Emergency department patient satisfaction Essay

Customer returns initiatives in health lot construct become a popular bearing of attempting to improve patient felicity. The effect of clinic everyy focused client portion cultivation on patient satisfaction in the setting of a 62,000-visit exigency segment and level 1 trauma center is investigated. The around dramatic improvement in the patient satisfaction discipline came in ratings of science of the apprehension physician, likeliness of returning, aptitude of the arrest department think about and overall satisfaction. These results suggest that much(prenominal) learn may spell a substantial competitive grocery advantage, as well as improve the patients perception of case and outcome. A practicians response to the case mull is also included. Customer overhaul initiatives in health do by cast become a popular way of attempting to improve patient satisfaction. The effect of clinically focused guest gain readying on patient satisfaction in the setting of a 62,000-visit extremity department and level 1 trauma center is investigated. The most dramatic improvement in the patient satisfaction survey came in ratings of expertness of the emergency physician, likelihood of returning, attainment of the emergency department nurse and overall satisfaction. These results suggest that much(prenominal) readiness may offer a substantial competitive market advantage, as well as improve the patients perception of theatrical role and outcome. A practitioners repsonse to the case prove is also included.Youhave requested on-the-fly machine translation of selected cognitive content from our databases. This functionality is provided solely for your convenience and is in no way think to replace human translation. Show full disclaimer Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated AS IS and AS lendable and are non retained in our systems. P ROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL take out OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A point PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimerTranslations ply by LEC. Translations powered by LEC.Headnotevisit emergency department and level I trauma center. Analysis of patient cathexiss, patient compliments, and a statistically verified patient-satisfaction survey indicate that (1) all 14 key quality characteristics identified in the survey change magnitude dramatically in the drive period (2) patient complaints decreased by over 70 per cent from 2.6 per 1,000 emergency department (ED) visits to 0.6 per 1,000 ED visits next customer return training and (3) patient compliments increase more than 100 percent from 1.1 per 1,000 ED visits to 2.3 per 1,000 ED visits. The most dramatic improvement in the patient satisfaction survey came in ratings of expertness of the emergency physician, likelihood of returning, skill of the emergency department nurse, and overall satisfaction. These results stage that clinically focused customer service training improves patient satisfaction and ratings of physician and nurse skill. They also suggest that such training may offer a substantial competitive market advantage, as well as improve the patients perception of quality and outcome.INTRODUCTIONRecent changes in health do have led to increasing competition and the perceived commercialization of the health care provided to patients. At the same quantify, a need for reaffirmation of the grandness of the patient-physician relat ionship has been expressed in the midst of such powerful forces (Laine and Davidoff 1996 Glass 1996 Pellegrino and Thomasma 1989). One aspect of the patient-physician relationship deserving further strike is the role of customer service training in healthcare. While numerous customer service training tools exist in business and industry, no studies have clearly delineated the efficacy of customer service training for patients in a clinical setting. This study examines the effect of a infallible customer service training program taught by healthcare professionals on patient and family complaints, compliments, and satisfaction in a high-volume high- pungency emergency department.METHODS longanimous Base any patients presenting to the Emergency incision at Inova Fairfax Hospital, Falls Church, Virginia, between May 1, 1994 and April 30, 1995 make the control conference, representing the period prior to emergency department customer service training. patients presenting to the eme rgency department between May 1, 1995 and April 30, 1996 formed the study group, representing the period following customer service training intervention. The mechanism of patient complaint/compliment analysis and the survey criteria were identical in the control and study periods. Patient on the qui vive was assessed by collar measures the number and percentage of patients admitted to the hospital the number and percentage of patients with Current Procedural Terminology 1996 (CPT) evaluation and management (E/M) codes 99281-99285, (Kirschner et al. 1996) and a nursing acuity rating scale (EMERGE, Medicus Systems, Evanston, Illinois). Inova Fairfax Hospital is a 656-bed not-for-profit institution that is a t apieceing hospital, regional referral center, and level I trauma center.Customer Service TrainingAll emergency department staff involved in patient contact (physicians,nurses, ED technicians, registration personnel, core secretaries, social workers, ED radiology, and ED respir atory therapy) were required to attend an eight-hour customer service training program. The numbers and types of staff involved in training are listed in Table 1. Because of logistic limitations, emergency medication residents attended a focused fourhour required training course. The eight-hour program consisted of the following modules basic customer service principles, recognition of patients and customers (Are they patients or customers?), service industry benchmarking leaders, filtrate recognition and management, communication skills, negotiation skills, empowerment, customer service proactivity, service transitions, service fail-safes, change management, and specific customer service core competencies. (More detailed information on the content of these modules is listed in Appendix 1.) These core competencies follow making the customer service diagnosis (in addition to the clinical diagnosis) and providing the right treatment negotiating agreement outcome of patient expectat ions and building moments of truth into the clinical encounter.Following the initial required training, new physicians or ED employees were required to attend identical customer service training within four months of their initial employment. Additional mandatory customer service training updates were offered three times per year and included modules of conflict resolution, customer service skill updates, advanced communication skills, and assertiveness training.Patient triumph DataPatient satisfaction data in both the control and study groups consisted of patient complaints, patient compliments, and a telephone patientsatisfaction survey conducted by an unaffiliated research firm (Shugoll Associates, Rockville, Maryland) that was blinded to the study hypothesis and course content. Patient complaints and/or compliments were systematically identified from all available means, including verbal, written, telephone, or electronic mail sources. Sources of patient complaints, data analy sis, and categorization of complaints were identical in the control and study groups, which was coordinated by hospital quality improvement analysts. EDstaff were instructed to report all potentiality complaints and concerns, regardless of how minor, to appropriate physician or nurse managers in both the control and study periods.Complaints were logged into a central office and were investigated initially by three authors (TM, RC, DR). In cases where classification of type of complaint differed, redundant information and/or clarification was sought from staff, patients, and family. Any discrepancies were resolved by group-consensus techniques. All complaints and the classification thereof were independently reviewed and verified by quality-improvement analysts. Patient complaint and compliment letters were referred for comment or clarification to appropriate ED staff in both the control and study periods.Outpatient satisfaction surveys were conducted by an independent research fir m (completely blinded to the study and its hypothesis) utilizing a 50-item questionnaire to identify key factors in customer satisfaction. This survey instrument was validated on a sample distribution of more than 3,000 patients prior to implementation in either the control or study group. The study used a telephone survey on a randomized number table basis to 100 ED outpatients per quarter (Appendix 2). Logistic regression analysis performed on these data identified 14 areas of more important/key attributes in the ED (see Table 2). Patient compliment and complaint data, as well as acuity data, were subjected to a 2-tailed ttest and the Fisher fill test. Patient satisfaction surveys were subjected to a two-tailed t-test with a 95 percent confidence level.Patient Turnaround successionsPatient backsliding times (TAT) were calculated from time of initial arrival in the ED to either discharge or transfer to an inmate unit. Turnaround times were routinely calculated on each patient and on an aggregate basis by day, month, quarter, and year.RESULTSED Volume/AcuityNeither ED volume nor acuity changed to a statistically pregnant degree between the control and study periods, based on both admission percentage and nursing acuity (see Table 3). Analysis of CPT 96 evaluation and Management Codes showed a statistically significant increase in codes 99283 and 99285, with a similar decrease in codes 99281 and 99284. The number of pediatric patients did not change in a statistically significant fashion during the study period. The only payor mix category to rise in a statistically significant fashion was managed care (p .01), with a nearly identical decrease in commercial insurance. Neither compliments nor complaints correlated with payor category.Patient Turnaround TimeMean patient turnaround time dropped from three hours and 24 minutes (204 minutes) to three hours and seven minutes (187 minutes), but this difference was not statistically significant, nor did the per cent of patients at one and two standard deviations from the mean change in a statistically significant fashion. Patient Compliments The total number of patient compliments rose from 69 in the control period to 141 in the study period, an increase of more than 100 percent (p .00001) (see Table 3). Patient compliment letters reconciledly mentioned warmth, compassion, and skill of the emergency care provider as the reason for contacting management to praise the ED staff. There was no statistical difference between males and females among patient compliments. Patient ComplaintsPatient complaints dropped from 153 in the control period (2.5 complaints per 1,000 ED visits) to 36 in the study period (0.6 complaints per 1,000 ED visits), (p .00001) (see Table 3). Complaints about perceived rudeness, insensitivity, or insufficiency of compassion on the part of ED staff dropped most dramatically. Two-thirds of complaints in the study period were a result of delay times, billing, or delay s in obtaining an inpatient bed, compared to 30 percent in the control period. Nevertheless, complaints regarding waiting times, billing, and wait time for an inpatient bed still decreased 50 percent in the study period (p .001). There were no significant differences in patient complaints based on age or sex, confirming results of the study by Hall and pressure (1996).Patient Satisfaction Survey DataBaseline survey data were subjected to logistical regression analysis that indicated that 14 surveyed areas formed a core group of key satisfaction attributes. All of these 14 attributes showed increases in the study period (p .001, see Table 2). The largest increases were in the following areas skill of the emergency physician, skill of the nurse, likelihood of returning, overall quality of medical care, doctors ability to explain condition, diagnosis, and treatment options, and triage nurses sensitivity to pain.DISCUSSIONThe patient-physician and patient-nurse relationships are argu ably the oldest in the history of medicine. These relationships have recently been depict as being under siege because of an increase in the tension between the art and science of medicine, as well as the strains attendant to changes in the economic structure of healthcare (Glass 1996). To this list may be added a third causative factor the pretermit of rigorous, dinner dress training for healthcare professionals in the customer service fundamentals of the patient-provider relationship.The fundamentals of such training are closely tied to what has traditionally been described as the art of medicine or the concept of beneficence (Pellegrino and Thomasma 1989). Physicians have for the most part learned appropriate patient interaction skills through observing their mentors and peers during the course of graduate medical education. However, there has only recently been substantial study of this important subject (Buller and Buller 1987 Aharony and Strasser 1993).While customer servi ce has been emphasized in American business and industry in recent years (Zeithamal, Parasuraman, and Berry 1990 Jones and Sasser 1995 Reichheld 1996 Berry and Parasuraman 1991 Berry 1995), few training modules are specifically targeted toward physicians and healthcare professionals. For this reason, the authors created an eight-hour customerservice training course for their ED providers, based on principles of adult education, benchmarks from the customer service industry (Sanders 1995 Spectre and McCarthy 1995 Carlzon 1987 Connelan 1997), experience in the clinical setting, and the existing literature on patient satisfaction (Pelligrino and Thomasma 1989 Thompson and Yarnold 1995 Thompson et al. 1996 Bursh, Beezy, and Shaw 1993 Rhee and Bird 1996 Dansk and Miles 1997 Hall and Press 1996 Eisenberg 1997). This literature emphasizes the importance of communication skills, managing information flow, actual versus perceived waiting times, and the communicative quality of physicians a nd nurses. All of these concepts were built into the training modules, including practical clinical examples of behaviors reflecting these and other concepts.Our philosophy in designing this course was simple. Customer service is a skill for which we hold our staff accountable but in which they had never formally been trained. We believed that this dilemma required, at a minimum, two sentinel events to occur. First, the department required to have a clearly articulated and easily understood cultural transformation to a solid commitment to customer service. Second, staff members needed education in a practical, pragmatic fashion regarding precisely how such customer service principles could be applied in the clinical setting. Just as advanced cardiac life support, advanced trauma life support, and pediatric advanced life support courses can be used to improve cardiac, trauma, and pediatric resuscitation, respectively, we believed customer service outcomes could be improved by well-d esigned, mandatory, rigorous application of customer service training.The training was provided by active clinicians involved in day-to-day patient care activities (TAM, RJC). We believe this clinical credibility may have played an important part in the customer service transformation, inasmuch as the staff knew the trainers were well certain of the inherent problems of applying pragmatic customer service skills in a busy emergency department.The data from this study strongly support the hypothesis that clinically based, formal customer service training grounded on these principles candramatically decrease patient complaints, increase patient compliments, and improve patient satisfaction, at least in a high-volume, high-acuity ED. Patient complaints dropped by over 70 percent and compliments more than doubled during the study period, such that patient compliments actually slide by complaints in our 62,000 patient visit emergency department and level I trauma center. National data indicate that ED complaints average between three to five per 1,000 emergency department patients, although no data are available regarding rates of patient compliments (Culhane and Harding 1994). Our emergency department was slightly below that internal standard level even during the control period.Analysis of the patient satisfaction survey data revealed an extremely important trend. Specifically, patients rated skill of the emergency physician, overall quality of medical care, and skill of the ED nurse as three of the most improved areas during the study period compared to the control period, despite the fact that there were no changes in the ED physician staff during the study and there was very little turnover among ED nurses. This strongly implies that patients rate the quality of care and the skill of the physician and nurse based on elements of the customer service interaction. These data suggest an important causal relationship between the technical component of care and t he patient caregiver interaction, which has not been previously demonstrated. It is important to recognize that both customer service and technical skills are competencies to which hospitals and healthcare systems should hold their staff accountable on a daily basis. Hospitals spend substantial dollars to ensure that their staffs are technically competent to deliver quality medical care (Herzlinger 1997). However, to ensure that customer service is impelling, clinically based customer service training is essential to give staff the appropriate skills in the clinical setting to deliver service competently.This concept is indirectly supported by data from Mack and colleagues (1995), who found that satisfaction with interactive aspects of emergency medical care produced higher correlations with measures of future heading to use the service than did satisfaction with medical outcomes themselves. Their study, however, did not undertake interventions to improve the interactive,communica tive aspect of healthcare in that setting. Similarly, Smith and colleagues (1995) evaluated the effect of a four-week training program, focusing on patient interviewing, somatization, patient education, and self-awareness, that was taught to first year internal medicine and family practice residents. Their data were not conclusive, but suggested that some but not all aspects of patient satisfaction could be improved by such training. This study tends to confirm the work of Thompson and colleagues (1996) that demonstrated in a much smaller sample size that expressive quality and management of information flow to the patient had an effect on patient satisfaction. However, their study did not assess the shock of strategies and techniques for ED staff to improve patient satisfaction by improving expressive quality.While several studies (Thompson et al. 1996 Thompson and Yarnold 1996 Dansk and Miles 1997 Hall and Press 1996) have emphasized the importance of waiting time and exceeding p atient expectations regarding length of waiting time, our study demonstrates a dramatic improvement in patient satisfaction without a statistically significant reduction in patient turnaround time. This supports the work of Bursch and colleagues (1993), who found in a study of 258 patients that the five most important variables for patient satisfaction were the amount of time it took before being cared for in the ED, patient ratings of how caring the nurses were, how organized the ED staff was, how caring the physicians were, and the amount of information provided to the patient and family. However, the study did not assess strategies to improve satisfaction based on this knowledge. All of this information was built into the training modules to assist staff with practical strategies to manage waiting time effectively using information flow, queuing theory, and verbal skill training.The implications of the higher ratings of the skill of the emergency physicians and nurses are intrigu ing and could have a far-reaching impact on healthcare. Perhaps the strongest implication is that perceived skill stands as a marker for quality and/or outcome in the mind of patients and their families. It has been shown repeatedly that patient conformance increases with confidence in the physician (Frances, Korsch, and Morris 1969Sharfield et al. 1981 Waggoner, Jackson, and Kern 1981 Schmittdiel et al. 1997). While our study did not directly assess improvements in outcome, quality of care, or appropriateness of care, it certainly appears that patients rated the skill of the healthcare providers as a key quality characteristic in this survey. Furthermore, the fact that ratings of quality of medical care and likelihood of returning also increased dramatically speaks to the importance that effective customer service training may have in offering a competitive market advantage to hospitals and healthcare institutions. This is particularly important as the concept of customer loyalty is closely tied to the likelihood of a patient or their family returning to that healthcare institution. As the focus on outcomes management and evidence-based medicine increases, it is important to take into account the effect that customer service skills have on patients perceptions of quality and outcome.This study may be subject to several criticisms. First, while statistical data on patient compliments and complaints obtained substantial statistical significance, the number of patients contacted for the outpatient satisfaction telephone survey may have resulted in sampling bias. While a larger sampling is planned in the future, the patient satisfaction survey data trends were consistent throughout all quarters and appear to be a valid statistical tool, despite the number of patients sampled. Second, it was not possible to blind those responsible for canvas and classifying complaints and compliments. However, we did attempt to reduce or eliminate possible reporting or observer bias by identifying complaints from all sources and ensuring that all complaints and their classification were reviewed and approved by an author who was not involved in ED operations and by quality improvement analysts. Third, information is not available on national or regional trends of patient complaints and/or satisfaction during the study period. It is possible that the data in this study may reflect local, regional, or national trends toward decreased complaints and increased satisfaction, either globally throughout healthcare or in ED patients specifically.However, this is highly unlikely as no such trends have been previously reported, nor would such trends fully explain the data from this study, even if they were present. The data on patient acuityindicated an increase in CPT codes 99283 and 99285, suggesting a slight trend toward higher patient acuity. This could mean that patients with higher levels of acuity are more satisfied and less likely to complain. No data are av ailable to either prove or disprove this possibility, but the trend toward higher acuity would not appear to completely explain the dramatic improvement seen in this study. Furthermore, the patient-satisfaction telephone survey excluded inpatients, who exist a larger percentage of patients in the 99285 service code. Further study is needed to delineate the relationship of ED patient acuity to satisfaction.Despite these potential limitations, this study demonstrates that clinically based customer training for ED staff can decrease patient complaints and increase patient satisfaction in a large volume, high-acuity ED, and that satisfaction is independent of patient turnaround times. Furthermore, the data support the concept that patients rate the skill of the emergency physician, overall quality of medical care, and skill of the ED nurse significantly higher after such training is provided to the ED staff. Additional studies in ED with different volumes, acuities, and geographic loca tions are needed to demonstrate whether these results can be duplicated. Studies of the impact of customer service training in other healthcare settings would also be of benefit. Nonetheless, clinically focused customer service training has been shown in this study to improve patient satisfaction and ratings of the skill of physicians and nurses. If verified by other studies, customer service training should be considered an important part of graduate and undergraduate medical education to improve both the art and science of the patient-physician relationship.The clinically based customer service training described in this study is now a required part of competency based orientation for all physicians, nurses, residents, and support staff in the emergency department. All professional and non-professional staff interviewed for positions in the emergency department are advised of the institutions strong commitment to customer service training and the necessity of attending the require d training course. As healthcare increasingly emphasizes accountability for customer service in its staff, it is increasingly important that practical andeffective customer service training is provided.While not directly addressed in this study, the data on ratings of quality of medical care, skill of the physician and nurses, and likelihood of returning strongly suggest that effectively completing the customer service transition offers a competitive market advantage to hospitals and healthcare systems.ReferencesAharony, L., and S. Strasser. 1993. Patient Satisfaction What We Know About and What We Still Need to Explore. Medical Care Review 50 (1) 49-79. Berry, L. L. 1995. On Great Service A Framework for Action. in the raw York bighearted Press. Berry, L. L., and A. Parasuraman. 1991. Marketing Services Competing Through Quality. New York Free Press. Butler, M. K., and D. B. Buller. 1987. Physicians Communication Style and Patient Satisfaction. Journal of Health and Social Behavi or 28 (4) 375-88. Bursh, B., J. Beezy, and R. Shaw. 1993. Emergency Department Satisfaction What Matters Most? Annals of Emergency medicine 22 586-91. Carlzon, J. 1987. Moments of Truth New Strategies for Todays Customer-Driven Economy. New York Ballinger Publishing.Connelan, T. 1997. Inside the wizard(prenominal) Kingdom. Austin, TX Bard Press. Culhane, D. E., and P. J. Harding. 1994. Quality in Customers Great Expectations. Presented to the American College of Emergency Physicians Management Academy, Boston, Massachusetts, May 19, 1994. Dansk, K. H., and J. Miles. 1997. Patient Satisfaction with Ambulatory Healthcare Services delay Time and Follow-up Time. Hospitals and Health Services Administration 42 (2) 165-77. Eisenberg, B. 1997. Customer Service in Healthcare. Hospitals and Healthcare Services Administration 42 ( 1 ) 17-32.Frances, V, B. M. Korsch, and M. J. Morris. 1969. Gaps in Doctor-Patient Communication. Patients Response to Medical Advice. New England Journal of mu sic. 280 535-49. Glass, R. M. 1996. The Patient-Physician Relationship JAMA Focuses on the Center of Medicine. Journal of the American Medical Association 275 147-48. Hall, M. F., and I. Press. 1996.Keys to Patient Satisfaction in the Emergency Department Results of a Multiple Facility Study. Hospitals and Healthcare Administration 41 (4) 515-32. Herzlinger, R. 1997. Market-Driven HealthCare. New York Free Press. Inova Health System. 1997. Outpatient Satisfaction Research. Shugoll Research. Rockville, MD. Jones, T. O., and W. E. Sasser, Jr. 1995. why Satisfied Customers Defect. Harvard Business Review 73 88-99. Kirschner, C. G., R. C. Burkett, G. M. Kotowicz, et al. 1996. Physicians Current Procedural Terminology-CPT 96, ed 5. Chicago American Medical Association. Laine, C., and F. Davidoff. 1996. PatientCentered Medicine A Professional Evolution lournal of the AmericanMedical Association 275 152-56. Mack, J. L., K. M. File, J. E. Horwitz, and R. A. Prince. 1995. The Effect of Urgen cy on Patient Satisfaction and Future Emergency Department Choice. Health Care Management Review 20 7-15. Pellegrino, E. D., and D. C. Thomasma. 1989. For the Patients Good The Restoration of Beneficence in Health Care. New York Oxford University Press. Rhee, K., and J. Bird. 1996. Perceptions in Satisfaction with Emergency Department Care. Journal of Emergency Medicine 14 679-83.Reichheld, E E 1996. Learning from Customer Defections. Harvard Business Review 74 56-69. Sanders, B. 1995. Fabled Service Ordinary Acts, Extraordinary outgrowths. San Diego Pfeiffer and Company. Schmittdiel, J., J. V. Selby, K. Grumbach, and C. P. Quesenberry. 1997. Choice of a private Physician and Patient Satisfaction in a Health Maintenance Organization. Journal of the American Medical Association 278 (19) 1596-1612. Sharfield, B., C. Wray, K. Hess, and E. M. Smith. 1981. The Influence of Patient-Practitioner Agreement on Outcome of Care. American Journal of Public Health 71 127-31. Smith, R. C., J. S . Lyles, J. A. Mettler, et al. 1995. A Strategy for Improving Patient Satisfaction by the Intensive Training of Residents in Psychosocial Medicine A Controlled, Randomized Study Academic Medicine 70 729-32. Spectre, R., and P. D. McCarthy. 1995. The Nordstrom Way The Inside Story of Americas 1 Customer Service Company. New York John Wiley and Sons.Thompson, D. A., P. R. Yarnold, D. R. Williams, and S. L. Adams. 1996. Effects of Actual Waiting Time, Perceived Waiting Time, Information Delivery, and Expressive Quality on Patient Satisfaction in the Emergency Department Annals of Emergency Medicine 28 657-65. Thompson, D. A., and P. R. Yarnold. 1995. Relating Patient Satisfaction to Waiting Time Perceptions and Expectations The Disconfirmation Paradigm. Academic Emergency Medicine 2 1057-62. Thompson, D. A., P. R. Yarnold, S. L. Adams, and A. B. Spaccone. 1996. How Accurate Are Waiting Time Perceptions of Patients in the Emergency Department? Annals of Emergency Medicine 28 652-56. Wag goner, D. M., E. B. Jackson, and D. E. Kern. 1981. Physician Influence on Patient Compliance A clinical Trial. Annals of Emergency Medicine 10 348-52. Zeithamal, V. A., A. Parasuraman, and L. L. Berry. 1990. Delivering Quality Service Balancing Customer Perceptions and Expectations. New York Free Press. You have requested on-the-fly machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated AS IS and AS AVAILABLE and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR P URPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimerTranslations powered by LEC. Translations powered by LEC.