Thank you for joining us for the Active Shooter Prepare, Respond, Survive, Part 1 webinar. A few housekeeping notes before we get started. All attendees are in listen-only mode. We will be using the Q&A function today to gather questions for our speaker. We will not be using the raise hand function. Please submit questions through the Q&A and interact with other attendees by posting comments to the chat. When using the chat, just be sure to select all panelists and attendees from the drop down above the message box before submitting your chat so everyone can see it. This webinar is being recorded. Please know we will be sending all registrants the webinar recording and PowerPoint slides via email in the next couple of days. Our speaker for today is Jacob Yates with Healthcare Compliance Pros. Now I'll turn it over to Jacob to get us started. Wonderful. Thank you. Thank you, everyone, for attending today. I'm excited to have you here and hope that you find today's webinar informative as part of Part 1 of this Part 3 series. So before we get started, I wanted to let you know the title of this webinar is very intentional. I wanted to make you think of the hit song by Pat Benatar, but I want you to also remember what we discussed today, because really it's important that as you walk away, you feel confident in being able to prepare and also prevent an active shooter incident from happening within your organization. So I will warn you, you know, obviously this can be a very heavy, very uncomfortable topic, especially as of late. So as such, if you feel at any point that you are starting to feel apprehension, anxiety, fear, whatever the case may be, please feel free at any point to step away for a few minutes. As was mentioned, this is being recorded, so you can go back and review the recording at a later time if needed. All right. So when we look at active shooters, we'll start where we look at history and what we can learn from the history that we've already seen in these situations. So we'll start first with our history and then look at preparation and prevention. So to give you a little bit of background as far as where a lot of this data and information is coming from, everything as far as tracking goes really started as a result of the Columbine High School shooting. That was kind of the pivotal moment where the United States government really made effort to start tracking this information formally. And then starting in the year 2000, the actual formal tracking began. But Columbine is kind of the straw that broke the camel's back, so to speak, as far as tracking this information and actively trying to educate and prevent these incidents from happening in the future. As far as when it hit the health care community, this hit back in March of 2009 at Pine Lake Health and Rehabilitation Center in Carthage, North Carolina. Gentleman Robert Stewart came inside and began shooting individuals. This is where his estranged wife worked. He was actually coming after her. And ultimately, before he was apprehended, he had killed eight individuals and wounded three others. He was ultimately apprehended as a result of being wounded during an exchange of fire with police forces. But this is the first formally recorded incident in a health care setting as far as an active shooter goes. Since then, we've had 18 other health care active shooter incidents. And that has resulted in the deaths of an additional 25 people. The most interesting thing that I found about this is over 25% of these have occurred just this year alone. So these incidents are not decreasing. They are increasing at an exponential rate. Even the most recent shooting at Methodist Dallas Medical Center on October 24th. So these things are they're happening regularly. They're happening more frequently, which is which is why we're here today. So all of these instances, you look through this, you know, can feel a little bit daunting. And we it brings up the question of where where are these active shooters coming from? Like who who are these people? Do they take a particular form? And the short answer is, is no, they really don't. If all these different instance, you've had doctors who have been fired that have come back to their employer and began actively shooting patients, relatives, friends, former former romantic interests of employees or patients. There's really no one set identity of an active shooter incident in in a health care setting specifically. So since the FBI began tracking this data, there have been kind of three consistent states with the highest number of active shooter incidents as a whole. So that's California has had 54 incidents, Florida has had 34, and Texas has had 33. And this is holistically not just health care. And that's not to not to alarm anyone in those states, statistically speaking, you are at higher odds of being in an active shooter situation in in those areas. Now we have five fortunate states who have never had a documented active shooter incident. That is not an invitation to sit back and relax. If anything, it's a reminder to not be complacent, because these things can be prevented to a large degree. So when we look at some of these other things, and it doesn't show well on this map, but in in the last two years alone, states like Michigan, Idaho, Massachusetts and South Carolina have doubled the total number of active shooter incidents from just those two years versus the prior 19. Most states have seen an increase in active shooters, not quite that aggressive. And a lot of that growth has been just in the years 2020 and 2021. So they they are on the rise and definitely something we need to prepare for and be ready for. All right, now that we've kind of covered some of the history there of active shooter scenarios, let's look at some of the some of the causes that we found. So as we look at the primary stressors, we find that about 62% of total active shooter incidents are a result of depression, anxiety, or mood disorders, so some type of mental health stressor. This does not necessarily mean the person was formally diagnosed, simply means that they were observed to be struggling with some some sort of mental health stressor at some point. When we look at the other statistics here, about 49% of incidents were linked to financial strain of some kind, 35% were linked to job related stressors, 29% were linked to conflicts with friends or peers, 27% linked to marital problems and 22% linked to abuse of illicit drugs or alcohol or including alcohol at some times. So as you can see, there are a variety of additional stressors there, physical injury and so on that also contribute to these, but to a lesser degree than those those top primary stressors. All right, so we're going to do a little exercise. So take a moment, grab a piece of paper that's handy, you won't need a lot, so scrap paper is fine, or pull up a Word document or somewhere where you can type down this information. And we're going to run through a little scenario and we're going to use this a couple more times throughout our webinar today. So we're going to kind of walk through this. So it is a little bit more of a kind of imagine type scenario. So what we'll kind of set the scene, the scene takes place wherever you're at, right at this very moment, maybe that's behind a reception desk, in your office, in a patient exam room, or maybe a conference room, maybe you're watching this with your co workers. Now imagine while you're here, watching the webinar, you hear or you see or maybe both a man enter the practice and proceeds up to the front desk, you start recognizing the voice, you recognize him as a regular patient, and one who in the last couple weeks had recently experienced a mistake during a procedure in the office. And he has been calling every day. He's been complaining, saying that he's going to sue the practice, make the doctor pay for his mistake. And your staff has done a great job of handling his calls each time. But they start becoming so frequent and so incessant that it's interrupting business operations. So eventually, those calls have to be screened in order to make sure that their calls from your other patients are going answered. Now, the man starts to become more and more irate, and you can see or you can hear this situation escalating. He's yelling, he's extremely agitated. And suddenly you hear it, three loud bangs, and you recognize them as gunshots. Now that begs the question, what do you do next? So I'm going to give you a minute just to write down what your initial reaction is. So you want this kind of your gut instinct as if this was happening right now. Okay, so when we look at active shooters, and what we do to prevent and really prepare for these situations, we're going to talk about three keywords, and you will hear this a lot over the next three webinars. They've been described really as kind of this generation's version of stop, drop and roll that became very popular in the 80s, when there were a lot of incidents with fires, and having to teach people how to survive if they caught on fire. So the three keywords are run, hide, and fight. So each one of these, we'll dive into in a little more in a little more detail. But I want to kind of highlight one thing first. As we look at these three areas, remember that some people around you may panic and become indecisive about running, hiding, fighting. It may seem heartless. But if they panic or hesitate, you need to leave them behind and either run, hide or fight without them. Again, it does it does feel very heartless, but the odds of you surviving that situation by trying to coax or encourage someone to go with you that is hesitating could cost you your life as well. So much like similar to oxygen masks on an airplane, you put yourself on first and then you go and help others. So same kind of a thing. If you can encourage people to go with you along the way, perfect. All right. So looking at running first, it's always the first and best option. So always run if at all possible. A moving target is harder to hit is one of the primary reasons why. So running increases your chances of survival because of that very reason. As you escape, bring others along if they'll come. Otherwise, again, leave them behind. If you can't get them, if you can't safely get to an exit or your exit, your only exit option is towards the active shooter. Your next best option is to hide. So being your second best option, we want to do a few key things. First, you want to find somewhere where you can hide that has a door that closes. And if possible, locks is ideal. Again, there may be others around. Encourage them to follow you. If you can, get in a room, lock the door, barricade it is very important. So grab anything you can to keep that door from opening, even if it is a locking door, large furniture, chairs, just anything to keep that door from opening. You'll want to turn off the lights and then immediately silence any cell phones. You don't want that going off and alerting a shooter of your location and where you're at. The next thing you need to do right away is make a plan to defend yourself. Just because you're hidden in this room does not mean that an active shooter may not try and gain entry to the room. So prepare to defend yourself by finding things in the room that you can use to defend yourself. And then ultimately, if you can't hide, if that's just not a realistic option for where you're at, you'll fight. Now fighting is always the last resort. One of the reasons is it poses the highest risk of being injured or killed. So we don't want to necessarily be the superhero that's trying to charge and take down this gunman because chances are we won't survive that. So when you fight, again, this sounds a little gruesome, a little inhumane, but if you're going to fight, you need to fight to kill. If you hesitate, that can cause death, that could easily cause your death and then the death of additional people as well. So you need to remember you're already at a disadvantage. That shooter is not going to hesitate to shoot you. Your goal is to take them out by whatever means you need to because if you can take them out, you can save potentially additional lives that could otherwise be lost. So if you need to fight, quickly find objects around you, anything that you need to to, you know, improvise weapons. If you're with others, quickly plan what areas of the shooter you're going to attack. You know, someone aim for the head, the torso, legs, arms, someone aim directly for the gun. Whatever you do, don't hesitate on your plan. Honestly, that one second of hesitation can truly be the difference between life and death. All right, so we're going to take a quick moment of levity here. Everything we've spoken about to this point has been pretty deep and pretty heavy. So we're going to take a few minutes and watch this quick clip with Lucille Ball. This is one of my favorite episodes. I mean, they're all great. But this clip really reiterates two very important things we've learned. One, your first course of action is run to an exit if at all possible. And you'll hear Lucy say this, a moving target is hard to hit. And the second one is if someone hesitates or is indecisive, leave them behind. Okay, I will make sure the link is included when the material is sent out. But I'll give you kind of a brief, brief descriptor of this, this scene here. So Ethel walks in, she sees Lucy hiding and Lucy jumps out. She's in her dressing gown. And Ethel comes in and asks Lucy what she's hiding from. And she says, Ricky's trying to kill me, he's going to try and shoot me. And so she's like, I get a sinking feeling right here and you hear a tink, a tink across her abdomen. And we find out that Lucy has covered herself in some pots and a garbage can lid to try and protect herself, give herself armor basically against Ricky. And then you see Lucy start frantically jumping around and she's like, this is what I'm going to do. She's like, okay, Ricky, what's the trouble between us? What can we do? And then Ethel goes, why are you jumping around? What's the point? She goes, well, moving target is hard to hit. Then of course, Ricky comes home. So what does Ethel do? She leaves. She leaves Lucy because she can't stand to see her, quote unquote, riddled with bullets. So Ethel leaves and Ricky walks in. And what does Lucy start to do? She immediately starts moving around, bopping around and Ricky's looking at her with a very puzzled face, asking her why she's doing it. And then the scene ends with her basically saying, you know, just go ahead and shoot me. I, you know, I can't keep doing this. And then they come to this, of course, in a very Lucille Ball fashion realization that Lucy misunderstood something she heard Ricky say, leading to her thinking that he was going to kill her. So again, I'll send you the clip. It's a nice little moment to just take a breather. It's about a three minute clip. So I'll make sure that gets sent along to you. OK, so we're going to start moving into preparation and how we can prepare for that. So in my line of work, I consult with a lot of people. I consult with a lot of people who believe certain situations or incidents can't happen to them. It can be as a result of the size of the practice, the size of the town they're in and so on from there. One thing to reiterate is an active shooter situation can happen anytime, anywhere. There's nothing that's going to necessarily preclude you from being in one of those incidents. A great example of this, I received a call from my sister on Monday and my six year old nephew was at school and she got a notification from the school saying that they were on lockdown because of an active shooter in the area. Thankfully the active shooter was well, not necessarily thankfully, but the active shooter was at a residence and not at the school. So quickly acting, all these teachers were able to lock down the school, keep everyone safe, keep the kids calm. But just as an example, these things are happening more frequently and odds are they're going to happen to someone you know sometime in the future. One of the other things that I've seen a lot as far as preparation goes was at a prior organization I worked for that submitted medical claims and medical records to Medicare on behalf of Part C insurers. And at that time I supervised a team of employees and I had one employee who was obsessed with guns. Hunting, target shooting didn't really matter. That was his topic of choice. So a lot of this time he's bringing these things up, mentioning his prowess with a gun, things of that nature. And unfortunately due to his very poor performance we decided as the HR group, my supervisor and I to terminate his employment. Because of his obsession with guns and his belligerent attitude, we actually had to develop a plan of action in case he came back with a gun and sought retribution or revenge for him being fired. Thankfully, we never had to act on that plan. He never came back to the office, but I will say that it had a very strong impact on everybody in the office for multiple weeks following that, that he was going to come and seek retribution. So the number of active shooter incidents in healthcare, again, are increasing at an exponential rate. The unfortunate truth is we can't plan on this never affecting us in some way anymore. That's the unfortunate truth of it. So we'll talk a little bit more about what we can do to prepare. All right, if you cannot see the screen, how do I prepare? Please feel free to throw a comment in the Q&A and we'll make sure that we get that taken care of. So if it isn't a part of your disaster recovery plan already, planning for an active shooter situation should be included as part of that. So from there, it's an important thing to look at your active shooter plan annually as you're renewing your active shooter kind of business plan along with your other disaster recovery preparations. If it's not a current part of your disaster recovery plan, I would highly recommend getting something in place and just including it as a part of your annual updates with that plan. Just like with a fire or a flood, having your PHI and your EPHI protected and accessible is just as important in an active shooter situation. For example, you could consider if there was a situation, perhaps a patient gets injured and they have a life-threatening injury, they get sent to the hospital, the hospital needs some information. Being able to quickly send that information could save this patient's life. It could make the difference between their life or death. So making a plan now for how to maintain that business continuity, even in the event of something as disastrous as an active shooter scenario is so important to do. All right, so how do you prepare an active shooter plan? So before we kind of dive into this, I want you to think back on the exercise we completed a few minutes ago. Now that you've had a few minutes, we've talked about a few other things. I want you to think about what you would do differently. Would you make a different choice? Do you think that the course of action you chose at that time is still the right course of action? Take about 30 seconds or so and just write down any of your thoughts there, whether you were right on target with where you needed to be or if you would do something to change. So looking at this, go ahead and keep those responses handy. We're gonna use that sheet of paper one more time. So some of you may have already prepared your active shooter plan. If so, great. For those that haven't, this may take several drafts. It may even require an approval from an executive committee before we get to the point where it can be formally published or even tested. So first thing we want to do is identify our key stakeholders. Make sure all your necessary parties are involved. Make sure that everyone that's involved in that action plan is committed to it. And then from there, the second thing I would encourage you to do is consider two very important perspectives that frequently get missed. And that is consider the other employees and consider the patients. So if a shooter, for example, came into the waiting room, your office manager or receptionist or whoever's at the front desk, their options to run, hide or fight are going to be very limited, especially as compared to employees who are further from the front office or in their own office. They are going to have more time to react and respond. So consider what it would be like to be in a different area of your office as you're creating your plan. You know, it's going to look very different if you were in an exam room, a procedure room, administrative offices and so on. So just consider who else could be in the practice. Another one that's also frequently missed is any vendors that may be in the office coming in to refresh supplies or for removing biohazard waste, things like that. So think about if your plan incorporates those individuals as well and what you'll do to keep them safe. Now, I would encourage you to work with your local law enforcement. They are going to know very specifically what type of incidents are happening in your area and they can provide some additional guidance and information that will be more unique to your local circumstances and the local risks you face. So each year, it's not a bad idea at all to reach out to your local law enforcement and even review your active shooter plan with them and see if they have any additional feedback for you in that regard. Now, one of the hardest parts about writing this plan is gonna be the ethical considerations. For example, if you were a surgery center and an active shooter incident occurs, does your surgical center abandon the patient they're operating on? Do they try to barricade the doors? Do they try and fight the attacker to protect the patient? There's decisions like these that bring into a lot of ethical questions and really answers that need to be decided and made. And by the time an incident happens, the decision is too late. It's too late to prepare for that. So the most important thing to remember is we're always seeking for preservation of life. That's the most important objective in an active shooter situation. The other thing that's important to consider is to plan for all of these variety of situations that could be occurring. For example, a surgery happening, maybe it's time to invest in some locking doors or something like that. Consider a patient maybe with limited mobility. How are we going to help them effectively escape or get away from an active shooter situation? Maybe in that case, the wiser course of action is to hide. So think about these different scenarios as you're preparing your plan or as you're renewing your plan to make sure we're accounting for these different areas. So now that we've kind of looked at this, there's a lot of physical office updates that are very important to consider when you're preparing. So for example, shelter in place. It's never a bad idea to have a few designated shelter in place locations within your office. Again, some offices are going to be smaller and may not have the capacity to necessarily have designated spaces. Patient exam rooms are typically ideal most of the case, they either have minimal windows or they have no windows at all. So places like that are an ideal shelter in place situation. You may consider making sure that there are doorknobs on those patient exam rooms that lock from the inside or that are harder to get through, thicker doors, those types of things are things to think about. Now, if you choose the route of designating some shelter in place rooms, I would highly encourage you to make sure you've always got a very good and well-stocked first aid kit in those rooms. There are going to be injured people in this incident. And if you can get to a room to hide, you may need to start performing some type of immediate medical care for the people you're with, if they have been wounded. The police force job is first to take out that active shooter and then attend to the wounded. So having those first aid materials readily available could, again, meet the difference between someone's life and someone's death. Notification systems are a great way to do this. In middle school, we actually had an active shooter incident. Thankfully, no one was injured, but the teachers were all well-trained and prepared and they had a very easy way to notify them that an incident was happening or was looking like it was going to start happening. So the principal would come on the intercom and simply say, students and teachers, Mrs. Joukowsky's red typewriter's missing. Will the student or teacher who borrowed it please bring it back? And that was the announcement. So this did a few things. One, we know the red typewriter indicated an active shooter incident. The second was when they announced, will the student or teacher who borrowed it bring it back? So from this, they can also convey if there was an adult or whether it was a student or a child aged individual that was the active shooter. So all of those things, gratefully, I'm grateful that no one was wounded or anything like that, but a simple notification, something like that, that's somewhat covert is a great way to notify your employees. Again, evacuation maps, signs, having those things in place so that people who are visiting can quickly get to safety are great. You can even incorporate that in with your fire escape signs. Access, limiting access to who can get in and out of the office. One of the interesting things is, as the FBI has been evaluating these different active shooter incidents, they found that most of the active shooters conduct surveillance for as much as two weeks prior to actually carrying out the attack. So the people that are coming are coming frequently, they're examining this, they're planning. So by limiting the amount of places folks can enter and exit your practice is going to help you a lot as far as identifying any suspicious behavior or trends or things you see like that. Again, involving local law enforcement is a very important part of this. If you're a larger facility, I would highly recommend creating a first responder kit. Typically you can just mount them to the outside of the building and give them a special lock box code or something of that nature. So when first responders arrive and when law enforcement arrives, someone can give them that code, they can get into that box, which will have copies of the keys, access cards, a map of the facility so that they know where potential shelter in places are. So they can go through and quickly and effectively resolve the situation. All right, turning our plan into action. So as you're developing that plan, conduct simulations. You know, it doesn't necessarily need to be anything grandiose to start out with, but it gives you a really easy way to identify gaps. And from there, you can address those issues, you can make any type of corrections that you need to. Because the main thing to remember is if an active shooter incident happens, it will cause chaos and it will cause shock in individuals. So if the plan needs to be clear, needs to be easy to follow for someone who is under extreme duress. Again, kind of one of those ahead of time is always the best time to plan and fix any of those inconsistencies or issues in the plan. So once you fix those gaps and inconsistencies, work with your local law enforcement again and conduct a full out drill, including notifying them, having them come, having them clear the building. All, basically all of the pieces, all put together in a formal drill. And that will really help you make sure that you have everything in place that you need in order to successfully prepare for an active shooter incident. All right, now, as we come into the kind of last leg here of the webinar, we'll dive into prevention. That being said, there are going to be rare times when you can do everything right and an active shooter incident is still going to happen. Every active shooter incident that's ever happened has been unique in some way. They're just as unique as the individuals who are leading them out. So when we look at some things, we have found some key data that helps us along kind of understanding and knowing where we need to be. So using this information is going to significantly reduce the likelihood of an active shooter incident at your practice or your organization. So some key things to watch for. And honestly, I wish I could say that every preventative measure is going to stop active shooter incidents from happening. None of us want this to continue on. And I can truthfully say that. So even though the statistics are... Basically with what the statistics are speaking, there are still odds that an active shooter incident could occur at random. So these are key ways to be prepared and prevent an incident. But there are those incidents that will and can be carried out at complete random. Again, they're very few and far between, but we have had those types of incidents. So let's look first at our top five most concerning behaviors. And these are all observable behaviors. So about 85% of the time, these behaviors were noticed through some type of verbal or other physical action type communication. In the case of this, again, mental health is right up there at the top. These are observable behaviors such as depression or anxiety. Again, not necessarily diagnosed, but behaviors you can see that are different from how the individual is normally acting. There are interpersonal interactions that may kind of clue you in that something's not quite right with the individual you're speaking with. One of the interesting things and a new term that I learned while preparing this webinar is the term leakage. Basically, it's almost like a Freudian slip where someone is talking to you and they express something and you can tell they didn't mean to let it leak, but at the same time, they keep talking about it. So that leaking information is a high indicator that there is an active shooter or other violent incident about to happen. So typically, when we see who active shooters are talking with, they're usually talking to a friend, a coworker, or a family member. So some of the information that they're sharing and some of the behaviors are typically noticed more in the workplace just because people spend more time in their workplace typically. So as you're talking with individuals in the office, watch that quality of thinking or communication. Often you'll find that either it just doesn't make sense, something that they're saying doesn't make sense, or there's gaps in how they're communicating with you. But overall, most coworkers have noticed these behaviors prior to family members. So just be aware of the folks around you and the folks you're working with. So when we look at the signs listed here on the right, you'll notice none of them are subtle. They are not subtle type of indicators at all. So by just taking a few moments to check in with your coworkers, patients, friends, family members, and watching, seeing if they're exhibiting any of these signs, you could prevent an active shooter incident from happening. And as you're looking at this, you may notice that many of these are the same signs of suicidal ideation and depression. So you could be saving a life in more than one way just by noticing these things and taking the time and attention to address them. All right, so as we start taking our steps to prevention, it's important that each employee knows what the process is and what the plan is in case of an active shooter situation. You know, they need to understand what's expected of them and what they need to do so that they can act without hesitation. One of the most important things to teach them is how to recognize the behaviors we just reviewed on the prior slide. If we can recognize those behaviors in advance, this is really going to help mitigate any potential threats and ultimately everyone will be better off as a result of it. So some of the little things are an easy way to mitigate these type of items. Things like customer service, good customer service, treating others with respect or kindness go a very long way, and they're very small things. And I get that that feels a little altruistic, but as your staff, and as you're focusing on these little things, you're going to notice when behaviors don't seem quite right for an individual you're interacting with. So when you notice these things, speak up immediately, speak to a supervisor, whoever the case may be, don't keep it to yourself. You want to make sure that you are not only protecting yourself, but also protecting your coworkers, but also helping that individual. Again, looking at the statistics of it, about three quarters of active shooter incidents that have happened in the last 22 years had a connection with the place that the incident occurred. So a majority of the time they are not random shootings, they're very specific to that place, to specific people. So just by spending an extra few minutes caring for a patient, a visitor, a coworker, staff, these things can really prepare and keep you out of a disaster potentially striking the office. So as we start wrapping up the webinar, I've listed a few kind of high level steps here to begin planning or updating your active shooter plan. First, make a plan, making sure all your stakeholders are involved and that everyone is supporting it from your senior leadership team all the way down to your regular line staff. The second one is practice your plan. Make sure there's no gaps, make sure everyone knows their responsibilities and their role, make any adjustments you need. And then finally take the preventative measures. Train your employees on behaviors to watch for and how to properly respond and report those concerning behaviors within the practice. From there, if you have any facility changes that need to be made to create a safer office, involve any of those parties that you need to make those decisions. Really ultimately at the end of the day, saving a few dollars is not worth someone losing their life. So if it makes sense for you to make some facility updates and changes, it's worth the investment now. So we're gonna pull out that sheet. One more time, that piece of paper. And I want you to take just the next minute and write down three simple action steps you can take in the next 24 hours to help prevent an active shooter situation from happening in your office. And again, we're talking very, very simple steps. Maybe that's checking a first aid kit. Maybe that's checking in with one of your employees. Maybe you've noticed some off behavior with them. Three simple things you can do. So we'll give you about a minute here. Okay. Well, everyone, I wanna thank you so much for your time today. I hope it's been beneficial for you. If you have any questions, feel free to throw them in the Q&A. I'd love to answer whatever questions you have today. Thank you so much to Jacob for hosting this wonderful presentation today. And thank you to all of our attendees for joining us. Thank you again and have a great rest of your day. Thank you. Bye-bye.

Active Shooter

Prepare

Respond

Survive

Plan

Simulations

Prevention

Collaboration