Physician Credentialing Assignment Example | Topics and Well Written Essays - 500 words

Physician Credentialing - Assignment Example Information submitted by any applicant should be thoroughly examined and cross-checked to ascertain honesty and experience of such an applicant. The education background should be verified by checking all certificates presented. It should be ensured that the resume is consistent with the age of the applicant since some applicants could try to fake their resumes hoping not to be noted. This is important as it helps to ensure that applicants will have gone through formal education and qualified in whatever fields they applied. This information will be got through certificates and also through contacting the education institutions stated on the resumes.  History of the practice of applicants is also important. This is the period that an applicant has been in practice. The medical field is not one whereby applicants work on probability but based on being sure of what they are doing. Hence, every hospital that an applicant claims to have practiced should be contacted and letters or reco mmendation reviewed. Conduct history is one other thing that thing that will not be overlooked (Matzka, 2007). An applicant needs to come with a certificate of good conduct showing that he/she has maintained integrity throughout the period of practice. Any penalty that an applicant has suffered in the course of practice is reviewed and the reason behind ascertained.  At Rural Outreach Community Hospital, any applicant is taken through a thorough scrutiny that ensures that they meet all the laid down procedures of approval. As the one in charge, I would ensure that there is a procedural interview process through which all applicants are taken through. There would be a practical exam where a hand on experience is checked by a qualified professional.  After this, the applicants who qualify are not hired on permanent basis but are first hired as interns. During this internship period, their performance is

Advantages and Disadvantages of Undercover Officers Essay

Advantages and Disadvantages of Undercover Officers - Essay Example It is evidently clear from the discussion that the use of undercover as an investigative technique has grown into all areas of criminal investigations in most of the countries. Though an undercover officer’s job is an exciting one, it consists of a lot of challenges and risks. â€Å"It’s perfectly legal for undercover officers and informants to engage in criminal activity to protect their cover. Because of the serious threats to their lives, while facing extreme terrorists and criminals, undercover officers are legally allowed to engage in any sort of activities to protect their lives. They can even kill the suspected people if there is no other option to capture them alive. â€Å"Undercover officers are legally allowed to lie when you inquire whether they’re law enforcement personnel.   It does no good to ask, â€Å"Are you a cop?†Ã‚   Undercover cops can just reply, â€Å"Of course not.† As part of their duty, undercover officers need not tell truths all the times. They can manipulate stories and even they can tell utter lies to execute their mission effectively. The aim or target is most important for the undercover officers rather than the method used to reach the target. â€Å"To those engaged in police investigations, undercover operations offer the opportunity for increased efficiency. They allow you to penetrate criminal organizations not susceptible to other investigative techniques.† (Burton) Criminals have well-defined methods to tackle any kind of operations from the police because they are able to watch and act based on the police activities because of their known identity. On the other hand, because of the unknown identity of the undercover officers, criminals may not get enough information about the actions and procedures of these officers and also most of the undercover operations occur unexpectedly. The criminals may not get enough time for preparation or resistance in most of the undercover operati ons.

Organic Ice Cream Essay Example for Free

Organic Ice Cream Essay There is hardly any person who has never bought or tasted any home-made or commercially produced ice cream. About 41. 38% have purchased ice cream once a week and Haagen Dazs was chosen as their favorite brand. Among the available flavors in the market, chocolate (62. 50%) and vanilla (50. 00%) are still the old time favorite. Although most prefer regular ice cream (93. 33%), about 25% have tasted organic ice cream. Due to the advancement of medicine and research, rapid information dissemination, and vast production of goods and services, consumers are aware of products that are sold in the market. Consumers these days do not only want to satisfy their palates, they also want what is best for their health. There is a growing market for organic fruits (68. 75%) and vegetables (87. 50%) and about 78. 57% are still not aware that organic ice cream exists in the market. However, about 57. 4% are willing to try it if the organic version taste as good or better than the regular version and if it is also healthier for them. People are switching to organic fruits and vegetables to avoid pesticides and other chemicals that are not beneficial to their health (Nagourney, 2007). They want to have a more nutritious, safer and better food than non-organic. Since Haagen Dazs, a leading ice cream manufacturer, has never introduced organic ice cream, it can capture 87. 0% of the consumers who showed interest in trying the product produced by their favorite brand. While there are still limited numbers of organic ice cream manufacturers, this is the best time for Haagen Dazs to introduce a product that does not only satisfy consumer’s palate but also enhance their well being. Another survey can be done to determine which among the organic ice cream fruit flavors would be most preferred by the consumers; e. g. strawberry, blueberry, etc. It would also be best to randomly survey an equal number of male and female participants.

Qualitative Characteristics of Financial Information

Qualitative Characteristics of Financial Information The purpose of financial statements is to give financial statements information about the change in financial position, financial performance and financial position of the organization. These can provide data use in decision making such as investment, credit and economic decision making which are useful for various users. There are seven main groups of users which are public, investors, lenders, employees, customers, supplies, government and other agencies and the needs of information is different for each group, for instance, employee will interest on the profitability, retirement benefits and employment opportunities and so on. Financial statement is supposed to relevant, reliable, understandable and comparable. In addition, financial statement may include other information, for example, the uncertainties and risks that influence the organization. Evaluation of the relevance, reliability, comparability and understandability Relevance is about the information that has the ability to influence the economic decisions of users. There are two main points relate to the relevance which are predictive value and confirmatory value. Predictive value can help users to measure the past, present or future performance. Confirmatory value can help users to confirm their past evaluations. The annual reports include ten-year statistics which have the recent ten-year figures. It includes profit and loss account, balance sheet and passenger services figures and so on. It can help the shareholders to confirm the past evaluations, measure the past performance and compare the relevance information at the same time. The annual reports embody a part of operating network with future extensions. In this part, the report has stated all properties that they are developing, constructing, planning and the properties that owned, developed and managed by them. It can help us to predict the present and future performance and verify the past evaluations. In the annual reports, we can find the CEOs review of operations and outlook. This part is the MTRs CEO taking about the MTR past performance which is good and which is bad, it also mentions the next year development of the MTR. It gives us a clear mind about the MTR what will do during the next year and briefly review the previous year performance. Reliability is about the information that is a complete and true representation. There are five major issues involve in reliability, free from material error, a faithful representation, neutral, prudent and complete. MTR use one of the big 4 accounting company that is KPMG. KPMG is a large international company and has a lot of auditing experience and professional staff. Therefore, shareholder can have a great confidence on the financial statements. On the other hand, the audit report state that the KPMG give a true and fair view that means the MTR reports are properly prepared with accounting standards which means the reports are free from material, faithful representation, prudence and complete. Also, the accounting firm is an independent audit firm which can fulfill the point of neutral. As a shareholder, we can have a great confidence on that reports, because it is accuracy and do not have any creative account. MTR is a public organization and it is managed by government. It has been required a high transparency that disclosure all information to public, such as, company policies, therefore, their information must be faithful, neutral, prudent and complete which are required by law. So, their information has a high reliability. From the view of shareholders, we can trust on it. The MTR have an internal audit team which is responsible for the internal control, project review, fraud investigation, due diligence and management review and so forth. It can help the MTR to give us a report that is reliable, free from material error, faithful, neutral, prudent. As a shareholder, we can have great confidence on the annual reports. Comparability is about the similarities and differences can be discerned and evaluated. There are two key matters include in the comparability which are consistency and disclosure. Inside the annual reports, we can find many figures that can give us to compare. Such as the Ten-Year Statistics, it includes ten years data for us to realize. We can see that the earnings per share are increased steadily each year from $0.81 per share in 2000 to $1.69 per share in 2009. Also, the profit is increased rapidly from $7,758 on 2006 to $15,182 on 2007. In addition, in the CEOs Review of Operations and Outlook part, it compare a lot of data, for example, the Average weekday patronage for the Domestic Service in 2009 was 3.5 million, which represents an increase of 0.9% over 2008 and the total revenue from property rental, property management and other businesses in 2009 was HK$2,928 million, an increase of 8.0% over 2008. Moreover, the financial statements have provided two years figures for us to compare which is 2008 and 2009. For instance, the Loans, other obligations and bank overdrafts is decrease significantly from $31,289 in 2008 to $23,868 in 2009 which decline 23.7%. The dividend per share is increase from 0.48 in 2008 to 0.52 in 2009 which increase 8.3%. From the figure that we have analysis above, we can see that the MTR profit is increase each year and the loan decrease each year, therefore, it is a signal for us continue to keep the share or investment more. Understandability is about the significance of the information can be perceived. There are two important points contain in the understandability, users abilities and aggregation and classification. Inside the annual reports, it contains a glossary part. In the glossary, it explains a particular domain of knowledge that uncommon, specialized or newly introduced. For example, operating margin means operating profit from railway and related businesses before depreciation and amortization as a percentage of the turnover and ordinary shares means ordinary shares of HK$1.00 each in the capital of the company and so forth. As a shareholder, it helps a lot during reading the annual reports, because not every shareholder also has that much professional knowledge. The annual report contains many picture, table and chart. An annual report is very thick, because it contains large information about the MTR performance. From the view of shareholder, if the reports are full text, it is hard for us to read it all, because it has a lot of words to read and understand. When reading the annual reports, it is not hard to find pictures, tables and charts, it can help us more easily to realize the information, especially the tables and charts, it convert the figures into a understandability form so that the readers can catch the main point easily. It also includes a content page and classifies similar data to similar group. When we look at content pages, it not only states the title but also state the number page which makes the shareholders more convenience to find the information what they need. This annual reports have different language version which can take care of different users, although this MTR is a Hong Kong organization, as a shareholders, I may be a foreigner and I can not read any Chinese words. Therefore, different language version is important as well. It is easy to find that the MTR annual reports have been prepared by two versions which are Chinese and English. Which one of the four qualitative characteristics of financial information is the most important? In my opinion, the reliability is the most important qualitative characteristic. If the financial statements are not reliable, the shareholders will not have any confidence on the MTR reports, because they feel that the financial statement information of the MTR is not faithfulness and truthfulness. Hence, they will not have any interest to realize the MTR reports, so that the objective of financial statement is invalid. Even though the annual reports has higher quality of relevance, comparability and understandability, but without reliability which will cause the shareholders and potential investors run away. In the opposite side, if the financial statements have a higher degree of reliability, the shareholders will have more confidence on the annual reports, because higher degree of reliability means the annual repot have meet the requirements of free from material error, a faithful representation, neutral, prudent and complete. When the reports meet those requirements, it attracts the shareholders stay and attracts more investors. When seeing the MTR annual reports, we can know that their reports have a good reliability. The MTR employ an external accounting firm which is KPMG to audit their accounting information, it fulfill the point of neutral. The audit firm also give a true and fair view to the MTR which means their information are faithful, complete, prudent and free form material error. From the above discussion, we can see that reliability is the most important qualitative characteristics in the financial statement. Conclusion During analysis the MTR annual reports, I know that the four qualitative characteristics have a great influence to shareholders. It has a significant impact on the decision making, because it can help them to understand, realize and build up the confidence on the MTR reports. The four qualitative characteristics also affect the shareholders invest or not. In my opinion, the reliability is the most important qualitative characteristic, it represents faithfulness and truthfulness. Shareholder will depend on it to decide whether those accounting information can trust or not, thereby to planning the investment decision. Word Count: 1553 words

Social Reproduction Essay -- Canadian Government, Capitalism

The growth of capitalism and the decline in government help with social reproduction along with cuts to social serves within Canada have lead to many issues within the privet sector. These cut backs leave families struggling, and while the family struggles the main care taker who is majority of the time the women, they are also the ones struggling with more responsibilities in the privet sphere of life. However, the home is not the only place that deteriorates when cut backs take place. When the individual struggles in the privet sector, the public sector along with employment and work take a toll as well. While the women tend to be the care givers of the home they skill contribute to a capitalist society meaning they are now working two jobs. They take care of the home, and still tend to a job in the public aspect of life. Until improvements are made in both privet and public sectors through social reproduction many areas in Canada will continue to suffer. The book Social Reproduct ion focuses on specific issues that are happening in Canada. Chapter four is specific to the topic on social reproduction and the issues that it causes to Canadian individuals, along with how unions are working to change the government to better help the people of Canada. I will focus on how chapter four entitled Bargaining for Collective Responsibility for Social Reproduction by Alice Wolff, deals with the material at hand and also if I believe Wolff presents the material in a well mannered argument. I will start off by looking at what issues Wolff presents in this chapter, and move on to the difficulties it is causing individuals, while finishing off with a critique of the chapter. Social reproduction to Alice Wolff is an important issue that is ... ... would have brought a real life situation at hand for those who are reading about this topic for the first time. I enjoy how the entire chapter focuses specifically within Canada which gives us as Canadians who are reading it a realisation of where Canada stands on this issues and where we possibly need to go. Another area I think she could have spent some more research on would have been how social reproduction differs between the different cultures we have represented in Canada. Canada especially has many different cultures and nationalities represented throughout; it would have been interesting to see how things differed from each culture. Overall I believe Wolff did a great job with the topic and I agree with what she has stated and how it is important to get this message out to others so that possibly soon we can find a way to help relive work-life tensions.

The Affects of the Human Genome Project on Society Essay -- Genetics S

The Affects of the Human Genome Project on Society Today’s society has an ever growing thirst for knowledge as we have for many hundreds of years now. Scientists work around the clock studying the affects of nearly everything they can think of to conduct experiments on. This quest for knowledge is the supposed start to a better life for man kind and ultimately a world without disease or hunger. The human genome project is one that has been going on for about 20 years. This project set out to map, down to the last detail, every part of the human DNA structure (â€Å"Human†). The project has recently been completed and the scientists are now starting another project with their newly found information, to cure mankind of its ailments. Although there are many positive things that can come of this recent discovery, there are many adverse affects that society is not yet fully aware of and as the experiments and test results come in, more and more will society be blinded to the downsides of genetic research because of the glitz, glamour, and promises provided by the corporations and universities This paper will not just hone in on the recently completed human genome project but will also take a look at the many adverse affects of what is now possibly to come if the science of human perfection is to continue unchecked. The possibilities for this new science are great, but without the general public guiding it every step of the way, the universities and corporations will be free to do as they wish. With the power to change life on this planet as we know it, the teams of scientists may ultimately one day have the ability to control what is happening through nearly every second of our life: what we eat, what we drink, what happen... ...uman Being, The Medusa and the Snail: More Notes of a Biology Watcher. New York: Viking Press, 1979. Thomas, in his book of short stories explores many different issues of human nature and in this book gives his viewpoint on many well known topics and some unknown yet still interesting topics alike. Although this book is somewhat dated, the articles present are still applicable to a lot of the situations we are facing in this current day and age. The author of the book is quite refreshing in the way that he is able to look at both the light and dark of a situation yet keep a positive attitude towards most of the nearing innovations in science. Reference List †¢ Human Genome Project Information. US Department of Energy. April 20, 2003. http://www.ornl.gov/TechResources/Human_Genome/home.html †¢ Clinton, Bill. Whitehouse Press Conference. June 25, 2000.

Energy and the Environment: Fossil Fuels Essay -- Environment Environm

Energy and the Environment: Fossil Fuels Fossil Fuels are one of the most important things on this planet to the human race. Without fossil fuels we wouldn't have today's current means of transportation, we would have less heating for the general population, energy uses would be more expensive, and overall the economy and the world would not be able to sustain themselves. Even still, the fact that fossil fuels are on this planet will never change, but how we use them and what impacts their use has will always be an issue. Even though fossil fuels provide for the most percentage of energy usage in the world, there is still the issue of pollution and other environmental impacts. Just oil and natural gas alone provide for more than 60 percent of the energy consumed in the United States (US Dept. of Energy). With this amount of fossil fuel usage taking place, and the fact that burning, transporting, recovering, and processing fossil fuels creates pollution, one can see how much total damage that is occurring on a daily basis. Some of the many environmental impacts from the result...

E-Business and E-Commerce Web Apps Essay

Transforming a brick-and-mortar business to an e business is not an easy task. The first step in creating an e-business is to conduct a market research on the competition we need to gather information such as shipping costs, price points, web navigation shopping cart procedures, and alternate revenue streams. The next step would be to create a detailed business plan with sales projections, budgets, goals, and actions. The third step is creating a Domain name that reflects your business for example: UNFO.com/ UNFO.ORG. After this step we have clearly identified the target market in the different fishing towns in Michigan, then an advertising budgets for online strategies, we also need to establish different distribution channels of the merchandise if shipping is required. Then we UNFO need to determine if the company is going to sell goods or services or advertising. One of the most important aspect of the customer information that is going to be handle would be Data Management, since we are handling customer data, such as credit cards information, mailing addresses, it is essential to have a published policy detailing how the information would be gathered, stored, and secured. A well effective return policy would be clearly stated and acknowledged by the customers. The other important aspect is weather the data will be updated and maintained in-house or outsource support. At last we will need to implement a Customer Service department and determine the methods for online customer service. Analyzing the market and the recent emerging technologies it would be recommended to implement a fully integrated ERP, UNFO will have a distinct advantage an internal transaction engine in place to deliver on the promises of the company’s Web pages, and the ability to truly show â€Å"one face to the customer,† not only in front-end Web-page design, but also in the way Web-based functions integrate with  internal â€Å"back-office† functions. This integration means that Web-based entry flows directly into real-time available-to-promise and order fulfillment. For suppliers, it means that the company truly is able to manage the flow of materials into the production process to the advantage of both parties rather than merely to push inventory onto the supplier. Implementing an effective Internet marketing strategy UNFO will follow the 10 online marketing avenues that craft-based Web site. Participate in craft-related forums building relationships. These relationships come from the customer. Drive articles to the web site with article links, issue an online press releases for new fishing products or services, develop a link exchange program with related web sites, use click based advertising on related sites , and register the bookmarks of your business online with companies. The enhancing the customer service delivery also involves ensuring security for communications and protecting customer information, using VoIP provides less-expensive alternatives for the different hubs, implementing a secure access for remote employees secure remote communication channels would need to be implemented , UNFO would need to use a virtual private link between the employees and the remote network or a VPN. Also secure web protocols to provide a way to authenticate the clients and servers on the web to protect the integrity of the communication, (PPTP) Point to Point Tunneling Protocol creates a secure communication tunnel between the two points it also enables authenticated and encrypted transmissions between the clients and the servers, we can also implement (L2TP) Layer two tunneling protocol and it uses tunneling to deliver the data, also implementing (IPSecs) Internet Protocol Security to secure communications between systems on the network as well as outside to the different hubs or towns. UNFO needs to maintain a highly available and secure E-mail and web site hosting using the most advance methods in today’s industry for example: using redundant hardware configuration such as (RAID) for hard disks, multiple memory, and failover servers, hardening applications using the latest service pack and patches to prevent software failure, have all up to date antivirus, intrusion detection and protection systems, use secure protocols like the ones mentioned earlier, implement and use (UPS) for power outages to protect the web servers , and use a remote network location if the primary location be compromised the second location  can take over. One important part of E-Commerce is maintaining stringent site security, confidentiality for the customers, integrity, and availability, also a secure system must contain authentication verification of the user, Authorization, allowing manipulation of the resources in a specific way and Encryption for records and transactions.

Cause and Effect of Cheating in School Essay

Every action has a consequence, whether it is good or bad. The choices you make can follow you the rest of your life. Cheating is an issue that affects many students at one time or another throughout their education. There are many different ways to cheat: copying homework, looking over at a peers test, plagiarizing, and so on. Nothing good comes from cheating your way through school, the only person you are cheating is yourself. There are serious consequences for cheating. Every teacher has different ways of punishing their students. Some teachers are hard on their students and give them the maximum punishment they can give them. However, as i’ve witnessed teachers are surprisingly lenient on their students. Many just give them a warning or make them retake the test. The problem with teachers doing this is that the students never really learn their lesson. It enables them to cheat more, if they know they won’t have serious consequences for their actions, they will be more willing to try to test their luck. Cheating is most likely to occur in students who lack effort in their studies. Students who do not attend class or do not study are not likely to get passed on their own. Therefore, they find cheating to be a good and easy way for them to pass. Nothing can be gained by cheating. Of course, a better grade may be given, but they are not learning anything by stealing somebody’s hard work. The cheater may be passing the class with a great grade, but where will the cheater be when the finals come around and they no longer have a way to cheat. Cheating can result in a tragic cycle. Once you start it is hard to stop. A person may believe that they are benefiting themselves by cheating to receive a better grade. They put off studying and never really learn the material. At the same time they are doing well in the class. Many people may not see what the problem would be, less work and good grades. What’s to complain about! However, this cannot continue forever. It will catch up to you and you will regret it. When it comes time for you to know the material, you will have to learn from the beginning or receive an unsatisfactory grade. Even if you manage to get a good grade, it cannot make you feel good knowing you did not earn it. There is going to come a time in your life when you are going to need to put what you learned in school to use in real life. If you did not do the work, you will not be able to do this. In college they are to prepare you for your career. If you plan on cheating your way through college you may want to rethink your game plan. Imagine a surgeon cheating his way through school and not really learning what was necessary to perform his job. Would you feel comfortable having this doctor operate on you? There are more things at stake than good grades. You have to think of your future and the person you want to be. Nothing in life comes easy, if you want to make it you are going to have to work at it. There is no reason you should be rewarded for cheating your way through school. It is always better in the long haul to be honest and do your own work. Once you make doing your own work a habit it will become easier. It will also build your self-esteem. Having that pride when you graduate will be one of the best feelings in your life. You can think to yourself that you did this, it wasn’t because of anyone else, it was all you. All those late nights of studying and group study sessions have paid off. You know that you are able to set a goal for yourself and find the strength within you to accomplish this goal. If you are able to do this, you are capable of so much more. Your future will be bright. When looking for a job when you are older, employers look for certain qualities. They look for a good work ethic, someone with good leadership qualities and, someone who isn’t lazy but who is willing to do what is needed to be done to finish the job. You will have more confidence going into an interview if you are well qualified for the job. Nothing good comes from cheating. It may trick you in the short hall but you need to have the strength to do the right thing. You need to be more concerned with your future, and less concerned with cheating your way through a class just so you have more free time. Today’s generation will never succeed if they do not learn to take responsibility. We are truly blessed to be given a proper education, many countries are not as fortunate as us. In a way Americans have become spoiled and have taken their education for granted. They do not view it as being important. We need to look at other nations, and realize what they would give up just to be able to learn like we do. We need to get back to a place where we are thirsting for knowledge and not just doing the bare minimum to get by. Over all, the consequences of cheating vary greatly, from being dealt with on a serious level or to just have to live with knowing deep down inside that what you have done is wrong. Some say cheating is not wrong unless the person gets caught, but cheating is no different than stealing, and stealing is wrong no matter what. I think everyone would admit that. As an individual you must take pride in yourself and do your own work. It is your life and you should want to be the best you can be. Cheating in the short run will only hurt you in the future.

What is organizational behavior

Study of the impact Individuals, groups, and structure has on behavior within an organization. This Is studied by managers to improve an organizations work environment to find methods to increase the bottom line. Basically it is a study of the way people act within an organization when exposed to different elements such as leadership styles, behaviors of others, and Incentives. 2. Moscow theory hierarchy of needs? Physiological- Basic needs or body needs; food, water, shelter, sex, and other.Safety = security and protection. Social = Affection, belongingness, acceptance, and friendship. Esteem = Internal factors such as self- respect, autonomy and achievement. Self-actualization = Drive to be all we can be. As each need Is satisfied the next becomes dominant 3. What Is the four functions of Management? Planning, Organizing, Leading, and controlling are the four functions of management. Planning is defining goals and the overall strategy to achieve those goals with a developed and int egrated plan to achieve the goals.Organizing is the designing of an organizations structure including task and who will accomplish the task. Leading Is managements ways of motivating Its employees and directing their activities selecting means of communications and resolving conflicts. Chapter 1 1 . Management= one who achieves goals through others vs. Leader = of motivating Its employees and directing their activities selecting means of communications and resolving conflicts. 2.What Is Stress = A dynamic condition in which and Individual is confronted with an opportunity a demand or a resource related to what the Individual desires and for which the outcome is perceived to be both uncertain and important Chapter 2 Sexual Harassment = Unwanted sexual advances Ability = An Individual's ability to perform the various task In a Job Chapter 3 1 . Job Involvement= Really care about what the work they do vs. Job satisfaction= One who holds positive feelings about there Job. Low negative f eelings 2.Cognitive dissident = Car story – I don't like us cars, change mind when given late model ford. 3. Impact of Job satisfaction- Exit, Voice, Loyalty, Neglect 4. Personality- Sum of total ways an Individual reacts or Interacts with others Class Notes Chapter 4 1 . Emotion- Short lived, Specific event, Facial expression, action in nature 2. Moods – Longer, Caused general, No distinct expression, Cognitive 3. Positively offset – Normal situation the average person is in a positive mood. . Illusory correlation- People associate two event to their mood has no correlations 5.Emotional Dissonance – Show one emotion and feel the other. Hiding Chapter 5 1 . Briggs = Personality assessment- Extrovert Vs. Introvert, Sensing Vs. Intuitive, Thinking Vs. Feeling, Judging vs. Perceiving 2. Proactive personality = Identify opportunity, show Initiative, take action, preserver to the end 3. Values perceptions -?Process by which Individuals organize and Interpret t heir sensory Impression In order to give meaning to their environment. Chapter 6 FIFO Halo effect= One opinion shows whole character. General impression with a single characteristic. . Contrast effect= evaluations of a person's character that is affected by comparisons with others people recently encountered who rank higher or lower on the same characteristics 4. Self-fulfilling prophecy'= person inaccurately perceives a second person and the resulting expectations cause the second person to behave in ways consistent with the original perception 5. Stereotyping preconceived notions= 6. Rational decision making= a decision making model that describes how individuals should behave in order to maximize some outcome. Chapter 7 1 .Motivation – accounts for intensity, direction, persistence 2. Theory X -assumes employees don't like Job 3. Theory Y – assumes employees like work 4. Goal Setting theory – If the employees are involved, Goals are achievable and production is up 5. Management by objectives – Tangible verifiable, and measurable 6. Self Chapter 8 1 . Job design- The way the elements in a Job are organized 2. Job Enrichment- expands the Job so the employee controls the planning, execution and evaluation 3. Job Rotation- Moving around Cross-train 4. Employee Involvement- more involved, more productive employees 5.Participative management- Joint decision making Vs. Representative participation – workers are represented in a small group (Union). Chapter 9 1 . Formal Group- Organized, Such as work group 2. Informal Group – No Formally structured nor organized 3. ESSAY – Five-stage Model Forming- Beginning of group Storming- Accept existence of group but are working out the kinks Morning-setting standards Performing- Work get done Adjourning- Job completed 4. Role- What is expected by an organization 5. Role Perception – What you think your role is 6. Norms – Standards so you know when people are outs ide the norm set by leaders 7.Deviant workplace Behavior- behavior that violates organizational norms. 8. ESSAY – Group vs. Individual Strengths of group decision is from many, Increase diversity, more knowledge. Individual – Expeditious, single point of success 9. Social Loafing- Expend less effort when working in a group-causing cacaos Chapter 10 1 . Work group – Primarily to share information 2. Work Team – Set Goal Accomplishment work on a project to get something done 3. Teams – Problem solving – Particular problem, Self-managed worked team work as lead- Cross-functional team-to use different team sets. Virtual – distance 4. Willing to adjust .Team Efficacy – Team believes they can accomplish goals Chapter 1 1 1 . What is communications? Transferring and understanding of meaning. 2. Formal and Informal Channels of communication 3. Formal- Professional 4. Informal- Socializing 5. Downward Communication – Explaining t o Subordinate 6. Upward – Up the Chain of command 7. Lateral Communication – Peer to Peer – Team to Team 8. Essay -Discuss the difference between interpersonal communication and organizational communication. Oral written nonverbal / Organizational conduct business one to many documented email. Blobs. 9. Oral, Written and Non-verbal.Identify the pros and cons of interpersonal communication. 10. Information overload – Communication overload. 11 . Channel Richness – The amount of information that can be communicated to a certain number of people at one episode 12. Filtering -a senders manipulation of information so that it will be seen more favorable by receiver 13. Cultural Context- High and Low for global organizations you need to know the difference between High and Low. Chapter 12 1 . Leadership- Ability to influence a group toward the achievement of a vision or set of goals 2. Employee oriented leader- 3. Production oriented leader- 4.Situational Leadership theory – Theory that focuses on followers readiness 5. Path Goal Theory- A theory that states that it is the leader's Job to assist followers in attaining their goals and to provide the guidance to their goals. 6. Charismatic Leader a leader that has visions and risk-taker 7. Transactional Leaders- Guide followers to established goals clarifying goals and tasks 8. Transformational leader- spire followers transcend their own self-interest and who are capable of having a profound and extraordinary Chapter 13 1 . Power is a capacity to influence the behavior of other 2. Power = Requires follower dependency .

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buy custom Technology and Patient Safety essay Using a national representative and large sample of Medicare patient data, the authors of this article sought to link implementation of health IT to the clinical outcomes, which allowed them to apply a difference-in-differences method to measure adjustments in patient safety with adjustments in health IT investments. Data spanning four years (1999-2000) was observed for each hospital that was examined. Three health IT applications were analyzed and these included picture archiving and communications systems (PACS), electronic medical records (EMRs), and nurse charts applications. The outcome measures of the study included three patient safety indicators and these were: post-operative hematoma or haemorrhage, infection as a result of the medical care, postoperative deep vein thrombosis (DVT) or pulmonary embolism. The authors selected these indicators after consulting with the health care professionals to get the outcomes that were likely to be influenced by health IT. Patient charact eristics such as sex, race, and age among others were controlled. Multivariate regression analysis was used to determine the relationship between the patient safety indicators and a group of health IT indicators, patient controls, as well as interactions between time and health IT applications. The authors also included a complete set of hospital, as well as time fixed effects which allowed for estimation of changes in patient safety outcomes following the adoption of health IT. The stud found EMRs to be the only health IT application having a distinct and statistically significant effect on patient safety. EMRs use was particularly associated with significant reductions in infections due to medical care. However, nurse charts and PACs were found to have no systematic association with any indicator. This study contributes to the inconclusive literature that exists about the issue of technology/informatics in promoting the patients safety. Kilbridge, P.M. Classen, D.C. (2008). The Informatics opportunities at the intersection of patient safety and clinical informatics. J AM Med Inform Assoc, 15: 397-407. This position paper addresses obstacles that prevent the use of health informatics in improving patient safety. The authors of the article note that while health informatics has been demonstrated to promote patient safety, various challenges make it quite difficult to improve it. The article aims at offering recommendations on ways of dealing with these challenges. The authors provide recommendations on how health informatics can be effectively used to promote and improve patient safety. Some of the recommendations include adequate health staff training on the use of available informatics, conduction of more research addressing health informatics and patient safety, and encouragement of hospitals to adopt electronic health records. The authors believe that once the arising challenges of the use of health informatics are addresssed, the greater improvement in patient safety will be achieved. IOM (2011). Health IT and Patient Safety: Building Safer Systems for Better Care. Consensus Report, Institute of Medicine. Realizing the widespread use of IT in medical care, IOM was directed by the Department of Health and Human Services to compile this report which is basically an evaluation of health safety issues arising from the use of health IT and recommendations on how these issues can be addressed at both the governmental and private sector levels. According to the report, an effective use of health IT depends on many factors including patients and healthcare professionals. The report found that the safety concerns of health IT should not be addressed from a single cause perspective, but from a much wider perspective involving the whole care system, in order to come up with an intervention to improve the safety of the system. According to the report, all stakeholders including patients, health professionals, private sector, and the government have distinct roles to play. In the report, the IOM makes certain recommendations, which include promotion of sharing of safety data, improving measures, s tandards, and criteria for the safe use, and finally promoting accountability and transparency. It is important to note that these recommendations are not similar to the ones found in Kilbridge and Classen study cited above. Buy custom Technology and Patient Safety essay

The Difference Between Molality and Molarity

The Difference Between Molality and Molarity If you pick up a stock solution from a shelf in the lab and its 0.1 m HCl, do you know if thats a 0.1 molal solution or a 0.1 molar solution, or if there is even a difference? Understanding  molality and  molarity is important in chemistry because these units are among the most commonly used to describe solution concentration. What m and M Mean in Chemistry Both m and M are units of the concentration of a chemical solution. The lowercase m indicates molality, which is calculated using moles of solute per kilograms of solvent. A solution using these units is called a molal solution (e.g., 0.1 m NaOH is a 0.1 molal solution of sodium hydroxide). Uppercase M is molarity, which is moles of solute per liter of solution (not solvent). A solution using this unit is termed  a molar solution (e.g., 0.1 M NaCl is a 0.1 molar solution of sodium chloride). Formulas for Molality and Molarity Molality (m) moles solute / kilograms solventThe units of molality are mol/kg. Molarity (M) moles solute / liters solutionThe units of molarity are mol/L. When m and M Are Almost the Same If your solvent is water at room temperature, m and M can be roughly the same, so if an exact concentration doesnt matter, you can use either solution. The values are closest to each other when the amount of solute is small because molality is for kilograms of solvent, while molarity takes into account the volume of the entire solution. So, if the solute takes up a lot of volume in a solution, m and M wont be as comparable. This brings up a common mistake people make when preparing molar solutions. Its important to dilute a molar solution to the correct volume rather than add a volume of solvent. For example, if youre making 1 liter of a 1 M NaCl solution, you would first measure one mole of salt, add it to a beaker or volumetric flask, and then dilute the salt with water to reach the 1-liter mark. It is incorrect to mix one mole of salt and one liter of water. Molality and molarity are not interchangeable at high solute concentrations, in situations where the temperature changes, or when the solvent is not water. When to Use One Over the Other Molarity is more common because most solutions are made by measuring solutes by mass and then diluting a solution to the desired concentration with a liquid solvent. For typical lab use, its easy to make and use a molar concentration. Use molarity for dilute aqueous solutions at a constant temperature. Molality is used when the solute and solvent interact with each other, when the temperature of the solution will change, when the solution is concentrated, or for a nonaqueous solution. You would also use molality rather than molarity when youre calculating boiling point, boiling point elevation, melting point, or freezing point depression or working with other colligative properties of matter. Learn More Now that you understand what molarity and molality are, learn how to calculate them and how to use concentration to determine mass, moles, or volume of the components of a solution.

A Book on Writing for Novelists

A Book on Writing for Novelists A Book on Writing for Novelists A Book on Writing for Novelists By Maeve Maddox Before launching myself into the historical novel Ive been thinking about, I decided to read some books on writing before getting too far along. My luck was to pick up Sol Steins How to Grow A Novel. Some writing books are good for beginners, but some are not. I think that the writer who has completed a book length manuscript will get more out of the Stein book than one who is just getting started. I almost didnt read this book because of its title. As Ive mentioned elsewhere in DWT, the use of the transitive verb grow with a non-biological direct object produces a blackboard moment in me. Im glad that I didnt let this prejudice keep me from the trove of great advice to be found in this book. What hooked me was the subtitle: The Most Common Mistakes Writers Make and How to Overcome Them Stein knows what hes talking about. Hes a writer as well as an editor. He has written plays, poetry, and novels. The book is arranged in four sections of unequal length: The Responsibilities of the Writer The Responsibilities of the Publisher Envoi Practical Matters The first section is the meat of the book and discusses the expectations of the reader, the importance of conflict in every scene, and the development of plot, character, dialogue, and setting. Im not going to comment on every section. Theyre all useful, but I know that this is a book Ill read more than once. This time around I was most taken with what Stein says about conflict. Chapter Two poses the question Is Conflict A Necessity? This is how Stein answers it: Yes, conflict was and is a necessity, it is the essence of dramatic action. The engine of fiction is somebody wanting something and going out to get it. And if you let him get it right away, youre killing the storyWithoutopposition, fiction is a vehicle without an engine. What Ive taken away from this first reading of How to Grow a Novel is the importance of planning conflict into every scene before I take the time to write the scene. As I gear up to write my historical novel, Im taking the time to create a scene outline that I think will be more practical than any chapter outline Ive used for my previous novels. My new mantra is Conflict runs the engine. Each scene I sketch has a character who wants something and either gets it or doesnt get it by the end of the scene. When Ive got the first draft on paper, Ill go back to Steins book for help in revising it. You can find the book on Amazon.com Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Book Reviews category, check our popular posts, or choose a related post below:How to Format a UK Business LetterIn Search of a 4-Dot Ellipsis35 Synonyms for Rain and Snow

Opression And Puritian Ideals

Opression And Puritian Ideals Most of the readings from this semester were from the Puritan Era. It was the beginning of the American dream and the ideals that go along with it. Ideals like home of the free, and land of the brave; but we have seen through the writings of the time this was not totally true. America was home of the free if you were a white male. All minorities and women were oppressed during this time and these practices came to be law until this century. We see this ideals form in both the writing of the Puritans along with the writings of the minorities of that time. John Smith and Jonathan Edwards are two writers that wrote about oppression from the side of the white male. Olaudah Equiano, Harriet Beecher Stowe were two black people who wrote about the oppression they endured. Mary White Rowlandson was a women, but also a Puritan who was kidnapped by Indians, so even though she is a woman, she writes to oppress the Native American people.Signature of United States author Harriet Beecher ...John Smith was one of the founders of America; he was one of the first groups of settlers trying to tame this land. Taming the land to Smith meant taming and controlling the Indians of the land. He saw them were uncultured and savage who needed to be out into their place. This is seen in his writing "Advertisement for the Unexperienced Planters of new England, or Anywhere, Or the Path way to Experience to Erect a Plantation", he talks about using all the riches and resources of the land of the good of the English and to oppress the Indians of their land and wealth. "The Warres in Europe, Asia, and Africa, taught me how to subdue the wild Salvages in Virginia and New England,

Step into the GLM Time Machine

Step into the GLM Time Machine Step into the GLM Time Machine Step into the GLM Time Machine By Maeve Maddox The Global Language Monitor (GLM) is an Austin, Texas-based entity that  documents, analyzes and tracks trends in language and publishes a list of the years most used English words, names, and phrases. According to GLMs algorithm, 2009s most used word, both online and in print, is Twitter. GLM’s top ten for 2009: Twitter Obama H1N1 stimulus vampire 2.0 (as a suffix attached to the next generation of everything. Ex. Web2.0) deficit Hadron healthcare transparency A look at the Words of the Year for 2000-2008 recalls the prominent events and personalities of those years: 2000 chad 2001 GroundZero 2002 misunderestimate 2003 embedded 2004 incivility 2005 refugee 2006 sustainable 2007 hybrid 2008 change Taking the decade as a whole, here are the top ten words with GLC comments: 1. Global Warming (2000) Rated highly from Day One of the decade 2. 9/11 (2001) Another inauspicious start to the decade 3. Obama- (2008 )The US President’s name as a ‘root’ word or ‘word stem’ 4. Bailout (2008) The Bank Bailout was but Act One of the crisis 5. Evacuee/refugee (2005) After Katrina, refugees became evacuees 6. Derivative (2007) Financial instrument or analytical tool that engendered the Meltdown 7. Google (2007) Founders misspelled actual word ‘googol’ Surge (2007) The strategy that effectively ended the Iraq War 9. Chinglish (2005) The Chinese-English Hybrid language growing larger as Chinese influence expands [There are an estimated 300 to 500 million users and/or learners of English in the Peoples Republic of China.] 10. Tsunami (2004) Southeast Asian Tsunami took 250,000 lives To see the top phrases and names for 2009 and the first decade of the 21st century, explore the Global Language Monitor site. Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Vocabulary category, check our popular posts, or choose a related post below:20 Words with More Than One Spelling50 Types of PropagandaWords That Begin with Q

Persuasive Essays on Abortion

Persuasive Essays on Abortion Persuasive Essays on Abortion Persuasive essays on abortion should point out that whether or not abortion should be allowed has long been a controversial topic for heated debate and discussion: Persuasive essays on abortion should start by taking a stand that is either for or against abortion by offering a thesis statement in the first paragraph that reads something like, It is the contention of this essay that abortion should be easily available for women who have an unwanted pregnancy due to the following reasons If you need an essayof the highest quality place an order on our website and get 15% off on your first order. Points for abortion Even though it has been argued that aborting a child once it is conceived boils down to the taking of a helpless life-others feel that a child in the womb has not yet developed in to a human being-(some argue that the soul only enters an infant shortly before birth)-and so it is not wrong to do away with an unwanted pregnancy at an earlier stage. Those that vehemently decry abortion do so on religious grounds by stating that it is a sin to take a helpless life. Two of the main religions that oppose abortion are: The Catholics Muslims The entire argument has divided the public into those that vehemently oppose abortion and these have become known as pro-life activists; while those that are for the free choice of women are known as pro-choice activists. Both have strong views for and against abortion. Persuasive essays on abortion should point out that while many oppose abortion on religious and ethical grounds- women who are actually carrying the child feel that they need to get ownership of their own bodies-(instead of having people telling them what to do) Pro-choice activists also firmly believe that life only begins at birth and so there is nothing wrong with terminating an unwanted pregnancy. Persuasive essays on abortion should draw attention to the fact that pro-choice activists arguing for abortion may be doing so for a number of very good reasons like:- Reluctant mothers may be trying to terminate an unhappy marriage They lack the means to support a child They are too young and a teenage pregnancy can result in the life of both the mother as well as the child-getting ruined. Pro-choice activists argue that a mother that does not want her child and is forced to have the baby is also most likely to ill-treat the child or deny the nurturing love and care that he/she would require growing into a mature and well balanced human being. Visit our safe paper writing service to get A+ essay right now! Read also: The Stolen Party Term Paper Sample Papers Report Writing Help Process Analysis Case Study Police Performance Term Paper

The Impact of Private Education On Expatriate Teachers In Saudi Arabia Research Proposal

The Impact of Private Education On Expatriate Teachers In Saudi Arabia - Research Proposal Example The main objectives of this study are: to gauge the emotional, social and financial impact on the expatriate teachers of their jobs in private educational institutes in the Kingdom of Saudi Arabia; to explore the difficulties that they may have faced due to the changed educational system; to assess if there has been any change in the teaching methods of the expatriate teachers, and if they intended to adapt the changes when they return to teaching in their native countries. The current study proposes to use a descriptive research method that helps in elaborating upon the existing state of affairs. This study is hoped to be designed so that the data collected is authentic and accurate. In order to ensure this, both the secondary data, via a literature review, and primary data, through a questionnaire are to be used. A rigid research design is to be adopted to reduce bias and improve reliability. For this a sample is to be selected on the basis of convenience sampling, and data collected via interview method using an open ended questionnaire. The data collection is qualitative in nature as the responses are proposed to be recorded by the researcher verbatim and later analyzed, again using a qualitative approach. The sample for the current research will be taken from among the expatriate teachers community living in the Kingdom of Saudi Arabia. The teachers who are proposed to be included in the study would be from elementary schools, high schools and coll eges and would have spent between 1 to 5 years in Saudi Arabia.

The Drinking Age Essay Example | Topics and Well Written Essays - 500 words

The Drinking Age - Essay Example This phenomenon is known as â€Å"binging† when the young adults begin consuming above the average amount of alcohol a body should consume- often they do this action as a sign of rebellion against the institution and the authority. A study conducted by Indiana University showed that 32% of underage drinkers are heavy drinkers as compared to the 24% of legal aged drinkers (Engs). The most underage drinking is observed by college students who while trying to get initiated into fraternities try to impress their peers or simply just because they get the chance to experience drinking. Many of the problems affiliated by drinking such as getting low grades in class, skipping out classes due to overdrinking the previous night, and getting into fights due to drinking are observed to be higher among people falling below the age of 21. The incidents of such acts occurring over the legal age are relatively less. It is recommended that young adults should be given proper awareness of the effects of alcohol and they should be permitted to drink alcohol in a controlled environment where they can be observed and assisted if they face any complications. That may be a reason why more than 100 college presidents signed a petition to lower the drinking age (Roan). One of the arguments in support of the 21 age restriction is that there has been a noted decrease in the number of traffic accidents caused by young adults who were intoxicated. But the decrease could also be attributed to more awareness of the effects of drinking while driving, implementation of designated driver programs, lower speed limits and free taxi services from drinking establishments. So the argument placed that it is solely the implementation of a higher age limit which has reduced the number of car accidents is incorrect. The drinking age should be decreased to 18. If the young adults are considered to be

Introduction To Pre-Negotiation Essay Example | Topics and Well Written Essays - 1750 words

Introduction To Pre-Negotiation - Essay Example According to William Zartman, a leading scholar of international negotiations, Pre-negotiation begins when one or more parties considers negotiation as a policy option and communicates this intention to other parties. It ends when the parties agree to formal negotiations, or when one party abandons the consideration of negotiation as an option. In essential terms, pre-negotiation is the span of time and activity in which the parties move from conflicting unilateral solutions for a mutual problem to a joint search for cooperative multilateral or joint solutions. It is the diagnostic phase of negotiation. (Dr. Plamen Pantev., Negotiating in the Balkans: The Pre-negotiation Perspective. National Security and the Future Volume One, Number 1, 2000). Jane Gross Stein has differentiated between the pre-negotiation and actual negotiation, 'Pre-negotiation was generally characterized by important structuring activity. It set broad boundaries, identified the participants, and, in at least half the cases, specified the agenda for negotiation. Even in those cases where it produced only a rough outline of the agenda, it nevertheless reduced uncertainty and complexity by establishing what would be kept off the table. In every case, pre-negotiation framed the problem and set the limits of the negotiation to follow. According to Brain W. ... iation includes identification of the problem, search for the feasible option, and reflect commitment towards negotiations, agreement to negotiate, and setting the parameters. (Dr. Plamen Pantev, Negotiating in the Balkans: The Pre-negotiation Perspective. National Security and the Future Volume One, Number 1, 2000). STAGES OF PRE-NEGOTIATION Irrespective of the nature of the dispute, the mediator and facilitator struggles to help the parties to reach an understanding with reference to procedural and structural questions, before the commence of formal negotiation process. This practice has several advantages as it provides the parties with sense and chance of success on the preliminary round. It is important to workout the procedural and structural questions so that the reluctant party can be understood the worth and significance of the practice and association. The objective of the pre-negotiation is to acquire the commitment of the parties to negotiate their differences and concerns. The objective is achieved by identifying the eliminating the obstacles to negotiations. There can be series of differences and obstacles which are likely to hinder the pace and prospects of pre-negotiation. The main hindrance is often that the parties fail to organize the negotiation in the required manner. There is possibility of existence of differences which is likely to turn the group unable to organize itself and present a consistent set of interests. Another obstacle is likely to be the lack of credible representative or spokesperson on the behalf of respective parties. There are likely to be many other substantial hurdles prior to the commencement of negotiation. Similarly the opening phase of the negotiation is likely to be problematic as well. Problems can be experienced

Understanding Students with Hearing Loss Research Paper

Understanding Students with Hearing Loss - Research Paper Example This paper deals with the said issue, teaching and learning relationship when the student has the problem of hearing. Understanding Hearing Loss Before hearing loss is explained, a brief introduction to the process of hearing is very important in the context of this research. The listening of a sound can be described in two basic notations, one being audition on the other being vibration. Audition is the hearing process; whereas; vibration is the interpretation of pattern, of air molecules on the ear drum. Sound itself can be divided into two parts. The first one is the frequency on the sound and the second one is its loudness. Being deaf means unable to hear any kind of a sound but this is not the only form of hearing disability. Hearing disability can be broker down into two main parts. One is deaf, which means that the person has a hearing loss of 70-90 dB and cannot hear with any kind of amplification. The second part is the person who has loss of hearing in the range of 20-70 dB but can hear with use of amplification devices. Both there forms of hearing disability can cause great stress in every-day life of a human as well as being the sole reason for slow learning of this person. The report looks into the methods of overcoming this disability and making these students in a classroom attain good grades and live a normal life (Ann, 1995). Communication between teachers and students on the same frequency is the only secret for the success of the teacher-student relationship, be it a normal one or one in which the student has some physical disability. There are many ways a teacher can communicate or transfer knowledge into the minds of a person who has a hearing disability. The first and foremost method is oral communication by enhancing or amplifying sound to develop language skills as well as understanding skills. After oral, the most used method is applied which is manual communication. In manual communication sign language or finger spelling is used. A universal sign language has been developed for the help of teachers and students alike. Finally the simultaneous method in which both amplification is sign language by the teacher to explain the phenomenon of science, math , literature or any other subject under light. Challenges Faced There are numerous issues faced by both teacher and the student alike, student more that the teachers though. The first basic and foremost challenge is one, especially to students in primary classes, is of reading and writing. As the process of learning to read is dependant on hearing and the one of writing is dependant on reading. Therefore it is the first challenge that comes across a hearing impaired child. The second problem is not directly related to the class environment but directly affects the emotional behavior of a student in class. This problem is due to a various number of interactions a hearing impaired child faces in his everyday life. His interactions with the parents, friends and the sense of social isolation all play a vital role. Teacher in these scenarios can play a vital role and sail the child from the storms of social disparities against such students (Elizibeth, 2010). Teaching Strategies Various steps can be taken by the teacher in a class for the teacher to enhance the learning abilities of a hearing impaired student and in turn have a bet ter understanding of the student. Every student with this

Strategy For Public Sector Organization Essay Example | Topics and Well Written Essays - 2750 words

Strategy For Public Sector Organization - Essay Example This paper will critically analyze how public sectors are managed and why they fail to deliver quality and efficient services despite improved management. Role of public sectors organization Public sector organization plays a vital role in national economic growth. Economic growth of a country is relatively proportion to the growth and development of industries and infrastructures. Small enterprises also depend on the large enterprises as their suppliers and consumers. Development of infrastures and large organizations require huge capital to establish and most lending institutions can readily avail such facilities to public sectors and not to private owned organizations (Haider 2010). Infrastructures such as railways, sewerage pipes, power lines among others requires a huge investments and private owners cannot invest in such facilities that have low return but public sectors can invest in such infrastructural facilities that to provide important services to the public. Infrastructu re development helps to attract private investor into a region to provide other profitable service (Mohammed? and Umar n.y, P. 473). Publically owned organization always strive to maintain balanced growth across the region and area of operation by investing in both developed and undeveloped areas thus ensuring regional balances (Haider 2010). Government owned facilities like education institutions and heath institutions are fairly distributed across the national boundaries while private organization concentrate in urban area to boost their profit and minimize operation cost. Sparsely populated areas have higher uncertainty, low number of consumers and negative factors that profit based... This article stresses that the U.K has assumed a centralized target approach in the management of public service and public sector is not spared in this new trend of management and it is clear no single measure is conclusive in providing a lucid performance target where leadership anticipates a balanced perception in weighing financial and operations assessment in delivery of services. New performance targets in the United Kingdom were tied to budgetary allocation in all sectors of the public sector where performance indicators were set based on headline targets fragmented into detailed lower level targets. This paper makes a conclusion that public organizations are crucial to economic growth in any country since they provide basic services and goods for the general public despite the economical return to the economy and the organization. These services may not be profitable to the private sectors and therefore most private owned organization avoids them. Previously most public organizations were faced with several challenges such as funding, poor management, poor services, and discriminatory cultural practices among others. In recent times most organization has changed to adopt new strategy to improve their service delivery and competitive advantages. However there is need use more management tools and conduct intensive analysis of internal and external environmental factors that affect their service delivery to ensure that their strategy are effective and improve their management since lack of proper analysis has turned out tragic rather than beneficial.

Disabilities within the educational setting Essay - 1

Disabilities within the educational setting - Essay Example This type of â€Å"in classroom† therapy requires the speech therapist to maintain constant communication with other educators working with the same student. Other therapists may be included in the student’s education plan, such as occupational therapists, physical therapists and behavioral therapists. The involvement of these specialists allows the student’s specific educational plan to remain consistent and customized to provide the student with maximum results. In addition, frequent observation of the student by the educators and therapists will allow for the goals designed for that student to be more quickly reached, as well as to intervene when goals are not being reached. This will also allow the educators to design progress plans around that particular student’s specific capabilities and challenges. Observation and assessment also pinpoint delays or complications in the student’s learning and development. This type of assessment and observation can be done in an inclusive situation where the student is integrated into a regular classroom setting with his or her peers. This can also occur in a specialized and segregated setting where the student may be severely disabled and requires a more specialized classroom environment. Children suffering from spectrum disorders such as autism can be placed in inclusive classroom settings if their degree of autism is on the low end. If the student, however, suffers from a high degree of autism and perhaps requires more one on one teaching, the individual will most often need to be placed in a specialized classroom setting. Children with disabilities can certainly range from speech and learning disabilities to physical disabilities to spectrum disorders such as autism. It is important to note that regardless of the presence of a disability or not, all children have the right to an education. It is unlawful to not accommodate the learning needs

White Collar Crime in America Research Paper Example | Topics and Well Written Essays - 2000 words

White Collar Crime in America - Research Paper Example â€Å"White-crime statistics are drearier still. Though two out of every three Americans have been the victims of a white-collar crime, 85 percent of victims don't file reports with the authorities. An untold number may never even know they have been the victims of crimes such as stock manipulation, double billing for purchases, unnecessary home or auto repairs, embezzlement, or as evidenced by recent events, Ponzi schemes.† (O'Donnell, Jan 29, 2009.) Is there a permanent solution to root out white-collar crimes from American society and if so what are the measures to be initiated? White collar crime baffles definition. The industrialization and the internet revolution which are the foundation stones of the materialistic civilization have contributed much to the advancement of the white-collar crime. Explaining the inability of the thinkers and writers on the subject to come to an acceptable conclusion to tender a definition that is acceptable to all, David O Friedrichs goes to elaborate the major crimes which can be classified as white collar crimes. He writes, â€Å"Some of these terms include economic crime, commercial crime, business crime, marketplace crime, consumer crime, respectable crime, â€Å"crime at the top†, â€Å"suite† crime, elite crime and deviance, official crime and deviance, political crime, governmental crime, state (or state-organized) crime, corporate crime, occupational crime, employees crime, vocational crime, techno-crime, computer crime †¦.†(Friedrichs, 2006, p, 5) That which is evident needs no further app reciation, explanation or elaboration. White collar crime has taken hold many segments of society and is growing in all directions like the octopus. This is also a contentious topic- whether one is committing a legitimate business activity in a free enterprise system which is the hallmark of a capitalist society or indulges in white-collar crime.  

Managing Information Systems Essay Example | Topics and Well Written Essays - 3750 words

Managing Information Systems - Essay Example Data in a Data Warehouse is arranged by subject not by function. As a result a data warehouse provides a peculiar view of the data that is amenable to manipulation for decision support. Levine and Siegel (2003) identify the key elements of a data warehouse as: "They are subject orientated, integrated, time variant, nonvolatile, and contain a collection of both detailed and summary data." The data warehouse can enable a business to solve many problems that can only be diagnosed when someone looks for a pattern in data. For instance, someone can determine problems associated with a product buy analyzing return and repair records. Data warehouse can be used for customer profiling where customer behavior in past promotions can be used to predict results of a planned campaign. A targeted campaign can be launched on a specific set of profiled customers where the anticipated response is expected to be higher. A data warehouse manager is the key person in defining requirements and format of a data warehouse. He or she must ensure at all the time that the data warehouse is meeting a company's strategic objectives. A data warehouse manager leads in specification of new solutions for the business. He or she is in charge of a team of experts that are involved in data warehousing projects. He or she has to ensure that any projects are implemented on time and properly and meet the company's objectives. The data warehouse manager needs to understand the different job responsibility of customers including the user computer skills. It is important that he understands the nature of decisions that need to be supported. In monitoring the system the manager should identify the most effective users of the warehouse. Expand usage of the system within company by identifying non-users of data warehouse and schedule them for appropriate training. The manager must ensure that the user interfaces are user-friendly. Data integrity issues are also the responsibility of the data warehouse manager. It is important to make sure the data in the warehouse is trustworthy. To this end data should be continuously monitored. The manager must search for new data sources and adapt the warehouse to changing data profiles, reporting requirements, and business priorities. The manager must highlight any successful decision made using data warehouse. Finally, "[k]eep your business users, executives, and boss happy". Data warehousing is a dynamic process. The warehouse manager has to ensure that the data is refreshed frequently and no data goes stale. Monitoring of utilization of the warehouse is also important for the data warehouse manager to understand how suitable each of the warehouse solutions is to the business. Being essentially a team leader a data warehouse manager has to supervise a high level team of programmers and database experts. With his or her team the data warehouse manager devises projects such as load processes automation and data modeling. The data warehouse manager must understand high-level business modeling and decision support to assist in development of business solution. Components of a data

Individual case study analysis(Money is not always the best reward ) Essay

Individual case study analysis(Money is not always the best reward ) - Essay Example The analyzed data has further been presented comprehensively to recommend strategies that would help in enhancing the performances of the employees. Table of Contents Executive Summary 2 Table of Contents 3 Introduction 4 Discussion 5 Key Issues identified in the case 5 Critically Analyzing and Evaluating the Case Issues 5 Conclusion and Recommendations 10 References 11 Bibliography 13 Introduction After being appointed as the CEO of a sporting and community club, Tim Johnson was bestowed with the responsibility of developing an innovative organizational structure as well as to implementing human resource systems for the effective performance of the club. During that period, the annual turnover of the club was more than $ 33 million with 75 employees which depicted the financial viability of the organization along with its size, augmenting the necessity to develop an organized and effective organizational structure. After his joining, Tim Johnson recognized that the management of the club was ineffective due to the lack of effective Human Resource (HR) as well as operational policies which is essential to yield superior performance from employees. Strategically, Tim Johnson conducted a survey on the employees and was able to identify that a lack of morale as well as motivation persisted within the workforce. Correspondingly, he formulated plans to develop and implement strategies such as position descriptions, systems related guidelines, job specifications as well as other HR and operational policies to be followed by the employees. Formal meetings were also organized with the motive of informing the employees about the change in the organizational structure. The HR and the operational policies were further intended to be legally enacted so as to ensure ethical viability within the reframed organizational process. One of the most significant changes brought by Tim Johnson in the philosophy of the restructured organizational process indicated an increased focus on improving the performance of the employees through empowerment rather than considering the monetary reward system. The discussion will thus emphasize on the identification as well as the analysis of various issues which have been identified in this case. The results of the analysis will further be used to recommend strategies which are required to mitigate the identified issues. Discussion Key Issues identified in the case In the referred case, the issues which were faced by the sporting and community club hampering the performance of the employees depicted that the club lacked effective leadership from the senior decision makers of the organization. Owing to the ineffective organizational structure and ill-organized process related policies, the organization had to face various problems related with lack of morale among the employees which further obstructed an enhanced performance from the human resources of the club. Lack of motivation to work in accordance with the standards specified by the management for the effective achievements of the goals was also observed as a restriction to the enhanced performance of the club. The club did not have Human Resource Management (HRM) for effective HR as well as operational polic

Strategic entrepreneurship Essay Example | Topics and Well Written Essays - 1750 words

Strategic entrepreneurship - Essay Example This form of entrepreneurship encompasses advantage seeking and opportunity seeking behaviour which benefits an organization for long run. Collaborative innovation is a foundation for strategic entrepreneurship. In today’s competitive world it becomes important for firms to seek continuous innovation and generate new ideas. Sustainability in intense competitive industry makes it necessary for firms to give more importance to teamwork and promote collaborative innovation approach. However strategic management comprises of certain issues which are faced by managers in due course of adopting such concept. Corporate entrepreneurship and strategic entrepreneurship can be defined as an approach that helps to create wealth and value in organization. A typical example of such entrepreneurship can be observed in research and development department of an organization that creates value and supports functional department of a firm and even provides value to the end users. The major intention of such form of entrepreneurship is to create competitive advantages and then exploit them so as to stay competitive in the market place. Strategic entrepreneurship and corporate entrepreneurship as described by Hitt, Ireland, Sirmon, and Trahms (2011) enables a firm to utilize its capabilities and knowledge in the present environmental condition as well as exploring future opportunities through enhancing capabilities as well as application of new knowledge. Novelty and flexibility are considered to be the two most important elements that describe such form of entrepreneurship. This approach even states that there needs to be a balance between exploiting and exploring by a firm. It is partially dependent on the type of competitive environment of an organization. The input-output-process model of SE describes the resources required for strategic entrepreneurship along with its probable outcomes. As per

Time Value of a Dollar Essay Example | Topics and Well Written Essays - 750 words

Time Value of a Dollar - Essay Example Critics are already arguing that the dollar can no longer be the reserve currency especially after the collapse of the U.S mortgage market, which set off the most awful global recession recently. There are a couple of reasons people prefer the present value of a dollar. If they can invest the money to earn interest over a period of time that is greater than a future payment, they will invest it in the present. Inflation is also a key factor in time value evaluations since it reduces the spending power of a dollar. Inflation is the persistent increase of prices and a dollar today may buy less quantities of a similar commodity in the future. Taking this into consideration one would rather invest now in a project that would earn them continuous cash flows rather than save that money to use it at a future date. Another reason is the default risk, which is the threat of not receiving the promised dollar in future. To understand time value of money we define the terms Net Present value, Fu ture present value and present value. The net present value is the value of future streams of cash flows into the cash at hand in the present date. The future value is the value of the money an individual has now at a later day. ... Different scholars explain that there is need to create strong fundamentals of the U.S economy, build investor confidence and diversify out of the dollar in order to protect it from depreciating with time. The U.S economy has weak fundamentals such as huge national debt, high unemployment rates, and international military operations. In a highly publicized vote the senate recently raised the debt ceiling to $14.3 trillion to avoid defaulting debt obligations which would be a catastrophe by itself. This could create a debt driven crisis that could strain standards of living by being detrimental to economic growth, dampen wages and restrict the government from investing or providing a safety net. It is necessary that the debt ceiling is not exceeded so as to prevent this debt driven crisis as it would accelerate the depreciation of the dollar. Military expenses are not productive and are a nonmonetary reason for inflation, an opinion that most economists share. There is the need to sho w creditors that the government is serious about stabilizing federal debt. Spending cuts are necessary to protect against the decreased value of money in future. Building investor confidence is a key to protecting the future value of money, and the government must ensure that it restores investor confidence for most believe that printing excess money for bailouts and stimuli will eventually weaken the dollar (Steverman). Asset prices should be watched carefully so that they remain in line with their underlying values and also do all it can to ensure economic growth. So far, the low dollar policy has helped as it has ensured that exports remain higher than imports. And if this keeps up there is hope that in the future the value of the dollar will be

Managing Information Systems Essay Example | Topics and Well Written Essays - 3750 words

Managing Information Systems - Essay Example Data in a Data Warehouse is arranged by subject not by function. As a result a data warehouse provides a peculiar view of the data that is amenable to manipulation for decision support. Levine and Siegel (2003) identify the key elements of a data warehouse as: "They are subject orientated, integrated, time variant, nonvolatile, and contain a collection of both detailed and summary data." The data warehouse can enable a business to solve many problems that can only be diagnosed when someone looks for a pattern in data. For instance, someone can determine problems associated with a product buy analyzing return and repair records. Data warehouse can be used for customer profiling where customer behavior in past promotions can be used to predict results of a planned campaign. A targeted campaign can be launched on a specific set of profiled customers where the anticipated response is expected to be higher. A data warehouse manager is the key person in defining requirements and format of a data warehouse. He or she must ensure at all the time that the data warehouse is meeting a company's strategic objectives. A data warehouse manager leads in specification of new solutions for the business. He or she is in charge of a team of experts that are involved in data warehousing projects. He or she has to ensure that any projects are implemented on time and properly and meet the company's objectives. The data warehouse manager needs to understand the different job responsibility of customers including the user computer skills. It is important that he understands the nature of decisions that need to be supported. In monitoring the system the manager should identify the most effective users of the warehouse. Expand usage of the system within company by identifying non-users of data warehouse and schedule them for appropriate training. The manager must ensure that the user interfaces are user-friendly. Data integrity issues are also the responsibility of the data warehouse manager. It is important to make sure the data in the warehouse is trustworthy. To this end data should be continuously monitored. The manager must search for new data sources and adapt the warehouse to changing data profiles, reporting requirements, and business priorities. The manager must highlight any successful decision made using data warehouse. Finally, "[k]eep your business users, executives, and boss happy". Data warehousing is a dynamic process. The warehouse manager has to ensure that the data is refreshed frequently and no data goes stale. Monitoring of utilization of the warehouse is also important for the data warehouse manager to understand how suitable each of the warehouse solutions is to the business. Being essentially a team leader a data warehouse manager has to supervise a high level team of programmers and database experts. With his or her team the data warehouse manager devises projects such as load processes automation and data modeling. The data warehouse manager must understand high-level business modeling and decision support to assist in development of business solution. Components of a data

Strategic entrepreneurship Essay Example | Topics and Well Written Essays - 1750 words

Strategic entrepreneurship - Essay Example This form of entrepreneurship encompasses advantage seeking and opportunity seeking behaviour which benefits an organization for long run. Collaborative innovation is a foundation for strategic entrepreneurship. In today’s competitive world it becomes important for firms to seek continuous innovation and generate new ideas. Sustainability in intense competitive industry makes it necessary for firms to give more importance to teamwork and promote collaborative innovation approach. However strategic management comprises of certain issues which are faced by managers in due course of adopting such concept. Corporate entrepreneurship and strategic entrepreneurship can be defined as an approach that helps to create wealth and value in organization. A typical example of such entrepreneurship can be observed in research and development department of an organization that creates value and supports functional department of a firm and even provides value to the end users. The major intention of such form of entrepreneurship is to create competitive advantages and then exploit them so as to stay competitive in the market place. Strategic entrepreneurship and corporate entrepreneurship as described by Hitt, Ireland, Sirmon, and Trahms (2011) enables a firm to utilize its capabilities and knowledge in the present environmental condition as well as exploring future opportunities through enhancing capabilities as well as application of new knowledge. Novelty and flexibility are considered to be the two most important elements that describe such form of entrepreneurship. This approach even states that there needs to be a balance between exploiting and exploring by a firm. It is partially dependent on the type of competitive environment of an organization. The input-output-process model of SE describes the resources required for strategic entrepreneurship along with its probable outcomes. As per

Social inequality (contrast between UK and Brazil) Essay

Social inequality (contrast between UK and Brazil) - Essay Example Differences in living standards is evident in that there are people who live in luxurious houses while others live in slums, differences in life expectancy can be associated with proper health accessed by the rich and not by the poor, conflict in the society is associated with what Karl Marx referred to as polarisation between classes resulting to a revolution and finally progress will occur in the society in that the rich will inspire the poor to become rich. The conflict perspective of inequality by Karl Marx perceives inequality as one that does not play a useful role in society, Karl argues that all societies have two groups of people the owners of resources to production and the workers, the rich exploit the workers to make more profits through more working hours and low wages, the rich want to maintain the status quo while the workers want to change the existing situation and therefore there is always conflict in the society.2 The functionalist perspective by Davis and Moore perceive society stratification and inequality as one that plays a role in the proper working of society, according to this theory all social systems share certain functional prerequisite which must be met for the society to operate efficiently. One of these prerequisites is effective role allocation and performance and this means that all roles must be filled by those who are best able to perform them and that roles must be performed well by trained individuals. The mechanism that ensures proper role allocation is social stratification, roles are different in terms of importance and therefore there is the need to attach unequal rewards to the role.3 Living standards in the UK are higher than those of Brazil, this is attributed by the fact that the UK is more developed and industrialised; therefore the inequalities in the UK are better off compared to cases of inequalities in Brazil. Higher incomes in the UK are one

How coherent a work is Herodotus' Histories Essay

How coherent a work is Herodotus' Histories - Essay Example s fragmented and digressing into fable and even those who were prepared to step outside the confines of the thinking of their own era, were often not prepared to make more than small concessions about the possible motives, expertise and literary devices found in The Histories. More recent research , however, suggests that, if understood within the intellectual climate of their time, The Histories reveal themselves as the multi-faceted work of a highly intuitive and progressive thinker, who used the past and the present, to record and draw parallels with the complexity of his own time, and who used a plethora of tools at his disposal to inform of the consequences of reliving the past - these were definitely not the rather clumsy, ‘anachrostic’ efforts of an ancient teller of tall stories (De Jong, I. J. F., 2003). Viewed with an appreciation of 5th century philosophy, science, epic heritage, political currents and literary know-how, The Histories is a historical record of high intellectual quality and significance, largely coherent in its aims and with considerable unity, once literary structures and devices have been understood in their ancient context. Although there is perhaps still much to be discovered, evidenced by the considerable amount of research that is continuing to offer new possibilities of understanding this important text. This on-going curiosity is now extending into a much broader field of inquiry and includes research into the uses of language, narration, moral, ethical and judicial concepts, as well as general themes, although the focus of the research has shifted and is no longer done to establish coherence, but aims instead to demonstrate the multiplicity of creative devices that Herodotus had at his disposal. Interest in The Histories has continued throughout the ages and the critiques of Thucydides and Aristotle were followed by others, classical scholars of the first few centuries CE and again, after the so-called dark ages. Given the

Fighting the Long War Essay Example for Free

Fighting the Long War Essay The strategy outlined in â€Å"Fighting the Long War† is a good one. There are, of course, other options. One is to flee and do nothing more than we have already done. Yet, as the presentation’s authors suggest, this would almost certainly lead to the ruin of America. Stopping action now will not clear away centuries of hate and rage, nor will it erase the religious and political goals of a long committed enemy. Those who are less patient and less willing to lose men to a war, might suggested a shorter war, brought about by greater use of force. The military has been tied back and prevented from executing its full power in the Middle East. The United States could, if it wished, use its nuclear weapons against the enemy. Yet it does not. This may be a good thing. Using nuclear weapons would be unquestionably risky. Other countries which boast nuclear technologies might be tempted to retaliate, which could lead to the eventual destruction of American cities. It could also lead to chaos with unpredictable outcomes. Therefore, the best strategy seems to be to follow the long war approach of the presenters. Perhaps the most important point made in the presentation, was that Americans need to understand the nature and necessity of a long war and that they need to be able to trust their leaders. The main objection to involvement in Iraq was not that Sadam Hussein did not need to be stopped – it was that President Bush went in with the wrong motives. Whether the president’s motives were benevolent or malevolent, much of the American public distrusted him and this hurt the war effort substantially. Also of great import is the section on promoting the good points of peaceful Islam. Criticizing a person’s religion often triggers hostility. Those who have already been provoked by maltreatment by non-Muslims are much more likely to be converted violent extremism than those who have lived peacefully among their peers for many years. Promoting Islam’s peaceful movements, then, is a good counter-measure. Likewise, promoting assistance in rebuilding and democratizing Iraq is an excellent idea. Japan has certainly come a long way. It would be nice if Iraq could too.

Comparison of Pneumonia Management Methods

Comparison of Pneumonia Management Methods INTRODUCTION 1.1 Background: Pneumonia is the inflammation and consolidation of lung tissue due to an infectious agent (Marrie TJ, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth leading cause of death (Brandstetter, 1993). Pneumonia causes excess morbidity, hospitalization, and mortality, especially among the elderly, the fastest growing sector of the population.According to first- or second-listed diagnosis, approximately 1 million persons were discharged from short-stay hospitals after treatment for pneumoniain the United States in 1990, and elderly persons aged 65 years or more accounted for 52% of all pneumonia discharges (Fedson Musher, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth cause of death (Brandstltter, 1993). In addition fine (2000) reported that lower respiratory tract infections affect three million persons annually and is the leading cause of death of infection in the United States. †¢ Pneumonia represented one of the 10th leading causes of hospitalization and deaths in Malaysia through 1999-2006 (Ministry of Health, Malaysia, 1999, 2000, 2001, 2002b, 2003, 2004, 2005band 2006b) Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided into: hospital acquired and community-acquired pneumonia.Community acquired pneumonia (CAP) is caused mainly by streptococcus pneumoniae. Its symptoms include coughing (with or without sputum production), change in colour of respiratory secretion, fever, and pleuritic chest pain (Fine, 2000). Nosocomial pneumonia or hospital acquired pneumonia is the second most common nosocomial infection in the United States and it causes the highest rates of morbidity and mortality. It is caused mainly by streptococcus pneumoniae and pseudomonas aeruginosa. The highest mortality rates occurred in patients with pseudomonas aeruginosa or acineobacter infection. It is characterized by fever and purulent respiratory secretion. Nosocomial pneumonia results in increase length of hospitalization and cost of treatment (Kashuba, 1999; Levison, 2003; Wilks et al., 2003). The clinical criteria for the diagnosis o f pneumonia include chest pain, cough, or auscultatory findings such as rales or evidence of pulmonary consolidation, fever or leucocytosis. In addition, there must be radiographic evidence, such as the presence of new infiltrates on chest radiograph, and laboratory evidence that supports the diagnosis. Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided in hospital acquired and community-acquired pneumonia. Pneumonia developing outside the hospital is referred to as community-acquired pneumonia (CAP). Pharmacoeconomic study Pharmacoeconomics is defined as the description and analysis of costs of drug therapy or clinical service to health care systems and society (Bootman et al., 1996). It has risen up as the discipline with the increase interst in calculating the value and costs of medicines (Sanches, 1994). Cost is defined as the value of resources consumed by the program or drug therapy of interest while a consequence is defined as the effect, outputs, or outcomes of a program. When identifying the costs associated with a product or service, all possible costs that include or related to the study are calculated (Sanchez, 1994). With the increase in financial pressure to hospitals to minimize their medical care costs, pharmacoeconomics can define costs and benefits of both expensive drug therapies and pharmacy based clinical services (Destache, 1993; Touw, 2005).Furthermore pharmacoeconomics can assist practitioners in balancing cost and quality that may result in improving patient care and cost saving to the institution (Sanches, 1994). Bootman and Harison (1997) stated that pharmacoeconomics and outcome research are very important to determine the efficient way to present a quality care at realistic rate. They suggested that pharmacoeconomics should have a remarkable authority on the delivery and financing of health care throughout the world. Different methods have been used to perform pharmacoeconomics analysis which includes: Cost-benefit analysis: Cost-benefit analysis two or more alternatives that do not have the same outcome measures. It measures all costs and benefits of a program in monetary terms (Bootman et al., 1996; Fleurence, 2003). Cost-benefit analysis could play a major role in identifying the specific costs and benefits associated with the pneumonia. Cost-effective analysis Cost-effective analysis compares alternatives that differ in safety, efficacy and outcome. Cost is measured in monetary terms, while outcome is measured in specific objectives or natural units. The outcome are expressed in terms of the cost per unit of success or effect (Bootman et al., 1996). Cost-utility analysis Cost-utility analysis compares treatment alternatives; benefits are measured in terms of quality of life, willingness to pay, and patient preference for one intervention over another, while cost is measured in monetary terms. It has some similarity to cost-effectivness with more concentration on patient view. As an example, looking for new druig therapy; benefits can built-in together with expected risks. Cost-minimization analysis Cost-minimization analysis is one of the simplest forms of pharmacoeconomics analysis. It is used when two or more alternatives are assumed to be equivalent in terms of outcomes but differ in the cost which is measured in monetary terms (Fleurence, 2003). Cost of illness analysis Cost of illness analysis is the determination of all costs of aparticular disease, which include both direct and indirect costs. Since both costs were calculated, an economic evaluation for the disease can be performed successfully. It has been used for evaluating many diseases (Bootman et al., 1996). 1.2 Study problems and rationale The management of pneumonia is very straight forward. However this is not always true for the diagnosis and selection of therapy. As there are some issues related to pneumonia that need to be addressed : The first issue pertains to the inappropriate diagnosis of the pneumonia. Some physicians do not properly identify the causative organism, I.e, whether, it is bacterial or viral. Bartlet et al (1998) found that the viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults (Bartlet et al, 1998). Secondly is the use of inappropriate medications. The prescription of inappropriate or un-indicated drug therapy such as the prescription of antibiotics for pneumonia caused by nonbacterial infection may increase the incidence of bacterial resistance (Steinman, 2003). Thirdly the adherence to guidelines improves quality of care and reduces the length of hospital stay (Marrie TJ et al, 2000). Fourthly the adherence to guidelines reduces the cost of treating pneumonia (Feagan BG, 2001). Fifthly Teaching hospitals are widely perceived to provide good outcome, and that reputation is thought to justify these institutions comparatively higher charges relative to non-teaching (general) hospitals. Despite their reputation for specialized care, teaching hospitals have traditionally relied on revenue from routine services, such as treatment of pneumonia, and the costs of specialized services and medical training. However, with managed care and competition creating pressures for cost containment, these higher costs have come into question: Do a teaching hospital provide good outcome for management of pneumonia, or do a general hospital provide comparable outcome at lower costs? 1.3 Significance of the Study This study has the following important issues: To the researchers: Several studies have compare the management of pneumonia in a university hospital versus a general hospital, but most of these studies were conducted in the USA and other parts of the world. There are no published studies in Malaysia or Asia to our knowledge. This study also provides the difference in the outcome, cost and cost-effectivness of treating pneumonia between a university hospital and a general hospital. To the practitioners: This study will provide information about the adherence to guidelines will reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. To the patients: This study attempts to highlight the benefits associated with adherence to the guidelines. To the policy makers: This study will help policy makers to develop new strategies for management of pneumonia. This study will help policy makers to develop new guideline for management of pneumonia according to the microorganisms and the population in Malaysia. This study also provides the difference in the management of pneumonia between a university hospital and a general hospital. This study will provide information about how we can reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. The results of this study will help in improving the management of pneumonia. It is the time to know whether a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs. By analyzing the cost and effectiveness of the regimens being used, the most effective therapy can be defined and the information can be offered to the policy makers to improve the deciosion making in treating pneumonia. The study will be able to help on: How we can make the drug therapy cost effective keeping effectiveness and outcome in our mind and try to suggest the best and most appropriate drug therapy which should be cost effective which help to decrease the financial burden on patients as well as Ministry Of health. This study will help to suggest how we can reduce the cost of therapy of treating pneumonia. The study will be able to provide data on: The incidence of pneumonia in (H-USM and Penang-GH). The most common organisms causing pneumonia in (H-USM and Penang-GH). The pattern of drugs used and management of pneumonia in in (H-USM and Penang-GH). The outcome of treating pneumonia in (H-USM and Penang-GH). The cost of treating pneumonia in (H-USM and Penang-GH). The cost-effectivness of treating pneumonia in (H-USM and Penang-GH). Whether a university hospital provide a good outcome for management of pneumonia, or a general hospital provide comparable quality at lower costs. 1.4 Hypothesis of the Study: H0: There is no significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). H1: There is a significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). 1.5 Aim of the study The aim of this study is to compare the management of pneumonia in a university hospital (H-USM) versus a general hospital (Pinanag-GH). 1.6 Objectives The objectives of this study are: To compare the incidence of pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the most common organisms associated with pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the drug therapy for pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost-effectivness of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). 1.7 Research Questions What are the difference between the organisms that is commonly associated with pneumonia at H-USM and Penang-GH? What are the difference between the antibiotics that is commonly used for the treatment of pneumonia at H-USM and Penang-GH? What are the difference between the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at H-USM and Penang-GH? What are the difference between the cost of treating pneumonia at H-USM and Penang-GH? And how can these costs be reduced? What are the difference between the cost-effectivness of treating pneumonia at H-USM and Penang-GH? Do a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs? CHPTER 2 LITERATURE REVIEW 2.1 Community-acquired pneumonia 2.1.1 Introduction Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, a new infiltrate on chest x-ray or auscultatory findings such as altered breath sounds and/or localized rales in community-dwelling patients (Infectious Diseases Society of America 2000). It is a common condition that carries a high burden of mortality and morbidity, particularly in elderly populations. Although most patients recover without sequellae, CAP can take a very severe course, requiring admission to an intensive care unit (ICU) and even leading to death. According to US data, it is the most important cause of death from infectious causes and the sixth most important cause of death overall (Adams et al. 1996). Even though the mortality from pneumonia decreased rapidly in the 1940s after the introduction of antibiotic therapy, it has remained essentially unchanged since then or has even increased slightly (MMWR 1995 ). Furthermore, significant costs are associated with the diagnosis and management of CAP. Between 22% and 42% of adults with CAP are admitted to hospital, and of those, 5% to 10% need to be admitted to an ICU (British Thoracic Society 2001). In the US, it is estimated that the total cost of treating an episode of CAP in hospital is about USD $ 7500, which is approximately 20 times more than the cost of treating a patient on an outpatient basis (Lave et al. 1999). CAP also contributes significantly to antibiotic use, which is associated with well-known problems of resistance. In treating patients with CAP, the choice of antibiotic is a difficult one. Factors to be considered are the possible etiologic pathogen, the efficacy of the substance, potential side-effects, the treatment schedule and its effect on adherence to treatment as well as the particular regional resistance profile of the causative organism and the co-morbidities that might influence the range of potential pathogens (such as in cystic fibrosis) or the dosage (as in the case of renal insufficiency). It may be a primary disease occurring at random in healthy individuals or may be secondary to a predisposing factor such as chronic lung disease or diabetes mellitus. CAP represents a broad spectrum of severity, ranging from mild pneumonia that can be managed by general practitioners outside the hospital to severe pneumonia with septic shock needing treatment in intensive care unit. Depending on severity of illness, about 20% of patients with pneumonia need hospitalization and approximately 1% of all CAP patients require treatment in ICU. Elderly persons and those with underlying conditions, such as cerebro and cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and alcoholism, are at increased risk for developing lower respiratory tract infections and complicated courses of infection. 2.1.2 Definition: Community-Acquired pneumonia (CAP) is defined as inflammation and consolidation of lung tissue induced by infectious microbes such as bacteria, viruses, or parasites. When the onset of symptoms and signs of this disease is before or within 48 hours after admission, it is considered as CAP (Bartlett JG et al., 1995). 2.1.3 Epidemiology Incidence: In the industrialized world, the annual incidence of CAP in community dwelling adults is estimated at 5 to 11 cases per 1000 adult population (British Thoracic Society 2001). The incidence is known to vary markedly with age, being higher in the very young and the elderly. In one Finnish study, the annual incidence for people aged 16-59 years was 6 cases per 1000 population, for those 60 years and older it was 20 per 1000, and for people aged 75 and over, 34 per 1000 (Jokinen et al. 1993). Annual incidences of 30-50 per 1000 population have been reported for infants below 1 year of age (Marrie 2001). Seasonal variations in incidence are also significant, with a peak in the winter months (Marrie 2001). The annual incidence of CAP requiring hospitalisation has been estimated at 1 to 4 patients per 1000 population (Marrie 1990, Fine et al. 1996). The proportion of patients requiring hospitalisation varies from country to country and across studies and has been estimated as ranging anywhe re between 15% and 56% (Foy et al. 1973, Minogue et al. 1998). Of those, 5% to 10% required admission to an intensive care unit (ICU) (British Thoracic Society Research Committee and Public Health Laboratory Service 1992, Torres et al. 1991). Conversely, about 8% to 10% of admissions to a medical ICU are due to severe CAP (Woodhead et al. 1985). Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world (WHO Statistical Information System (WHOSIS). WHO Mortality Database. Released: January 2005; Health, United States, 2005; Annual Report, Hong Kong, 2003/2004). Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone (Lynch JP, 1992). Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions,(National Hospital Discharge Survey, 1988) and about 50 000 people die as a result of community-acquired pneumonia (Farr BM et al 203). Bartlet et al (1998) found that viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults. Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone. Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions, and about 50 000 people die as a result of community-acquired pneumonia. In the USA, community acquired pneumonia is the fifth leading cause of death in people over the age of 65 years and an estimated 60 000 seniors die annually. Most of the excess deaths and hospitalizations due to lower respiratory infections occur in older adults, as reflected by the more than 44 000 hospitalizations for pneumonia and influenza in people aged 65 and older in 1997 in Canada. It is estimated that the age-specific incidence of pneumonia increases from 15.4 cases per 1000 in those aged 60-74 years to 34.2 for those 75 years and older. Residents of long-term care facilities, a distinct subpopulation of elderly people, are at particularly high risk for developing nursing-home acquired pneumonia. Health costs for this sector are growing at an accelerated rate as the age of dea th increases. Thirteen percent of the population is over the age of 65 in the United States and this is expected to increase to 20% by 2030. In Canada, the proportion of individuals over the age of 65 is expected to rise to 20% in the year 2021. Presently, while making up 12% of the Canadian population, older adults account for 31% of acute hospital days and half of all hospital stays. To meet their health-care needs and alleviate the burden onthe health-care system, we must improve our understanding of the management and prevention of pneumonia in this age group. Elderly people constitute an ever-increasing proportion of the population. CAP has traditionally been recognized as problems that particularly affect the older individuals. According to western studies, the overall rate of pneumonia requiring hospitalization increase with age, from 1 per 1,000 persons in the general population but increases to 12 per 1,000 persons for those over age 75 years3. As the population of those ov er age 65 years is predicted to rise from its current level of 11% to 25 % of the total population in the year 20504, respiratory tract infection will assume a greater degree of importance to the overall public health. In Hong Kong, pneumonia was the fourth leading death from a specific diagnosis in 2001. A total of 3026 people died of pneumonia in 2001 which 1526 cases were male. Out of the 3026 deaths, 2794 patients were 65 or older which accounted for more than 90% of the total death. Pneumonia in the elderly population is a major cause of morbidity and mortality and in some series represents the leading cause of death. The annual cost of treating patients age > 65 years with pneumonia to be $4.8 billion, compared with $3.6 billion for those 85 years need help with bathing and 10% need help in using the toilet and transferring. The present of any or all of following identifies elderly persons at greatest risk for functional decline: pressure ulcer, cognitive impairment, functiona l impairment, and low level of social activity. The attack rate for pneumonia is highest among those in nursing homes. It is found that 33 of 1,000 nursing home residents per year required hospitalization for treatment of pneumonia, compared with 1.14 of 1,000 adults living in the community. Pneumonia is a major cause of morbidity and mortality worldwide. In the UK as a whole, pneumonia is responsible for over 10% of all deaths (66,581 deaths in 2001), the majority of which occur in the elderly. Community-acquired pneumonia (CAP) remains a common cause of morbidity. Because CAP also is a potentially fatal disease, even in previously healthy persons, early appropriate antibiotic treatment is vital. In Japan, pneumonia is the fourth leading cause of death, and from 57 to 70 persons per 100,000 populations died per year of this disease in the last decade. Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world, including Hong Kong, Pneumonia is the second most common infectious disease in Thailand. Whereas diarrhea is more common, pneumonia is associated with more fatalities. CAP remains the leading cause of death due to infectious diseases, with an annual incidence ranging 1.6-10.6 per 1,000 adult populations in Europe According to the Ministry of Health Malaysia (MOH), pneumonia is the 5th cause of death in Malaysia and the 4th cause of hospitalization. A prospective observational study by Jae et al (2007) of 955 cases of adult CAP in 14 hospitals in eight Asian countries found that the overall 30-day mortality rate was 7.3%. A prospective study by Liam CK et al (2001) of 127 cases of CAP in Malaysia found that the Mortality from CAP is more likely in patients with comorbidity and in those who are bacteraemic. A prospective study by LOH et al (2004) of 108 cases of adult CAP in urban-based university teaching hospital in Malaysia found that the mortality rate from CAP in hospital was 12%. 2.1.4 Syndromes of CAP The presence of various signs and symptoms and physical findings varies according to the age of the patients, therapy with antibiotics before presentation, and the severity of illness. Patients with pneumonia usually present with cough (>90%), dyspnea (66%), sputum production (66%% pleuritic chest pain (50%), and chills is present in 40-70% and rigor in 15%. However, a variety of nonrespiratory symptoms can also predominate in pneumonia cases, including fatigue (91%), anorexia (71%), sweating (69%), and nausea (41%). Metlay et al. (1997c) divided 1812 patients with CAP into four age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 recorded symptoms there were significant decreases in reported prevalence with increasing age (p 37 °C at presentation. Crackles were present on auscultation in 80% of patients, and rhonchi in 34% to 47% (more common in the nursing home patients). About 25% had the physical findings of dullness to percussion, bronchial breathing, whispered pectoriloquy, and aegophony. Alteration in mental status was common. Marrie and coworkers (1989) reported confusion in 48% of the patients with nursing home-acquired pneumonia and in 30% of the other patients with CAP. Fine and colleagues (1998) define altered mental status as stupor, coma, or confusion representing an acute change from the usual state prior to presentation with pneumonia. This was present in 17.3% of the hospitalized patients. The decrease in symptoms with increasing age, tachypnea increased with increasing age (Metlay et al., 1997c). Thirty-six percent of 780 patients with CAP in the 18-44 year age group had tachypnea on admission versus 65% of the 280 patients who were = 75 years old. There were minimal differences in the proportion of patients with tachycardia and hyperthermia in the different age groups Pneumonia in the elderly are quite different from that in a younger population. These differences are due to age-related alterations in immunology, different epidemiology and bacteriology. It is important to remember that pneumonia in the elderly may report fewer respiratory signs and symptoms. The clinical presentation may be more subtle than in younger population, with more gradual onset, less frequent complaints of chill and rigors, and less fever. The classical finding of cough, fever, and dyspnea may be absent in over half of elderly patients8. Instead they may be manifest as delirium, a decline in f unctional status, weakness, anorexia, abdominal pain, or decrease general condition. The incidence of fever may decline with age, and the degree of fever appears lower in old population10. Tachypnea which respiration rate greater than 24-30 breaths per minute is noted more frequently in up to 69% of patients. Although rales are common and are noted in 78% of patients, signs of true consolidation are found in only 29%. Bacteremia, metastatic foci of infection and death are more frequent in older populations. As many elderly present with non-specific clinical symptoms and nonspecific functional decline that makes an accurate diagnosis difficult and may lead a life-threatening delay of diagnosis and therapy. Metlay et al. compared the prevalence of symptoms and signs of pneumonia in a cohort of 1812 patients and found that patients aged 65-74 years and over 75 years had 2.9 and 3.3 fewer symptoms, respectively, than those aged 18 through 44 years. The reduced prevalence of symptoms was most pronounced for symptoms related to febrile response (chills and sweats) and pain (chest, headache, and myalgia). These findings are consistent with those of Marrie et al. demonstrating reduced prevalence of non-respiratory symptoms among elderly patients. In a retrospective chart review by Johnson et al., the presence of dementia seemed to account for non-specific symptoms. However the sample size of the study was small and precluded a multivariable analysis. Roghmann et al found a significant inverse correlation between age and initial temperature in 320 older patients hospitalized for pneumonia. Evidence therefore does exist for a less distinct presentation of nonrespiratory symptoms and signs of pneumonia in the elderly. 2.1.5 Radiographic findings in CAP Radiographic changes usually cannot be used to distinguish bacterial from nonbacterial pneumonia, but they are often important for diagnosis of CAP, evaluating the severity of illness, determining the need for diagnostic studies, and selecting antibiotic agents. A chest radiograph usually shows lobar or segmental opacification in bacterial pneumonias and in the majority of atypical infections. Patchy peribronchial shadowing or more diffuse nodular or ground-glass opacification is seen less commonly, particularly in viral and atypical infections. The lower lobes are most commonly affected in all types of pneumonia. Small pleural effusions can be detected in about one-quarter of cases. Multilobar pneumonia is a feature of severe disease, and spread to other lobes despite appropriate antibiotics is seen in Legionella and M. pneumoniae infection. Hilar lymphadenopathy is unusual except in Mycoplasma pneumonia, particularly in children. Cavitation is uncommon but is a classic feature of S . aureus and S. pneumoniae infections. False negative results can be attributed to dehydration, evaluation during the first 24 hours, pneumonia due to Pneumocystis carinii, or pneumonia with profound neutropenia. 2.1.6 Etiology: More than 100 microorganisms have been identified so far as potential causative agents of CAP (Marrie 2001). They can be classified according to their biological characteristics as either bacteria, mycoplasma and other intracellular organisms, viruses, fungi and parasites. The most common causative agent of CAP is the bacteriumStreptococcus pneumoniae, which is implicated in 20% to 75% of cases of CAP (Marrie 2001) and about 66% of bacteremic pneumonia (Infectious Diseases Society of America 2000). Another causative bacterium is Haemophilus influenzae. So called â€Å"atypical† organisms have also been implicated as causal agents. These include Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila (Marrie 2001). Influenza is the most common serio Comparison of Pneumonia Management Methods Comparison of Pneumonia Management Methods INTRODUCTION 1.1 Background: Pneumonia is the inflammation and consolidation of lung tissue due to an infectious agent (Marrie TJ, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth leading cause of death (Brandstetter, 1993). Pneumonia causes excess morbidity, hospitalization, and mortality, especially among the elderly, the fastest growing sector of the population.According to first- or second-listed diagnosis, approximately 1 million persons were discharged from short-stay hospitals after treatment for pneumoniain the United States in 1990, and elderly persons aged 65 years or more accounted for 52% of all pneumonia discharges (Fedson Musher, 1994). Pneumonia has the highest mortality rate among infectious diseases and represents the fifth cause of death (Brandstltter, 1993). In addition fine (2000) reported that lower respiratory tract infections affect three million persons annually and is the leading cause of death of infection in the United States. †¢ Pneumonia represented one of the 10th leading causes of hospitalization and deaths in Malaysia through 1999-2006 (Ministry of Health, Malaysia, 1999, 2000, 2001, 2002b, 2003, 2004, 2005band 2006b) Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided into: hospital acquired and community-acquired pneumonia.Community acquired pneumonia (CAP) is caused mainly by streptococcus pneumoniae. Its symptoms include coughing (with or without sputum production), change in colour of respiratory secretion, fever, and pleuritic chest pain (Fine, 2000). Nosocomial pneumonia or hospital acquired pneumonia is the second most common nosocomial infection in the United States and it causes the highest rates of morbidity and mortality. It is caused mainly by streptococcus pneumoniae and pseudomonas aeruginosa. The highest mortality rates occurred in patients with pseudomonas aeruginosa or acineobacter infection. It is characterized by fever and purulent respiratory secretion. Nosocomial pneumonia results in increase length of hospitalization and cost of treatment (Kashuba, 1999; Levison, 2003; Wilks et al., 2003). The clinical criteria for the diagnosis o f pneumonia include chest pain, cough, or auscultatory findings such as rales or evidence of pulmonary consolidation, fever or leucocytosis. In addition, there must be radiographic evidence, such as the presence of new infiltrates on chest radiograph, and laboratory evidence that supports the diagnosis. Because of differences in pathogenesis and causative micro-organisms, pneumonia is often divided in hospital acquired and community-acquired pneumonia. Pneumonia developing outside the hospital is referred to as community-acquired pneumonia (CAP). Pharmacoeconomic study Pharmacoeconomics is defined as the description and analysis of costs of drug therapy or clinical service to health care systems and society (Bootman et al., 1996). It has risen up as the discipline with the increase interst in calculating the value and costs of medicines (Sanches, 1994). Cost is defined as the value of resources consumed by the program or drug therapy of interest while a consequence is defined as the effect, outputs, or outcomes of a program. When identifying the costs associated with a product or service, all possible costs that include or related to the study are calculated (Sanchez, 1994). With the increase in financial pressure to hospitals to minimize their medical care costs, pharmacoeconomics can define costs and benefits of both expensive drug therapies and pharmacy based clinical services (Destache, 1993; Touw, 2005).Furthermore pharmacoeconomics can assist practitioners in balancing cost and quality that may result in improving patient care and cost saving to the institution (Sanches, 1994). Bootman and Harison (1997) stated that pharmacoeconomics and outcome research are very important to determine the efficient way to present a quality care at realistic rate. They suggested that pharmacoeconomics should have a remarkable authority on the delivery and financing of health care throughout the world. Different methods have been used to perform pharmacoeconomics analysis which includes: Cost-benefit analysis: Cost-benefit analysis two or more alternatives that do not have the same outcome measures. It measures all costs and benefits of a program in monetary terms (Bootman et al., 1996; Fleurence, 2003). Cost-benefit analysis could play a major role in identifying the specific costs and benefits associated with the pneumonia. Cost-effective analysis Cost-effective analysis compares alternatives that differ in safety, efficacy and outcome. Cost is measured in monetary terms, while outcome is measured in specific objectives or natural units. The outcome are expressed in terms of the cost per unit of success or effect (Bootman et al., 1996). Cost-utility analysis Cost-utility analysis compares treatment alternatives; benefits are measured in terms of quality of life, willingness to pay, and patient preference for one intervention over another, while cost is measured in monetary terms. It has some similarity to cost-effectivness with more concentration on patient view. As an example, looking for new druig therapy; benefits can built-in together with expected risks. Cost-minimization analysis Cost-minimization analysis is one of the simplest forms of pharmacoeconomics analysis. It is used when two or more alternatives are assumed to be equivalent in terms of outcomes but differ in the cost which is measured in monetary terms (Fleurence, 2003). Cost of illness analysis Cost of illness analysis is the determination of all costs of aparticular disease, which include both direct and indirect costs. Since both costs were calculated, an economic evaluation for the disease can be performed successfully. It has been used for evaluating many diseases (Bootman et al., 1996). 1.2 Study problems and rationale The management of pneumonia is very straight forward. However this is not always true for the diagnosis and selection of therapy. As there are some issues related to pneumonia that need to be addressed : The first issue pertains to the inappropriate diagnosis of the pneumonia. Some physicians do not properly identify the causative organism, I.e, whether, it is bacterial or viral. Bartlet et al (1998) found that the viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults (Bartlet et al, 1998). Secondly is the use of inappropriate medications. The prescription of inappropriate or un-indicated drug therapy such as the prescription of antibiotics for pneumonia caused by nonbacterial infection may increase the incidence of bacterial resistance (Steinman, 2003). Thirdly the adherence to guidelines improves quality of care and reduces the length of hospital stay (Marrie TJ et al, 2000). Fourthly the adherence to guidelines reduces the cost of treating pneumonia (Feagan BG, 2001). Fifthly Teaching hospitals are widely perceived to provide good outcome, and that reputation is thought to justify these institutions comparatively higher charges relative to non-teaching (general) hospitals. Despite their reputation for specialized care, teaching hospitals have traditionally relied on revenue from routine services, such as treatment of pneumonia, and the costs of specialized services and medical training. However, with managed care and competition creating pressures for cost containment, these higher costs have come into question: Do a teaching hospital provide good outcome for management of pneumonia, or do a general hospital provide comparable outcome at lower costs? 1.3 Significance of the Study This study has the following important issues: To the researchers: Several studies have compare the management of pneumonia in a university hospital versus a general hospital, but most of these studies were conducted in the USA and other parts of the world. There are no published studies in Malaysia or Asia to our knowledge. This study also provides the difference in the outcome, cost and cost-effectivness of treating pneumonia between a university hospital and a general hospital. To the practitioners: This study will provide information about the adherence to guidelines will reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. To the patients: This study attempts to highlight the benefits associated with adherence to the guidelines. To the policy makers: This study will help policy makers to develop new strategies for management of pneumonia. This study will help policy makers to develop new guideline for management of pneumonia according to the microorganisms and the population in Malaysia. This study also provides the difference in the management of pneumonia between a university hospital and a general hospital. This study will provide information about how we can reduce the length of hospital stay, reduce the cost of treating pneumonia and improve outcomes of treating pneumonia. The results of this study will help in improving the management of pneumonia. It is the time to know whether a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs. By analyzing the cost and effectiveness of the regimens being used, the most effective therapy can be defined and the information can be offered to the policy makers to improve the deciosion making in treating pneumonia. The study will be able to help on: How we can make the drug therapy cost effective keeping effectiveness and outcome in our mind and try to suggest the best and most appropriate drug therapy which should be cost effective which help to decrease the financial burden on patients as well as Ministry Of health. This study will help to suggest how we can reduce the cost of therapy of treating pneumonia. The study will be able to provide data on: The incidence of pneumonia in (H-USM and Penang-GH). The most common organisms causing pneumonia in (H-USM and Penang-GH). The pattern of drugs used and management of pneumonia in in (H-USM and Penang-GH). The outcome of treating pneumonia in (H-USM and Penang-GH). The cost of treating pneumonia in (H-USM and Penang-GH). The cost-effectivness of treating pneumonia in (H-USM and Penang-GH). Whether a university hospital provide a good outcome for management of pneumonia, or a general hospital provide comparable quality at lower costs. 1.4 Hypothesis of the Study: H0: There is no significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). H1: There is a significant difference of the management of pneumonia between a universiry hospital (H-USM) and a general hospital (Penang-GH). 1.5 Aim of the study The aim of this study is to compare the management of pneumonia in a university hospital (H-USM) versus a general hospital (Pinanag-GH). 1.6 Objectives The objectives of this study are: To compare the incidence of pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the most common organisms associated with pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the drug therapy for pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). To compare the cost-effectivness of treating pneumonia at a university hospital (H-USM) versus a general hospital (Penang-GH). 1.7 Research Questions What are the difference between the organisms that is commonly associated with pneumonia at H-USM and Penang-GH? What are the difference between the antibiotics that is commonly used for the treatment of pneumonia at H-USM and Penang-GH? What are the difference between the outcome of treating pneumonia (mortality rate, length of hospitalization, pneumonia related symptoms at discharge and complications of pneumonia) at H-USM and Penang-GH? What are the difference between the cost of treating pneumonia at H-USM and Penang-GH? And how can these costs be reduced? What are the difference between the cost-effectivness of treating pneumonia at H-USM and Penang-GH? Do a university hospital (H-USM) provide good outcome for treating pneumonia or do a general hospital (Penang-GH) provide comparable outcome at lower costs? CHPTER 2 LITERATURE REVIEW 2.1 Community-acquired pneumonia 2.1.1 Introduction Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma that is associated with at least some symptoms of acute infection, a new infiltrate on chest x-ray or auscultatory findings such as altered breath sounds and/or localized rales in community-dwelling patients (Infectious Diseases Society of America 2000). It is a common condition that carries a high burden of mortality and morbidity, particularly in elderly populations. Although most patients recover without sequellae, CAP can take a very severe course, requiring admission to an intensive care unit (ICU) and even leading to death. According to US data, it is the most important cause of death from infectious causes and the sixth most important cause of death overall (Adams et al. 1996). Even though the mortality from pneumonia decreased rapidly in the 1940s after the introduction of antibiotic therapy, it has remained essentially unchanged since then or has even increased slightly (MMWR 1995 ). Furthermore, significant costs are associated with the diagnosis and management of CAP. Between 22% and 42% of adults with CAP are admitted to hospital, and of those, 5% to 10% need to be admitted to an ICU (British Thoracic Society 2001). In the US, it is estimated that the total cost of treating an episode of CAP in hospital is about USD $ 7500, which is approximately 20 times more than the cost of treating a patient on an outpatient basis (Lave et al. 1999). CAP also contributes significantly to antibiotic use, which is associated with well-known problems of resistance. In treating patients with CAP, the choice of antibiotic is a difficult one. Factors to be considered are the possible etiologic pathogen, the efficacy of the substance, potential side-effects, the treatment schedule and its effect on adherence to treatment as well as the particular regional resistance profile of the causative organism and the co-morbidities that might influence the range of potential pathogens (such as in cystic fibrosis) or the dosage (as in the case of renal insufficiency). It may be a primary disease occurring at random in healthy individuals or may be secondary to a predisposing factor such as chronic lung disease or diabetes mellitus. CAP represents a broad spectrum of severity, ranging from mild pneumonia that can be managed by general practitioners outside the hospital to severe pneumonia with septic shock needing treatment in intensive care unit. Depending on severity of illness, about 20% of patients with pneumonia need hospitalization and approximately 1% of all CAP patients require treatment in ICU. Elderly persons and those with underlying conditions, such as cerebro and cardiovascular diseases, chronic obstructive pulmonary disease (COPD) and alcoholism, are at increased risk for developing lower respiratory tract infections and complicated courses of infection. 2.1.2 Definition: Community-Acquired pneumonia (CAP) is defined as inflammation and consolidation of lung tissue induced by infectious microbes such as bacteria, viruses, or parasites. When the onset of symptoms and signs of this disease is before or within 48 hours after admission, it is considered as CAP (Bartlett JG et al., 1995). 2.1.3 Epidemiology Incidence: In the industrialized world, the annual incidence of CAP in community dwelling adults is estimated at 5 to 11 cases per 1000 adult population (British Thoracic Society 2001). The incidence is known to vary markedly with age, being higher in the very young and the elderly. In one Finnish study, the annual incidence for people aged 16-59 years was 6 cases per 1000 population, for those 60 years and older it was 20 per 1000, and for people aged 75 and over, 34 per 1000 (Jokinen et al. 1993). Annual incidences of 30-50 per 1000 population have been reported for infants below 1 year of age (Marrie 2001). Seasonal variations in incidence are also significant, with a peak in the winter months (Marrie 2001). The annual incidence of CAP requiring hospitalisation has been estimated at 1 to 4 patients per 1000 population (Marrie 1990, Fine et al. 1996). The proportion of patients requiring hospitalisation varies from country to country and across studies and has been estimated as ranging anywhe re between 15% and 56% (Foy et al. 1973, Minogue et al. 1998). Of those, 5% to 10% required admission to an intensive care unit (ICU) (British Thoracic Society Research Committee and Public Health Laboratory Service 1992, Torres et al. 1991). Conversely, about 8% to 10% of admissions to a medical ICU are due to severe CAP (Woodhead et al. 1985). Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world (WHO Statistical Information System (WHOSIS). WHO Mortality Database. Released: January 2005; Health, United States, 2005; Annual Report, Hong Kong, 2003/2004). Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone (Lynch JP, 1992). Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions,(National Hospital Discharge Survey, 1988) and about 50 000 people die as a result of community-acquired pneumonia (Farr BM et al 203). Bartlet et al (1998) found that viral infections have been associated with at least 10% to 15 % of CAP in hospitalized adults. Adult community-acquired pneumonia is a serious, life-threatening illness that affects more than 3 million people each year and accounts for more than half a million annual hospital admissions in the United States alone. Each year, more than 900 000 cases of pneumonia occur in the United States, accounting for nearly 3% of all hospital admissions, and about 50 000 people die as a result of community-acquired pneumonia. In the USA, community acquired pneumonia is the fifth leading cause of death in people over the age of 65 years and an estimated 60 000 seniors die annually. Most of the excess deaths and hospitalizations due to lower respiratory infections occur in older adults, as reflected by the more than 44 000 hospitalizations for pneumonia and influenza in people aged 65 and older in 1997 in Canada. It is estimated that the age-specific incidence of pneumonia increases from 15.4 cases per 1000 in those aged 60-74 years to 34.2 for those 75 years and older. Residents of long-term care facilities, a distinct subpopulation of elderly people, are at particularly high risk for developing nursing-home acquired pneumonia. Health costs for this sector are growing at an accelerated rate as the age of dea th increases. Thirteen percent of the population is over the age of 65 in the United States and this is expected to increase to 20% by 2030. In Canada, the proportion of individuals over the age of 65 is expected to rise to 20% in the year 2021. Presently, while making up 12% of the Canadian population, older adults account for 31% of acute hospital days and half of all hospital stays. To meet their health-care needs and alleviate the burden onthe health-care system, we must improve our understanding of the management and prevention of pneumonia in this age group. Elderly people constitute an ever-increasing proportion of the population. CAP has traditionally been recognized as problems that particularly affect the older individuals. According to western studies, the overall rate of pneumonia requiring hospitalization increase with age, from 1 per 1,000 persons in the general population but increases to 12 per 1,000 persons for those over age 75 years3. As the population of those ov er age 65 years is predicted to rise from its current level of 11% to 25 % of the total population in the year 20504, respiratory tract infection will assume a greater degree of importance to the overall public health. In Hong Kong, pneumonia was the fourth leading death from a specific diagnosis in 2001. A total of 3026 people died of pneumonia in 2001 which 1526 cases were male. Out of the 3026 deaths, 2794 patients were 65 or older which accounted for more than 90% of the total death. Pneumonia in the elderly population is a major cause of morbidity and mortality and in some series represents the leading cause of death. The annual cost of treating patients age > 65 years with pneumonia to be $4.8 billion, compared with $3.6 billion for those 85 years need help with bathing and 10% need help in using the toilet and transferring. The present of any or all of following identifies elderly persons at greatest risk for functional decline: pressure ulcer, cognitive impairment, functiona l impairment, and low level of social activity. The attack rate for pneumonia is highest among those in nursing homes. It is found that 33 of 1,000 nursing home residents per year required hospitalization for treatment of pneumonia, compared with 1.14 of 1,000 adults living in the community. Pneumonia is a major cause of morbidity and mortality worldwide. In the UK as a whole, pneumonia is responsible for over 10% of all deaths (66,581 deaths in 2001), the majority of which occur in the elderly. Community-acquired pneumonia (CAP) remains a common cause of morbidity. Because CAP also is a potentially fatal disease, even in previously healthy persons, early appropriate antibiotic treatment is vital. In Japan, pneumonia is the fourth leading cause of death, and from 57 to 70 persons per 100,000 populations died per year of this disease in the last decade. Community acquired pneumonia (CAP) is a leading infectious disease cause of death throughout the world, including Hong Kong, Pneumonia is the second most common infectious disease in Thailand. Whereas diarrhea is more common, pneumonia is associated with more fatalities. CAP remains the leading cause of death due to infectious diseases, with an annual incidence ranging 1.6-10.6 per 1,000 adult populations in Europe According to the Ministry of Health Malaysia (MOH), pneumonia is the 5th cause of death in Malaysia and the 4th cause of hospitalization. A prospective observational study by Jae et al (2007) of 955 cases of adult CAP in 14 hospitals in eight Asian countries found that the overall 30-day mortality rate was 7.3%. A prospective study by Liam CK et al (2001) of 127 cases of CAP in Malaysia found that the Mortality from CAP is more likely in patients with comorbidity and in those who are bacteraemic. A prospective study by LOH et al (2004) of 108 cases of adult CAP in urban-based university teaching hospital in Malaysia found that the mortality rate from CAP in hospital was 12%. 2.1.4 Syndromes of CAP The presence of various signs and symptoms and physical findings varies according to the age of the patients, therapy with antibiotics before presentation, and the severity of illness. Patients with pneumonia usually present with cough (>90%), dyspnea (66%), sputum production (66%% pleuritic chest pain (50%), and chills is present in 40-70% and rigor in 15%. However, a variety of nonrespiratory symptoms can also predominate in pneumonia cases, including fatigue (91%), anorexia (71%), sweating (69%), and nausea (41%). Metlay et al. (1997c) divided 1812 patients with CAP into four age groups: 18 through 44 years (43%), 45 through 64 years (25%), 65 through 74 years (17%), and 75 years or older (15%). For 17 of the 18 recorded symptoms there were significant decreases in reported prevalence with increasing age (p 37 °C at presentation. Crackles were present on auscultation in 80% of patients, and rhonchi in 34% to 47% (more common in the nursing home patients). About 25% had the physical findings of dullness to percussion, bronchial breathing, whispered pectoriloquy, and aegophony. Alteration in mental status was common. Marrie and coworkers (1989) reported confusion in 48% of the patients with nursing home-acquired pneumonia and in 30% of the other patients with CAP. Fine and colleagues (1998) define altered mental status as stupor, coma, or confusion representing an acute change from the usual state prior to presentation with pneumonia. This was present in 17.3% of the hospitalized patients. The decrease in symptoms with increasing age, tachypnea increased with increasing age (Metlay et al., 1997c). Thirty-six percent of 780 patients with CAP in the 18-44 year age group had tachypnea on admission versus 65% of the 280 patients who were = 75 years old. There were minimal differences in the proportion of patients with tachycardia and hyperthermia in the different age groups Pneumonia in the elderly are quite different from that in a younger population. These differences are due to age-related alterations in immunology, different epidemiology and bacteriology. It is important to remember that pneumonia in the elderly may report fewer respiratory signs and symptoms. The clinical presentation may be more subtle than in younger population, with more gradual onset, less frequent complaints of chill and rigors, and less fever. The classical finding of cough, fever, and dyspnea may be absent in over half of elderly patients8. Instead they may be manifest as delirium, a decline in f unctional status, weakness, anorexia, abdominal pain, or decrease general condition. The incidence of fever may decline with age, and the degree of fever appears lower in old population10. Tachypnea which respiration rate greater than 24-30 breaths per minute is noted more frequently in up to 69% of patients. Although rales are common and are noted in 78% of patients, signs of true consolidation are found in only 29%. Bacteremia, metastatic foci of infection and death are more frequent in older populations. As many elderly present with non-specific clinical symptoms and nonspecific functional decline that makes an accurate diagnosis difficult and may lead a life-threatening delay of diagnosis and therapy. Metlay et al. compared the prevalence of symptoms and signs of pneumonia in a cohort of 1812 patients and found that patients aged 65-74 years and over 75 years had 2.9 and 3.3 fewer symptoms, respectively, than those aged 18 through 44 years. The reduced prevalence of symptoms was most pronounced for symptoms related to febrile response (chills and sweats) and pain (chest, headache, and myalgia). These findings are consistent with those of Marrie et al. demonstrating reduced prevalence of non-respiratory symptoms among elderly patients. In a retrospective chart review by Johnson et al., the presence of dementia seemed to account for non-specific symptoms. However the sample size of the study was small and precluded a multivariable analysis. Roghmann et al found a significant inverse correlation between age and initial temperature in 320 older patients hospitalized for pneumonia. Evidence therefore does exist for a less distinct presentation of nonrespiratory symptoms and signs of pneumonia in the elderly. 2.1.5 Radiographic findings in CAP Radiographic changes usually cannot be used to distinguish bacterial from nonbacterial pneumonia, but they are often important for diagnosis of CAP, evaluating the severity of illness, determining the need for diagnostic studies, and selecting antibiotic agents. A chest radiograph usually shows lobar or segmental opacification in bacterial pneumonias and in the majority of atypical infections. Patchy peribronchial shadowing or more diffuse nodular or ground-glass opacification is seen less commonly, particularly in viral and atypical infections. The lower lobes are most commonly affected in all types of pneumonia. Small pleural effusions can be detected in about one-quarter of cases. Multilobar pneumonia is a feature of severe disease, and spread to other lobes despite appropriate antibiotics is seen in Legionella and M. pneumoniae infection. Hilar lymphadenopathy is unusual except in Mycoplasma pneumonia, particularly in children. Cavitation is uncommon but is a classic feature of S . aureus and S. pneumoniae infections. False negative results can be attributed to dehydration, evaluation during the first 24 hours, pneumonia due to Pneumocystis carinii, or pneumonia with profound neutropenia. 2.1.6 Etiology: More than 100 microorganisms have been identified so far as potential causative agents of CAP (Marrie 2001). They can be classified according to their biological characteristics as either bacteria, mycoplasma and other intracellular organisms, viruses, fungi and parasites. The most common causative agent of CAP is the bacteriumStreptococcus pneumoniae, which is implicated in 20% to 75% of cases of CAP (Marrie 2001) and about 66% of bacteremic pneumonia (Infectious Diseases Society of America 2000). Another causative bacterium is Haemophilus influenzae. So called â€Å"atypical† organisms have also been implicated as causal agents. These include Chlamydia pneumoniae, Mycoplasma pneumoniae and Legionella pneumophila (Marrie 2001). Influenza is the most common serio