior space above the second floor of the building, which is visible from patient rooms on the third, fourth, and fifth floors and accessible from the third floor. Along with varied landscaping, the courtyard includes a classical labyrinth for meditation and reflection. A walking path labyrinth garden provides spiritual enhancement for patients, family members, and visitors. Evidence-based design concepts were used to create nurturing healing spaces such as this garden (Exhibit 2).

Rooftop Garden Green Space

Exhibit 2 – Rooftop Garden Green Space

Services to be Offered

By the end of the design process, it was decided that Norton Brownsboro Hospital would be a full-service, community hospital, offering a complete range of services. Although complicated and high-tech procedures would be performed, the hospital would be known for being built completely around the patient from both design and process standpoints. The new hospital would also serve as a testing ground for new processes that would eventually be replicated throughout other hospitals in the Norton Healthcare system.

Hospital Construction: More Complex than Your Typical Construction Project

Hospitals are very complex and schedule driven compared with other types of construction. Norton Healthcare required greater integration of the latest technologies. Because of infection control concerns, the levels of clean up and moisture/water control during construction were extremely elevated and required more than the usual “normal construction” processes to build a hospital.

The construction team used the Lean Construction Institute's (2007) processes to help juggle and manage the three key aspects of permitting, design, and construction. Work activities for each phase were identified, constraints applied, and ownership of constraint approval was identified. This helped everyone focus at the strategic level on the overall project schedule.

Unique Regulations for Health Care in Kentucky

Health care facilities in Kentucky require additional approvals and expert involvement that you wouldn't normally have with standard construction for an office building. For example, Kentucky is a “Certificate of Need” (CON) state. New health care facilities cannot be built and/or new services cannot be added for existing facilities unless the requestor proves the need for such health care services exists in that area of the state; only then will permission be granted and construction can begin.

Norton Healthcare filed an application with the Commonwealth of Kentucky's Cabinet for Health and Family Services, Office of Health Policy to relocate an existing Norton Healthcare facility license to Norton Brownsboro Hospital. Approval of the application can be a lengthy process for the CON Office and consists of the following steps: (a) to declare the application complete, (b) to notify the public that the application has been filed, and (c) to provide the opportunity for interested parties to request a public hearing.

Once construction began, a six-month progress report had to be filed with the CON office to show continued progress on the schedule and to ensure the project did not go over budget.

Hospital construction is heavily regulated. Approvals are required from several agencies that are atypical in your normal construction project. The Kentucky Division of Public Health Protection and Safety staff ensures compliance with the requirements of Kentucky Radiation Regulations. which includes the Radiation Health Branch that governs the physical factors and lead shielding requirements for areas such as the catheterization laboratory, computer tomography, magnetic resonance, and radiology spaces.

Accelerated Schedule and Multiple Critical Paths

Programming overlapped design, and design overlapped the construction. Even with the accelerated schedule and multiple critical paths, construction stayed on schedule and on budget from the beginning. The 298,000-square-foot hospital went up very quickly, going from design to opening in a little over three years.

The official groundbreaking was on 12 July 2007. Construction of the hospital was completed in 23 months. A health care project of this size, scope, and complexity normally requires a 30-month construction schedule.

But construction was not without its share of issues. Beside the occasional tool theft, ladder mishaps, and coworker disagreements, the recession hit some of the sub-contractors hard. In one particular situation, to assist the affected small businesses, deadlines were extended, and sub-contractors were paid directly so they could continue to maintain their accounts and flow of orders.

Infection Control

Infection control in a hospital is critical. To pass the strict requirements for opening, it is necessary to “terminal clean” all spaces in the hospital and conduct air sample tests to ensure the hospital is safe to open. Terminal cleaning is a cleaning method used in health care environments to control the spread of infections.

Terminal cleaning is much more than dusting and emptying the trash. The area to be cleaned must be totally sealed off and inaccessible to anyone except the terminal cleaning staff until the air quality samples are tested and at acceptable levels. Coordinating terminal cleaning during final installation of equipment and integrated testing represented a challenge, which required coordination between the installation staff, testing, marketing shoots, and various other outstanding activities involved in getting ready for opening.

Program and Project Management – Leadership and Communication Are the Keys

Norton Brownsboro Hospital was a program with many projects and sub-projects. Maintaining control of the program was essential at all times. When changes occurred in one project, it was the program manager's responsibility to ensure the message was communicated throughout the program management team. Implications of changes, however small, could have wreaked havoc if not addressed promptly across the program. All projects had to cross the finish line together on opening day on 26 August 2009.

Leadership and communication were the two critical areas that ensured the success of each project and ultimately the success of the entire program. Lack of either could have jeopardized the schedule, budget, scope, and/or quality of any of the individual projects and possibly the entire program.

Norton Healthcare's Enterprise Program Management Office (EPMO) provided program management and project management along with project managers and project leaders from information services and an outside construction project management expert. The program manager from the EPMO was brought on board early in September 2006. It was the responsibility of the program manager to focus primarily at the program level, coordinating efforts between projects but not getting into the details of individual projects unless asked to do so.

The projects were organized into logical chunks of work using a program-level, work breakdown structure. The project manager with the most appropriate skill set was assigned to oversee and manage each project, assigning project leaders to technical aspects of the project.

Program Management Team

Program management was achieved through the use of a program management team (PMT). The PMT consisted of the program manager as the facilitator of the weekly team meetings with 14 experienced project managers, 6 of whom were certified as Project Management Professionals (PMP)®. Each project manager was responsible and accountable for managing his or her assigned projects within the program (Exhibit 3).

Program Management Team (PMT)

Exhibit 3 – Program Management Team (PMT)

The PMT met weekly to review progress, issues, risks, and concerns that needed to be addressed at the program level. Project managers had the authority to solve any issues within their own projects as long as it did not affect any other project in the program or affect their budget or timeline. Any issues that crossed multiple project boundaries were discussed at the weekly PMT meeting to ensure risks were managed.

In January 2009, the weekly PMT meetings transformed into weekly integration meetings. As the NBH leadership team was hired, they became part of the weekly meeting, which facilitated the transition process from a program to an operational facility. The business owners' input and feedback were extremely valuable in those final phases of the building completion. Business owners voiced any concerns regarding their areas of responsibility.

Each project manager was responsible for preparing a monthly detailed progress report listing schedule status, budget status, and accomplishments during the current reporting period for each of his or her projects. This was one of the most critical communication deliverables in the program. It was the responsibility of the program manager to extract key progress information and create an “integrated monthly program progress report,” which was published to an extensive list of internal executives and external constituencies. This report was also used by the Strategic Planning department to create the six-month progress report for the state.

Operational Challenges

Once construction of the hospital was well underway, it was time to shift focus and form the project teams to make the hospital an operational reality. Construction still continued to be an active part of the program management team.

Since the construction of Louisville's last new facility, the technologies, spaces, and processes of health care have evolved tremendously. To deliver the best health care you must possess the latest technology and the greatest people and processes; these changes not only required extensive training in technology and processes but also a corporate culture change.


Planning began for staffing in September 2007. The goal was to attract, train, and retain the brightest and best people to enhance the quality of health care services provided by Norton Brownsboro Hospital. Norton Brownsboro Hospital would be recognized as the employment destination of choice for clinicians in the region. Supportive spaces and amenities for staff were included to address work/life balance issues that are high priorities in today's workforce.

Employee Value Proposition

Expectations for the staff were different than those for a traditional hospital. All applicants were required to sign an “Employee Value Proposition” before being considered for a position. The intent was to create a clear understanding of what staff could expect from the hospital and what the hospital expects from staff (Exhibit 4).

Employee Value Proposition

Exhibit 4 – Employee Value Proposition

Recruiting Strategy

A job fair was held early in the recruiting process to provide information to potential candidates for various positions. There were several radio and television advertisements promoting staffing for Norton Brownsboro Hospital.

One significant challenge that posed a huge risk in the success of the recruitment was the discovery that pay rates for registered nurses at Norton Healthcare were not competitive with other health care organizations in the area. To overcome this, Norton Healthcare made system-wide market adjustments to the pay scales of all registered nurses and many other clinical positions, which helped level the playing field when it came to attracting candidates.

During the recruitment planning, the government made the decision to stop reimbursing registered nurses for their student loans. Norton Healthcare made the decision to pay off these student loans as an incentive for joining Norton Healthcare.

An innovative process was created for the actual interviews to help move the candidates through the system in an expeditious manner. Recruitment was the predecessor for training and education. If the staff was not hired according to schedule, there would have been a negative ripple effect through the remainder of the program, and opening day for the hospital would have been seriously jeopardized.

The project schedule for staffing was extremely detailed because of the multiple interdependencies between these tasks and the training and education tasks. The staffing project manager updated the project schedule weekly and kept the staffing team on task.

In the end, the staffing goal for opening day was exceeded. The goal was to have 85% of the nursing and ancillary positions filled by 26 August 2009; the results were: nursing was 98.5% filled and ancillary was 98% filled.

Education and Training

Once staff was hired, they had to be trained. Initial training began with a Norton Healthcare orientation, followed by training on general processes at an existing Norton Healthcare hospital.

It was the responsibility of each person's manager to create a detailed training plan customized for each direct report, which focused on their unique training needs for Norton Brownsboro Hospital. A comprehensive curriculum of courses for clinical processes, technology, and medical equipment training was developed. Norton Healthcare's online “Learning Management System” was used to load course schedules, training plans, and track the results of the training. A combination of web-based and classroom training was used.


The goal of process design was to create a more positive and uplifting environment for the patients and the staff who care for them. Although the design of new processes wasn't the most technical project in the program, it was one of the most challenging from a project management standpoint. It was the responsibility of the process teams to review the circulation patterns focusing on the patient journey from arrival to discharge.

Nurses' Alcove for Monitoring

Exhibit 5 – Nurses' Alcove for Monitoring

Construction, design, and processes needed to work together. Patient doors are positioned so a nurse can monitor patients and make chart entries at a computer-equipped station just outside their rooms to avoid interrupting the patient (Exhibit 5).

To ensure the final designs would provide an optimal arrangement for patient care, a mock intensive care unit (ICU) room, patient room, and surgery suite were built in Norton Medical Plaza. Mock rooms provided prototypes for clinical staff to test and provide input on room layouts to validate size and configuration, windows, doors, millwork, casework, cabinetry, finishes, colors, equipment, lighting, and furniture.

All new processes were tested using the mock rooms. Process design project team members, along with their staff, tested the proposed processes. For example, surgery staff was able to show whether the layout of the operating room suite would work well for a left-handed surgeon as well as a right-handed one. After each change, appropriate staff reviewed the changes in the mock room and retested the processes.

Participation, especially with large groups, is often avoided in projects because it is thought to be time consuming and difficult to manage; however, the participative process used by the design project team defied those beliefs. Large groups working together on process design resulted in spaces and processes that offer an extraordinary patient experience, from arrival to departure from the hospital.


Investment in technology is a critical component in the ability to deliver quality care. Advanced communication and diagnostic technology make the building more flexible.

Modifications to dozens of existing systems were relatively straightforward and required little to no learning curve to each application system and database; however, there was still a significant amount of work that required many resources to ensure the changes were made properly.

Project managers detailed project schedules for each information system to ensure all changes were made and tested in time for integrated testing. Failure of any of these projects to be completed on schedule could have had a severe negative impact throughout the entire program.

The greatest risks surrounded the new technologies that had to be selected, purchased, tested, and implemented. Many of those technologies were new in the industry and didn't have lengthy track records. There was no precedent to follow in developing processes; in many cases, it was purely trial and error.

Several of these systems also were closely tied to the information technology infrastructure in the building and/or other new technologies. Tight coordination was needed between the responsible project managers working in tandem with NBH staff and the vendors. New technologies included:

  • Computerized Physician Order Entry (CPOE)
  • Interactive TV system
  • Nurse call system
  • Emergency department management system
  • Patient self-registration system
  • Bed board management system
  • Patient vital signs monitoring system
  • Bedside medication verification system
  • Radio FrequencyIdentification (RFID) asset tracking system
  • Wireless mobile communication devices for staff

Risks were high. All of these systems required software and hardware acquisition, establishment of new vendor relationships, navigating a steep learning curve and training for the implementation teams and integration of various technologies, many for the first time. All systems were implemented successfully through careful planning and coordination among all the project managers and business owners.

Integrated Testing

Due to the interrelationships between the medical equipment, infrastructure, processes, people, and technologies, integrated testing was a separate project. Initiation of this project involved taking the output from all the other projects and working with departmental managers to develop the final round of full testing to ensure everything operated as planned from all perspectives. This final examination included the use of volunteers acting as test patients using testing scenarios of the most likely situations that could occur during the first few days of opening. For integrated testing to provide the desired results, all project managers had to work together as a team.

The results of the integrated testing project were invaluable. The testing teams uncovered several key issues prior to opening that could then be resolved before actual patients arrived. For example: (Exhibit 6)

Issues to be Resolved

Exhibit 6 – Issues to be Resolved

Process changes related to the third example outlined above could have meant the difference between life and death in a real-world situation if these problems had not surfaced and been corrected during integration testing.

All new technologies and medical equipment were tested in the test scenarios. Based on test results, changes were made to both technology and processes. Key process changes enabled the patient experience to be enhanced and gave the staff a greater sense of comfort.

Readiness Assessment

Business owners were held accountable for the readiness of their individual departments. A “readiness assessment” was conducted at 90 days out, 60 days out, 30 days out, and one week out from opening day (Exhibit 7).

Readiness Assessment

Exhibit 7 – Readiness Assessment

Norton Brownsboro Hospital became Norton Healthcare's fifth hospital in Louisville's Jefferson County, joining Kosair Children's Hospital, Norton Audubon Hospital, Norton Hospital, and Norton Suburban Hospital. Norton Brownsboro Hospital offers a wide range of inpatient and outpatient services including diagnostic, orthopedic/spine, oncology, cardiovascular, pulmonary, neuroscience, women's services, physical/speech/occupational/respiratory/music therapy, and intensive care services.

The hospital features the latest in health care technology and an innovative patient- and family- centered care model that promotes comfort, convenience, and healing for patients and families. Special features include:

  • Large, all-private inpatient rooms are furnished with a refrigerator, safe for valuables, television, outlets for personal electronic equipment, as well as a sleeper sofa spacious enough for a family member to comfortably spend the night. The hospital also features all-private preoperative and postoperative rooms.
    MRI Scanner

    Exhibit 8 – MRI Scanner

  • The latest trends in medical technology and patient safety, including computerized provider order entry (CPOE), which helps to improve patient safety, eliminates duplicate orders and reduces telephone calls and interruptions for physicians; a bedside medication verification (BMV) system to provide instant access to a patient's current laboratory or diagnostic test results and medications, significantly reducing the chance for medication errors; sophisticated surgical suites equipped with advanced technology; and state-of-the-art patient monitoring capabilities.
  • An entirely digital radiology department, providing enhanced patient comfort, and safer, faster, and more accurate diagnostic imaging test results. The hospital's cutting-edge equipment includes a 64-slice, open-bore CT scanner; 1.5-Tesla, wide-bore MRI scanner (Exhibit 8); cardiology system; angiography system; X-ray; ultrasound; nuclear medicines; radiographic fluoroscopy; and general radiography room.
  • Televisions in patient rooms equipped with the “Get Well Network,” an interactive education and entertainment system that allows patients to learn more about their medical condition, review important hospital information, communicate with hospital staff, and even have a little fun.
  • Computer stations available for guests and wireless Internet connectivity throughout the hospital.
  • 24/7 visiting hours.
  • Simplified registration through self-registration kiosks.

In the end, the hospital cost $143 million in capital to build, which was 2% under budget. Every penny saved in a health care environment is one more penny that can be used to care for patients' needs.


Norton Brownsboro Hospital was one of the most exciting initiatives Norton Healthcare had ever undertaken. The hospital was designed for maximum ease of use and efficiency for patients and medical staff. We accomplished what many said was not possible.

Throughout the entire program, potential problems were uncovered and corrected prior to construction. We gained an informed expectation of the final product, and members of the hospital staff and staff from the Norton Healthcare system as a whole felt a sense of ownership in the design of Norton Brownsboro Hospital.

Norton Brownsboro Hospital is a spectacular addition to the Norton Healthcare family of hospitals and related health care services. It has tremendous potential and will be serving the community for years to come.


Lean Construction Institute (2007) Retrieved from

© 2010, Janice Weaver
Published as a part of 2010 PMI Global Congress Proceedings – North America



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