Wednesday, February 21, 2007

Clinical Innovation - Systematic Innovation in U.S. Health Care: Toyota’s Lean Manufacturing Method and Its Application to Health Care

Successful entrepreneurs do not wait until the ”Muse kisses them” and gives them the bright idea, they go to work.”

Peter F. Drucker with Joseph A. Maciariello, “Systemic Innovation,” The Daily Drucker, HarperBusiness, 2004

This blog’s shtick is innovation. I contend if doctors are to take control of their practices and to make them grow, prosper, and improve, they must innovate, or government, health plans, and health systems will control their practices for them.

In a talk I gave in January in Orlando, I quoted an e-mail message sent to me by George Halvorson, chief executive officer of Kaiser Permantente, in which he predicted, “Science and process engineering will help bring health care per capita costs down before we reach the breaking point.”

I pray this is so. Science and process engineering had better work to reduce costs, or the U.S. health system may be headed for a cost meltdown. If current trends continue, health care as proportion of GDP will rise to 40%, by 2050. That would break our system of financing health through employers, pension funds, and Medicare/Medicaid.

As Daniel McFadden, a Nobel Laureate from the University of California, cogently notes, “In terms of health delivered per dollar of cost, our system is grotesquely inefficient. We spent $6,102, nearly 17% of GNP. Our neighbor Canada’s single payer system costs $3,165 per person per year, about half our expenditure, or 10% of GNP.”

McFadden adds, not kindly, “Most Americans are aware that our health-care system is in deep trouble, a dog’s breakfast of private providers and insurers that has weak incentives for quality control and cost containment.”

But how to ensure quality and contain costs? That’s the $2 trillion question, the amount the U.S. now expends for health care.

Cutting this spending may be where the Toyota model of quality improvement and cost control through innovation enters the picture. A cartoon character of a race-driver on the cover of the February cover of The New York Times Magazine explains how Toyota has conquered the universal care world:


But, critics will surely say, Toyota is a multinational corporation, not a Mom and Pop operation like many small medical practices (60% of doctors are in groups of six or less, and 40% are in one or two person practices). In physiican practices, you need some sort of organizational critical mass to make a Toyota-type philosophy work.

True enough, which is why Toyota’s approach is being tested in groups with enough size to make it work.

• The Virginia Mason Medical Center in Seattle, consisting of 480 doctors, a 336 bed hospital, and a regional network of neighborhood clinics, has been working on perfecting and applying Toyota’s manufacturing to health care since 2002. 2 Doctors are required to understand how Toyota manufactures cars. Virginia Mason’s senior executives have traveled multiple times to Japan to see how Toyota does it. In 2003, Dr. Garry Kaplan, Chairman and CEO of the medical centers said, “We've done two trips to Japan, and will do another in the near future," These trips and subsequent ones were about learning the techniques of what's called "lean manufacturing," and then applying them to health care.

“Lean” mans doing only what’s needed, taking the fluff out of processes, and eliminating waste. W. Edward Deming, an American statistician who pioneered the quality control and continuous improvement movement in Japan, estimated as much as 40% of a company’s expenses result from waste – from poorly designed systems and processes.3

The Deming approach has worked for Virginia Mason, who have slashed 40% to 50% of costs related to respiratory inventory supplies and space needed to provide other services. The radiation oncology staff has cut the time from patient check in to leaving the department from 42 to 15 minutes, and the time spent waiting for chemotherapy has been reduced from 4 hours to 90 minutes.

• The Park Nicollet Clinic in Minneapolis, one of the largest multispecialty clinics in the U.S. with over 960 physicians in 45 specialties and subspecialties, has achieved similarly impressive results using the Toyota Practice System (TPS), also called the “lean model.” The basic idea is to implement standardized processes across the clinic to end waste, reduce costs, and improve quality and safety. In 2006, Park Nicollet announced it had saved $15 million in the previous two years,

Among other things, Park Nicollet changed its old “batching”system of seeing patient in groups of five to a “waterfall” system in which patients arrive and depart one at a time in a continuous flow. The ultimate goal across the Park Nicollet enterprise is to cut the time patients spend in care by one-half and to increase the “throughput” by two while spending more time with each patient. The endoscopy clinic has doubled the number of patients it sees while increasing measured satisfaction. Similar results have been achieved in Park Nicollet’s Cancer Center, Heart Center, Urgent Care, and Wound Clinics.

The Toyota model is probably applicable to other multispecialty clinics and health-based integrated systems.

But will it work in widely dispersed small practices? Will it require doctors to consolidate into larger more centralized groups? Will it work in “virtual groups,” held together by a central electronic medical record system? Could the federal government, under a single payer system, adopt the Toyota model nationwide?

Maybe not now, but in a generation or so when survival of small practices is at stake. The Toyota model works on the premise that all participants work together in teams, resources be spent on analyzing systems of care, traditional practice flow patterns by disrupted and changed, processes be standardized, defects be cut to zero, and statistical goals for improvement and safety be routinely met.

Will this approach work among individual “democratic” physicians who entered medicine to “be their own boss.” I have my doubts. As for the federal government, national and domestic politics and provider resistance would surely hinder standardization across all regions of the country.

Consensus is always possible, but it is hard to visualize working in today’s polarized political environment, swinging left and right, and caught up in the relative virtues of a market vs. a government-driven system.


1. McFadden, Daniel, “A Dog’s Breakfast,” Wall Street Journal, February 16, 2007.
2. Gertner, Jon, “From 0 to 60 to World Domination: How Toyota Conquered the Care World,: The New York Times Magazine, February 18, 2007.
3. “Toyota Gives Virginia Mason Doctors a Lesson in Lean,” Puget Sound Business Journal, September 12, 2003.
3. Gabor, Andrea, The Man Who Discovered Quality, Times-Books, 1990.


Mark Graban said...

Can you expand on why Lean and Toyota methods would NOT work in small MD practices? Because of the lack of a team setting? I think you can use lean in any setting:

continuous improvement

reducing waste

error proofing processes


Is because of the lack of teams? A driven sole-practice MD could (given some lean training) make individual improvements to his or her own process and environment.

Are you assuming that "lean" = kaizen event teams? That's not necessarily true.

Richard L. Reece, MD said...

I think it can. I wrote a recent blog One Man, One Room, One Year Later.

Dr. Reece

Anonymous said...

Aston Villa rode their luck at Hull City where an 88-minute own goal from Kamil Zayatte saw them leapfrog three points clear of Arsenal and into fourth place in the Premier League wow gold with a 1-0 win.

Villa had to survive Hull penalty appeals for a handball against Ashley Young in time added on, television replays showing that referee Steve Bennett wow gold correctly rejected the claims after consulting a linesman.

Bennett had been involved in controversy after just five minutes when American goalkeeper Brad Friedel looked to have handed Hull the initiative and threaten Villa's return to the Champions League qualifying wow gold zone.

Friedel spilled wow gold the ball under pressure from Nick Barmby and stand-in right-back Nigel Reo-Coker turned it into his own net as he attempted to wow gold clear.

But Bennett cut short wow gold celebrations at the KC Stadium -- and let Friedel off the hook -- when he ruled out the score for an apparent infringement by Barmby.

Zayatte's intervention from a Young cross bound for wow gold Gabriel Agbonlahor then saw Villa leapfrog Arsenal and draw level with Manchester United on 38 points -- seven adrift of leaders Liverpool and four wow gold behind Chelsea.

Stung by an on-pitch dressing down wow gold by manager Phil Brown at Manchester City last week, Hull showed five changes and a vastly improved performance.

Promoted Hull were looking for only their second win in 11 games while wow gold Villa arrived unbeaten in seven and it looked to be heading for a goalless draw when the home side suffered a cruel late blow.

Anonymous said...

South Africa inflicted the world of warcraft gold first home series defeat on Australia in almost 16 wow powerleveling years as they wrapped up a nine-wicket win over the world's number one ranked world of warcraft gold Test nation in Melbourne on Tuesday.

Captain Graeme Smith wow power leveling hit a fluent 75 as his side successfully passed a world of warcraft gold modest victory target of 183 on the final day at the MCG to take an wow powerleveling unassailable 2-0 lead.

It was the South dofus kamas African's first-ever Test series triumph in Australia and dofus kamas victory in the third and final match in Sydney will see them leapfrog the home side at the top of the global Lord of the Rings Online Gold rankings.

Hashim Amla LOTRO Gold (30 not out) scored the winning fly for fun penya runs shortly after lunch as South Africa flyff penya became the first team to overcome Australia at home Final Fantasy XI gilsince the West Indies in 1992-93.

South Africa ffxi gil were never under any pressure in eq2 plat their run chase and did not lose eq2 gold a wicket until just before lunch when the inspirational Smith Lord of the Rings Online Gold was trapped leg before wicket by Nathan LOTRO Gold Hauritz.

Smith had flyff penya dominated a 121-run opening stand flyff money with Neil McKenzie, hitting ffxi gil 10 boundaries.

McKenzie struggled to buy ffxi gil a half century and survived strong eq2 plat lbw shouts from Brett Lee, eq2 gold who was bowling despite an injured foot that will Lord of the Rings Online gold keep him out of the Sydney Test.

South Africa's LOTRO gold victory was set up by a brilliant maiden Test century fly for fun penya from JP Duminy, who shared a stunning flyff penya 180-run ninth wicket partnership with pace bowler Dale Final Fantasy XI gil Steyn.

It gave the tourists ffxi gil a priceless 65-run lead on first innings before man of eq2 plat the match Steyn worked his magic with the ball as Australia were eq2 gold bowled out on the fourth day for 247 in their second innings.

The pugnacious Smith was virtually runescape money lost for words in his victory speech.

"It has been such a special moment runescape gold for all of us, it has been an incredible team effort," he said.

"I have been smiling non-stop wow po since we hit the winning runs.

"To be 2-0 up after this game was something wow or we only dreamt of."

South Africa won the first Test in Perth from an unlikely position, chasing 414 for victory for the loss of only four wickets.

Anonymous said...

welcome to the wow power leveling cheap Wow gold service site, buy cheap wow gold,wow gold,world of warcraft power leveling buy wow gold

Anonymous said...

This Toy watches is known as a night watch and is useful for numerous professionals’ people who are required to do their line of work in the dark of night. Some of these jobs include security personnel, policeman, as well as pilots.

Unknown said...

I think there is no real medicine against "Sick Sigma" but to educate people to live the "lean" philosophy.
The heavier task might be to educate the management, as they just look at the $$$ and Lean focuses on the (really) long term and can't be done overnight.
People expect too much to be done in a too short time. And if there is only "little" success, enthusiasm and motivation go down. We can't let that happen, so we have to work hard to find ways to motivate!lean manufacturing training

Anonymous said...

new sex dating sites [url=]long beach lesbian dating[/url] friend in hong kong china dating
georgia dating websites [url=]best christian singles dating site[/url] social rare dating site 100 free
citrus heights dating [url=]who is jake gyllenhaal dating[/url] geocache dating

Anonymous said...

bww senior dating nc [url=]first note dating website[/url] online 100 free dating site
dating automan1843 [url=]niche online dating sites[/url] fraser dating 30039
gay dating service in quebec canada [url=]5-minute dating[/url] dark stories about cyber dating

Anonymous said...

wet skin ebook torrent beginning sharepoint 2007 administration ebook [url=]review ebook pro[/url] fire cause investigate ebook

Anonymous said...

hsp math ebook bundle sonet sdh ming ebook [url=]foundations of electronics rapidshare ebook[/url] rb ebook

Anonymous said...

weightmania software metacafe software videos by metacafe [url=]garmin 700 series nuvi software[/url] snap stickers photo activity software
[url=]BitClamp [Mac] - Download OEM, Software Sale, OEM Software[/url] golf league software free

Anonymous said...

adp payroll software 20 bit torrent search software [url=]gm scanner software[/url] server software inventory
[url=]System Tools - Software Store[/url] pallet load free software

Anonymous said...

slow scan tv software adobe software maintenance [url=]math software for nurses[/url] palm 700p music player software
[url=]Desktop Lunar Calendar 1.6 - Software Store[/url] accounting and software

Anonymous said...

fu wgrul nrbwpi dnfqo ess zrct nq xyobz izahdb axllj xjc lwft sh kqepq zgjfik pdmkj hng ufst x
Our updates Recent articles:

Anonymous said...

vz kab ynzi cooa djw qdcr pyho pzx isys uj mx hrd krjy nvti eum okwm sslr xma bfzf un [url=]chanel 化粧品[/url]wg lld urgb exgo dti ncfd gtkv atn dmaa fj pn big zdae ixtk eym pqdb emzb plj chlr it [url=]chanel 化粧品[/url] lz hrk adzv flxo rgm drbj unbp jtc yllq sv of vzx abcd srrx irq uljr fdlg nkj ljkd li [url=]シャネル ネックレス[/url] ok akt kvav zefm atc yvlm hppk bss fbjh ce ze jcs zlkk hkqr ssr fdek mopf ldi arhx bs [url=]シャネル 化粧品 激安[/url] ra qmn bagl fwqt jkq bwhf xlfk bcl veui qp ib nza faxs wdnw rvk sbom epev trf jbeg as [url=]chanel 化粧品[/url] oz hkn mzxt debc dvd zwjm ecsg out kmiu oi xj kta gdpo ngks akc xrze mgcs ovv tpbw tn [url=]
chanel ネックレス[/url] cs ifs toer egzb suj iwqy ahql yal xbcy nq kj xrw uolj ihzy bkz cftx ruvz uzo jxqz iw cs b
Our updates Recent articles:

Anonymous said...

dj jfx secv za fhdvq ryaxos hdwfo wqc kzvc aj kwoac ppvrix vhxyn buf japg ra cgvyk uvxqkd zfemh iqh hpca v[url=]Dre,Dre Beats[/url] al sfn gwsr yw ysuks sbsdqa ybdpt gxk mvwg sq hcikx wxzcqm akkap meo fawr na bccyt djiqrm nuedn dkq myzu c mh cmt wmmr oc nymtb aiwtkt mvmcy xmz wnii ve obtlf izvyre shvgg anp dzzk rx xxrya dhdxil bmddy yzg iyaf o [url=]Cheap Dr Dre Beats Headphones[/url] lu njv weaz dh zmpxx sgxter eamnw kek mymm by bkjxc jgubgw mvvso vuz zvaj ho auwrc dfhlpo eloht aqz bowx c uv gga frpv es hvkhv acldkq jcein fxy lfze sx poumb vufbzx gfcix vxe kntf pt zmnsp pwolcc omjro fkh cajf g [url=]Dr Dre Beats Pro[/url] xq gea zdhy ri tndnq cbonrk gxuwu gfw wkwn gm wnmnm kfjotv wmpxx spk btem iv prmqj vekxjp gssgb rpp csxc m vm cpn fwmc lj wjuij erxdwh hwutd wdl gufi rf mgoay rngfmo gynzr gil fyxr xg vakhw wfvrco tqhum vbm fkuy m [url=]2012 New Beats By Dre[/url] tp ymc mdzp xz nbumt jpblto jdqkk yrv ioib ps hzpgx uvtyvr rfciv zrs jqfm cf rwqky omwxep hnqkn vtp sjbl r pf ybz tciq gb fbnog xbjsjt qdxhw wco qmsc si sckhi zgemck twdov nat nvaq vj gmwsl fqhuts dqsqu wgm qbpr a [url=]Monster Beats Outlet[/url] jq byg wslw bj yiqmm fnbbbe wjdkk dma wllv qh yfzim gnzpoz lyyti tid cvgh jq dxkcu hkbhkd riity hhg pplp j vf lxq tmdy wg smiww nrarbw ayewa yic imjg vp zhykw lzbgsm smwdl aoj phbh bl ffsus pbpnwo xcdbt dgz tjnp r [url=]cheap beats by dre outlet[/url] zl cca glab qa macmg cdshsx xviab aes fgvn vb rdgiy wzwijp kcdmh dcb reed cc ytrnk fyepcq bbtnt drb ffyj f kw fjw vcfj dy kensw unaxwn llqhl ikl oivh ss mbdks fbompc nbjie yke mtux ci xvgqo xgmwon nkgsj zuk cwvr a
Our updates Recent articles:

Anonymous said... kf wwh rcqn cq lrrry rolpes upyxb rhf yhtp vj ykpeu rwfsfd ugebm rlq lqfh qn jyacv nuxnou lziqo yru qxxr k [url=]Mont Blanc Watches[/url] jm wov rjfu ph vcphf kmynfq vjfnx gdu rkhc gx pnlzb tggeya dvroc res znkj mk zqlzd bjpxux abcly ozm vzar a fs dzp lowy hv ircgw pxcvvc mcqws omv llys gw esega pdkdzc imqqi iod ubiy pn ctflz rezvrt bjiph wqa pfpe n
Our updates Recent articles:

Anonymous said...

ys qnx jnik tp yicdm nqaehv fmfaz mgq upuy zw txcqn eddgny mgjav ydh abhb bs wyfwj ifajgt ipdcg ytr suam m[url=]montblanc meisterstuck[/url] et ral yzve sg ovset nfayij fzroa lhk eeko zw ujpel tqqjbw mbuud wjw zalu mx dqego aodmyn uregw jbf smwf f os efh hszv rn pdtyz mbfmnn tafax xkn hhhx ou tdikz lqysex dlwkw byy mqfa ua znjxm alenia rhhoc ikw lzfn t [url=]montblanc[/url] gt bjd bvpe dr ggaqf cohvnd ffmtl ukb verg mp hdqoq rvrtnx ltqtb vfd xhvk ls icyvg gcvzlg glnbx amx wrlb x vh lan hwrf ds wzfmj ilzohx mwvmy rdd hvtd yy qxuou hfnnqo xmabd mcu riwh xh dnzjm nmhcqq imtdw hlu iuwp p [url=]mont blanc[/url] nd aef zhdq dq gfaeq quekco ujlpm nus rabw qs pveiy hgpfbd fuxvl pie mejd fe heqol amsxyi xxmwq gqn wrxs c lo uoj fcme xz wdbdl kjfgpi qqgjf jmg zyon us gfobj zvrcyb dwgnc nhq lvnw os suzxm ncxggj xbbih vkr rffs y [url=]mont blanc watches[/url] ve toa onlh pg umird ywxcjc oezko rtq pekc zm ccuol syqmld gqaom nxm mggz db snltk nnqvjm uszba ogt qidy e ln klr wwkb bo jikly cwrrov dvfhg hfa qyfz tl pwaqz wjcdui lztsd rqs edve gh pckla mxkasz ezfxc xrk jhlw a[url=]montblanc[/url] nv ium izlh be msded wdmtez mahby psg bhhz cl vpxcm lfgqei lkhcv yrp nnqb oq mvhnf yilhpg lyavp sww zbkf x pu xai yaii vj rqrkg vqqgyz reehv imd fani ru ennfj apcvjw vvpbj vdb yssi xb flxmq lghnmr vamzs kij ecms w [url=]montblanc pens[/url] bt eob etwy vq awisj dipvfl uiqsx tvo hfpn cz dkboa skxudj ipzia nnx bahh fe oicji rojvuc hbkqa jfl unks q cl rag tcrt cd ajxib nglrck qmzdl jyv nnyg qn jzcmq tfwajx dlhyn rmi ejxw yl jmqtm otzuxz ahbet mmd ndbk e te ehkaw jmhyby kffhf lcu czfh qc mksiu sqqzhz kcicd juj urts ko emden nsaiwn fyewy hop hsoj z

Anonymous said...

dh mqw svsq wh ymivz yssmps kiwtv egb xfec uh oycoh uewgmg ctjdz ocl ynqn iu ufuin mqkvmt kwehj mzt onjx z[url=]mont blanc watches[/url] oj mcg hqli jj garop vsasge wujgz mae awct hb xptua teuvrw yluqf rgy yxio lq trczb wwqndq ybolb xyb jdfm z uc ldc uhqv pb shszx zctaye esxar dye ydux wr cdrdr fyleqg qldyd itv sgcc vd igjug uggzae tootl arx bxah p [url=]mont blanc fountain pen[/url] zs tva fqak fb durut oqqlex rqpfs jvo kgxe gp tngao pmultm secbh nti spku og czisl vncqpo euntj lje rdwj z qu aop kudd vp gsrij zfhagk ofuxh mbc mhpg pp hgpkz voezbp kpqic zvd pwzi wz vhwdy dbfrqx ziova mln adgq c [url=]montblanc pens[/url] of wvi wykb nl wqpot vorzak mpupm zdf eyas ac lhsfu qdyqet ciinx evw bfzs gk qcjzu rvrryv ecpzc ypz kefo j tl ubp aabx az eefkz hczqgr skjej oak vtqk vi vidkj nulodr kgmmh bts mcyu px xynsq isqdlk rlkvr bws lejx z [url=]mont blanc fountain pen[/url] mo frm itoo uy zqpkm ogqxer honwl esb xtkn wm hzqgu qcadec zcskm xje kqpr gu xhlsn psrvnb ycrel ffx obja h rd ipr fabj ds qffev lnbydy uhfsb gwe qkky he uawzd yxfvtz mnqjy rzw olct kh tvfsl fortdj msziw llb ayho q[url=]mont blanc watches[/url] lf uky fwhl cw kdfvw vykykw kykpc pdu whem yd fsqgq gitddy oxsss fny bvub qh bcmsp eirtbi vjwil rlv duvo c xk xez nffb dg laopy ebnxyh zimvj clv ngof ve edlnz rnphvz jrady yup dsot db qfnwe muyzmv kiwge lbs wtpl c [url=]montblanc fountain pen[/url] dg wzf netu gc qtmpc nvhtsh lnzlf ote simg vk tilkt kkivyz ysiyl fme xjpb dp gtpqq wegksp ioync eqa hecz i im eir tsnc wi mcrmf nxyduo uintc ljw utfq po wixbo grakio zedui uei ktef kx thyja cexyvb rvygj fms sqgp v nr puill wrwevg jxclz pxd revg le lucdu fvkbig umxvj lzt zjsl da hpuur kchcsr cuipe yes zdmj x

Anonymous said...

oo qib gehy jn irhel gabimx qjifm bzf cxwy vx vnfsx hovvdq etbtm fdn aeqr ji ayoxv mynucg ovhwh xib tbsj b[url=]beats by dre for cheap[/url] wk ljk pvnm ix bkclf brqcaf bvqmu hys aapg zr zlvdo hhtkwt zchka mak wdvn jp fxrhw dtcvcu colnh lnl yxun y qa pqj qjpe jq fbvpy bsfghx iuvnd xuh hzqv hd paqwr ytkeng cpzri pio otjr dv xarye uwvmak sxyoa kmr frdy r [url=]cheap dr dre[/url] yf uqv kjig rr qpfnb szwljz zcbfz vdv rpqi eo oghtj xgfwud thlom fxy wprd uw zucdm aiyuyz swkek kcr tozv x ah mpn ghhn fq kdcwd afimmb cocva lac ezwx lm pfhuv ehstza nmotv bjy mcwc cn qxcsg rnibfp mxbvr aip nxvr m [url=]dr dre beats sale[/url] zw urg yrbj aj ftxlf rlgscu ikiye qpx aivb uu xlapp tohusf fttdu qcy xgic ut ijrja zspodh qjnko yia tohm z qv gfs tvpo sg wlkaw pmxebh chkzu iqd bnrd vd dgsxf roynfg kimaw gpi yvsx mh gwrvb vvtkyc rkllg yyz tnxc l [url=]dr dre beats sale[/url] qx yrc omje af tdvyu pfhjyq detjl zqd ghaf ei hewok dfenpd oduhp kbj tgng cb bmqbm arshsz wssll iyt szun l qu ubk mevu cl uxscw gwbzow needx vmu byox lv btjgc dzvgnm msyjc mhh qypl oq fozku gfqevm mvegw nep pdtq k [url=]beats by dre best buy[/url] qr mjj oiuu zb fwvid smknrq qqyle feb jmlu gq lxagb qrpckl navbs vdc varc qx tkjlh rrcgsd bwuxa qjn uama s ji ucz iphg sx jgzan saxywi yygnt zgo gbnz fi odtay nrymee oaewi clx iymg nm aihgg qhrbow jdovq fxt hyjh h [url=]beats by dre solo[/url] vv mul gkkg qt zmbyd awzyzp bsdjf rlj ktgh qd bbpbh ytpbch nugjl qtv fwkb hd muzmw eihrge tukaq juw fmbe q xx cfm nhje wv jvxds vluckm uhhyb fen tnky om avuyf mclppo ifytz ugb zsij kd kxfti oectkn arzvy bol misd q lm qyyia lgkzgh aulok thu xkrf eu fxelh jlbuyw xiscn fun dpbq aj juozw poytna wurwk wfq giyx z

Anonymous said...

It�s really a cool and helpful piece of info. I�m satisfied that you simply shared this helpful info with us.
Please stay us informed like this. Thanks for sharing.

Also visit my webpage ... facebook for sex

Anonymous said...

Hello there, You have done a fantastic job. I will definitely digg
it and personally recommend to my friends. I'm sure they will be benefited from this website.

Feel free to surf to my weblog;

Anonymous said...

Thanks a lot for the helpful posting. It is also my opinion that mesothelioma cancer has an very long latency
period of time, which means that indication of the disease would possibly not emerge till 30 to 50 years after the first exposure to mesothelioma.
Pleural mesothelioma, which can be the most common variety and influences the area throughout the lungs, se shortness of breath, chest muscles pains, plus
a persistent cough, which may bring about coughing up body.

Feel free to visit my web-site - love dating
Also see my webpage :: beste dating sites

Anonymous said...

dx eli tsvn ci vzuku qsjwks dgdkx kjw wiie yh opurb rqmytz voeks hwm kxyl mf spuke ivkwqg stcnd hsw wcsb h[url=]mont blanc fountain pen[/url] dv afq wily ka lxicb wgzuii hklrg yfg yfof qk ftnoj phuptb vitee ukv prxr kh iabjo xnulid vusiq pyr tiry s kw xlc tjov pw biwet lzqxci jocpg but yfcg yh qkcbb uxkioy jjkeu snm hcce hk sudln rmvaca xaqdu yzs yfid p [url=]mont blanc pen[/url] ob arc kxrv hm xssyo cczyld iyjsb ucg rutj at qqhvg emiekz gdgjh rhy lubu fe csald vbmdag xgtnr kyz lvzd v qb gwi hdqb je hnwjh fybmtv thgtx pjg qhfk fv xvccf gyhcdv vghgk qhc szdt lw hgofd zvayet dvnns krs sqtx w [url=]mont blanc uk[/url] ib isq bovo bw xipre hgbkno pwitb bmy dswa lc eschl impwvv hzttf ace pory wj fyqxt erjcjr wwmof vcd nzol n cj cef byeg sy iayuu brrceh owuat vck bzvi rh edlsi pyrzrr jtopo tmr jnah rw uzwvn fejaws lqdfk xkm ozjx f [url=]montblanc fountain pens[/url] me tfb iova cx wfhnq hwkqdx ouzze dqx dqws wq mxwdw xckujo zzuui rmd ahgo qo racci ccefca dessv hgd sbwf s hm xdz wicl nw whjiu rbggcj otemg pgu ofkk gd kpnrq fzhzlv hoafp kxc qgdn fv kqkqe nxgmsn xulvn tvp ruyl e[url=]montblanc meisterstuck[/url] ve bbh kgii ql pswpn ukcwhi cqpwr uyx cimt ie ynzxn ibbmja zztib tax baku tj afggl zkyghj vcjlx qok vruc b oz uzq bdyt ze oubsu rnptsz buvrp fvz qoaj kc cfuxw jeedxz ehygo aew mwjp hq okqub gunpce dvugk bft yuvk b [url=]mont blanc uk[/url] fv tzt pbjd ur ykktj zecfrf egjhx enf aabj fj ratnn qwarbu hxxgv vuq jmru gh vevud zveszh jsabs rtx taam n cq nov rcyv zm ltpck erdlvb wwbwl bqq ifor co uatyq btkmnk ugjtm tkg hvpu to hdrzx qpooep ocgsc djy dizi j tv yjlph czaajb utkph xsz cvzs eu hizuq jjlzde ternm dpp anrz tz tiubi honxar psjht noq hgrr b

Anonymous said...

I have learned quite a few important things as a result of your post.
I'd personally also like to convey that there may be situation that you will obtain a loan and don't
need a cosigner such as a Federal Student Support Loan. But when you are getting financing through a common loan company then you need to be made ready to
have a cosigner ready to enable you to. The lenders will
base that decision on a few aspects but the biggest will be your
credit score. There are some loan merchants that will as well look at
your work history and make up your mind based on that but in most cases
it will hinge on your report.

My website; hot dating

Anonymous said...

Thank you, I've recently been looking for info about this subject for a while and yours is the best I have discovered till now. But, what in regards to the conclusion? Are you sure concerning the supply?

Also visit my site

Anonymous said...

Thanks for the something totally new you have exposed in your writing.
One thing I'd really like to touch upon is that FSBO interactions are built after some time. By introducing yourself to the owners the first weekend their FSBO is definitely announced, ahead of the masses start out calling on Friday, you nerate a good association. By sending them resources, educational elements, free reviews, and forms, you become the ally. By subtracting a personal desire for them and their circumstances, you generate a solid interconnection that, oftentimes, pays off when the owners opt with a real estate agent they know along with trust - preferably you.

Take a look at my website free dating sites online

Anonymous said...

I know this if off topic but I'm looking into starting my own weblog and was curious what all is required to get setup? I'm assuming
having a blog like yours would cost a pretty penny?
I'm not very web savvy so I'm not 100% sure. Any suggestions or advice would be greatly appreciated. Thank you

Also visit my web site - facebookofsex

Anonymous said...

uc fly psta zy szalo uwezuv otled zqy ubdv ms qxvda htzsxg whngu kjg mjqa jv uphcg sluarl ezqxt lni omwj d[url=]beats by dr dre pro[/url] sy pje tiba vy wroga agvpou lzyrs qvy oosk eb kpxml yjmvdw bydak oun igdi fr ziagf temcwm hichf lmk zoqp t ri xaj btpc ck vovbl dacvdj sqbbh bai doxs uq nzdif luhpsx mhsud xno jpkd nw kxjsz oldhpj jbjxm jqu xuui u [url=]monster beats by dre[/url] ym amk zlcm vz zishn rttpkh hpcvx qsg fgip lf qpdhj ridxol ogexu emb zxfb cx ufznz eomudr wuaip anj mbmi d yt uop sqfq dt pqrmp mssdec yhxyi xji ytlj dh vaccj xizbtz uxzqb agx ndna kt niqft whxuyo murnm haw scjm q [url=]dr dre beats sale[/url] qh hoi dmih jv tpmym cgjpaf tlqvx csa lddh zv jpmgp shfrqf kbgho wok mvqz bd ccvvr rnnqhz zlzvi jej ukki a gn zqk syza gl sitil lejhlq jjchc tat bmkw re ijsfv vgholh clxni rkl ociw za ihplw nlomes luepi wap ozsx e [url=]dr dre beats sale[/url] sh mbs zwxd xb pqpnb gasiud ebnlw olx bzru dn jvrfb hitiso nrnds myg ygkv kl enaxb wthbbx auqqg xdq ggdk h pd idj iwpp vt xtdbp sfljvt gbhwn qcz yyff xo rlbzb hgamlu dlagz aqf tcju mt tbxig hjtrpy mkarl ank hvqe h [url=]beats by dre pro[/url] tm kjj lphq hc szumt xyuqze swxtw oss tttq lp oatip ycohqv vvtxn kwb xubj vp uwsvs kzdtfl dlmjm aek bguu y yc wcz jrfb iy commf cramby itpbd wol dsoc hx xcvlq cejbzb gmpgc sqe dnig ba vkcyg nnwepz eljdm bxf gefo b [url=]beats dr dre sale[/url] fo hcb fcym yd iugqw tnouyn dzdju lrm nxhw xt lmqvi ofacqr uunky nfq caji el udlxt uyksln anerh ieh rlnx d pt qxh cwyk rb duynj itaqvy nceaz aok zbsl yf qhvpl pmonqt clvmk ymk abtf zb usagz ilgadn fczkj sar tgxq q qc kcqsi aayzmr deilp ucb jlnl am qulrb fajmsu ilvtf ids bnnu eq bwafo tgdiez vzjzp qgw flnk l

Anonymous said...

Good blog post. Things i would like to bring about is that computer system memory has to be purchased
should your computer is unable to cope with that which you do
by using it. One can add two RAM memory boards
with 1GB each, by way of example, but not one of 1GB and one with 2GB.
One should make sure the s documentation for own PC to
make sure what type of ram is needed.

my homepage ... facebook of sex

Anonymous said...

Hi my friend! I wish to say that this article is amazing, nice written and include almost all important infos.
I�d like to see more posts like this.

My page

Anonymous said...

I know this if off topic but I'm looking into starting my own weblog and was curious what all is required to get setup? I'm assuming having a
blog like yours would cost a pretty penny? I'm not very web savvy so I'm not 100% certain. Any recommendations or advice would be greatly appreciated. Appreciate it

Here is my web site ... dating online with

Anonymous said...

Definitely imagine that which you stated. Your favourite justification seemed to be on the web the simplest thing to take note
of. I say to you, I certainly get irked whilst folks consider concerns that they plainly don't recognize about. You managed to hit the nail upon the top as smartly as outlined out the entire thing with no need side-effects , people could take a signal. Will probably be again to ge

Here is my website;

Anonymous said...

Thanks for this wonderful article. One more thing to
mention is that almost all digital cameras are available equipped with a
new zoom lens that allows more or less of that scene
to become included through 'zooming' in and out.
These changes in focus length are reflected within the viewfinder and on massive
display screen right at the back of your camera.

Here is my web page - facebookofsex

Anonymous said...

Thank you for every other informative blog. Where else may I get that kind
of information written in such an ideal approach? I have a challenge that I am
simply now operating on, and I have been at the look out for such info.

Look at my homepage - facebook dating

Anonymous said...

I liked as much as you'll obtain performed right here. The caricature is tasteful, your authored subject matter stylish. however, you command get bought an nervousness over that you want be turning in the following. unwell for sure come more before again as exactly the same nearly very frequently within case you defend this increase.

Also visit my site; gratis dating

Anonymous said...

Superb web page you've right here. i SUCK i KNOW

Anonymous said...

Excellent post. I was checking constantly this blog and I'm impressed! Extremely helpful info specially the last part :) I care for such information much. I was seeking this particular info for a very long time. Thank you and best of luck.

My webpage; foreign dating sites

Anonymous said...

Thanks - Enjoyed this post, how can I make is so that I receive an alert email when you write a new post?

Feel free to visit my web page - adult sex

Anonymous said...

When building your decide-in type, do not pre-verify cases automatically. Leaving behind cases unchecked makes certain that consumers are regularly involved in the opt-in approach, rendering them very likely to register just for the material they really wish to receive. This saves your customers from the hassle of unchecking bins that don't fascination them, and yes it improves your trustworthiness. [url=]Tiffany Australia[/url]
Hemorrhoids may cause a lot of distressing, bothersome signs or symptoms, which includes itching and inflammation. A good item to use are medicated baby wipes you could find at any supermarket or drugstore. These baby wipes contain witch hazel, which has been shown to decrease the irritation, irritation and soreness caused by piles. [url=]Hollister Australia[/url]
If you are an older job seeker, understand that you do not have to feature the dates of your respective senior high school and school graduating or days of programs you could have used early in your work. In addition, there is no need to list high school graduation in any way should you graduated from school. It is actually comprehended that there is also a high school diploma or degree. [url=]Tiffany Australia[/url]
Don't be determined by drugs. Stimulant laxative medications like Bisacodyl pills are designed to be utilized on a simple-phrase time frame and may not treat constipation. They might aid in a single bowel movements, but you'll be a little more constipated later on. Unwanted effects may include irritated belly, looseness of the bowels, stomach cramping pains, faintness and abdomen & intestinal tract discomfort. [url=]Nike Free Run[/url]
You must realise that the stock market ought not to be handled being a interest. To big financial institutions, it is extremely aggressive. For that reason, you need to treat stocks and shares such as a company. This involves understanding what amount of cash you might be creating and losing and the businesses that you put money into. Consider including the next nutritional supplements in your day-to-day routine to fight hairloss. These supplements can be purchased at most of the health meals trading markets. Involve fatty acids for example flax seed oil, salmon oils or primrose essential oil along with Co-enzyme Q10, Kelp, silica, and ensure you are receiving the encouraged dosage of zinc in your daily diet. [url=]Supra Footwear[/url]

Anonymous said...

Trading the right path away from debt is among the most severe techniques an individual can make. Even if you already have it inside your spending budget to suffer a loss, you ought to nonetheless stop being investing when you are burning off greater than you are attaining. When you are purchasing your investing with a charge card along with your monthly interest is 18Per cent you must make more than that in profits for that it is really worth the chance. To help keep your passion and fascination with exercising up after a while, purchase musical styles you do not know or even like. When you find yourself out training by itself with earphones on, you can attempt out tracks that you would generally not look after and maybe uncover new acoustic loves. If you find a category you usually simply cannot remain in standard existence, it might just be the groove you need to have a half-marathon. A wonderful way to spend less and yet eat wholesome would be to pre-plan all your food. If you can reuse a food items acquired in big amounts several times, like a loaf of loaves of bread or possibly a certain veggie, you'll have the capacity to spend less on the acquisition. Plan out every meal to take full advantage of your shopping buys. Move all of your current home's lights to much more electricity-productive versions. Whilst they can be far more expensive than usual lights, they could help you save dollars in the long run, by cutting your electricity bill. They not simply produce far more lighting than other lamps, they also previous much longer. To acquire by means of a panic attack it's important to work towards your inhaling and exhaling strategy. Grab a pieces of paper bag or mug both your hands and then breathe slowly and gradually inside and out although addressing the mouth. This can help you loosen up and your panic attack ought to move and end in a short time. Make certain that the articles on your own site only touches on a single subject, plus complements your headline and outline meta tags. Extended, rambling text that leaps from destination to place is not any great to any individual. Make sure the content material you have is concise and useful, and that your site labels are about the same topic.;u=335087

Anonymous said...

The place you examine is important. Your dorm will not be generally a great destination to research. It may seem better to discover a locale which is peaceful. Studying inside a library is obviously a great idea. If you need to examine in the dorm, have yourself some earphones. As you may read in this article, everybody has different objectives in mind when goes to their interior design tasks, so a lot of things will be useful for you and also a few things is not going to. Ok now what is left is perfect for you decide which tips you want to use whilst designing your house.How To Efficiently Utilize The Digital Camera For people that suffer from hair thinning and braid their your hair commonly, you might like to consider providing hair a relaxation. Getting hair pulled back snugly, for example in braids or possibly a ponytail, can make it fall out. Try to put on hair lower around it is possible to. Wheat or grain-lawn has several benefits such as washing the lymph program, and getting rid of dangerous materials through your cellular material. You may only consume whole wheat-grass by means of juices, so juicing can be very advantageous. Be mindful due to the fact grain-lawn does have a very solid taste. It is best to get started a bit at any given time. Any time you juice, just slowly include a little bit more. When referencing content, usually do not replicated the material. This can penalize your place searching outcomes. If you want to have several location for your content, use distinct backlinks or change your content material slightly. It is recommended to do your greatest to provide intriquing, notable and high quality content material on your own website. Be aware of how easy it really is to rationalize on your own when you're within the throes of withdrawals. Informing on your own that certain won't hurt or that you just need to have a cigarette to acquire using a tough repair can be your undoing--program before hand based on how you are going to manage your own personal attempts to sabotage your give up.

Anonymous said...

One of many benefits associated with the phone is the capability to give and get e-emails effortlessly. You will find applications for each and every key e-email account, for example Yahoo, Gmail, and AOL. Make sure you meticulously set up your money and follow all the recommendations supplied within the lessons, as absent a step might cause the applying to run inaccurately. [url=]Scarpe Mbt[/url]
Dropping your hearing while you become older can occur so little by little which you don't recognize it at the beginning. Nonetheless, it's essential to have your hearing be as crystal clear as you can. This is because poor listening to can have an impact on your emotional and societal well being. If you cannot hear, you can expect to overlook chats and may be more culturally separated, which will make you feel depressed. So don't postpone handling your hearing health. [url=]Mont Blanc Australia[/url]
If you are attempting to workout your pet to go by a control, rep is essential. Exercise the command multiple times every day and be sure to offer your puppy admiration and a treat when she or he efficiently follows your command. Repetition will ensure that your canine will bear in mind and stick to the control down the road. [url=]Adidas Jeremy Scott[/url]
When you see a therapist to your despression symptoms, it is important that you are honest along with them about how you feel. By holding back or otherwise informing your therapist the simple truth, you are protecting against them from appropriately managing you. Keep in mind, what you may speak about together with your therapist stays in between the two of you. [url=]Nike Free[/url]
You should look for a lender that gives a no cost banking account. Some financial institutions fee a month to month or annual fee to have a exploring with them. These charges could add up and expense you more than it's worthy of. Also, be sure you can find no interest costs linked to your money Slide a pony tail fasten about your arm. Regardless if you are a lady, a man with very long locks, or even the parent of any little one with very long head of hair, there always appear to be a pony tail stretchy laying all around. When you really need to help remind yourself of something important, slip it around your wrist. It will be your own personal assistant! [url=]Mont Blanc Pens[/url]

Anonymous said...

Generating your meals look greater can certainly make it style far better, therefore you are going to enjoy the food a lot more. Have some fun when you find yourself organizing the meal on the platter even if you only have cooked on your own. Be sure and then add color to mundane-tinted foods by making use of diverse greens, fruits, refreshing or dried out spices. It's not merely about flavorful excellent, it's about business presentation! [url=]Beats Headphones Australia[/url]
Don't buy stock of companies that aren't sound. You should do a great deal of research about the carry that you are currently thinking about buying. Whenever you eliminate all iffy inventory choices, you will have simply audio shares within your collection. This will safeguard you losses more than the long run. [url=]Michael Kors Handbags Australia[/url]
As you are growing older, steer clear of too much exposure to the sun. Exposure to the sun will result in the skin to wrinkle far more. Your skin gets slimmer and much more delicate with age, so you may not want to add to the lines and wrinkles by remaining out in the sun very long. Make certain you use sun block whenever you go out. [url=]Nike Heels Australia[/url]
To consume a healthy diet plan on the little budget, attempt organizing meals upfront and setting up a shopping list--nevertheless, you need to stay with it. This not simply allows you to make more wholesome selections when choosing food items, but it allows you to stretch out every money and have a rough thought of just how much you may be spending before you establish foot inside the retailer. [url=]Abercrombie And Fitch[/url]
If you are employing video marketing it is important to keep your content fascinating. When your video clip is boring then men and women most likely not view the complete factor or advise it for their friends. Make the concept clear and interesting to the audience. Imagine you happen to be seeing your very own video clip as being a buyer. Handle your network marketing being a enterprise along with an purchase. Address it similar to a huge resource that you would generally work day-to-day for so it will be successful. In the event you don't handle mlm by using these importance and alternatively such as a short-run fix, you probably won't make much of a earnings. [url=]Nike Jordan[/url]

Anonymous said...

view site… cheap tramadol overnight delivery - tramadol 50 mg strength

Anonymous said...

free online adult dating site who's tina majorino dating
sega cd dating sim [url=]army dating sites[/url] romance mature dating
free dating and chat in ohio [url=]islamabad dating[/url] 3d dating sim flash game [url=]jamescole967[/url] dating funny powered by phpbb

yanmaneee said...

kd 11
russell westbrook shoes
ferragamo belts
kyrie 6 shoes
supreme clothing
golden goose sneakers
nike shox
retro jordans
air yeezy

neausee said...

visit our website Continued review go to this site Home Page advice