Race, Tribalism, and Genocide in the Sudan - 648 Words

Jpz777 03/11/2013 Order # 2087938 1.) How were tribes in the Sudan formed differently from the way races were constructed in the United States? As is the case with the vast majority of nations which were conquered and colonized by the British during their reign of global imperialism, the Sudanese people of Africa experienced a rapid restructuring of its age old cultural identity system. Located in the Cradle of Civilization, a region straddling both the African continent and the Arab-speaking Middle East, Sudan has long been home to a diverse population that is representative of its many cultural influences, with Arab adherents of Islam living in relative stability alongside tribal bands of native peoples. Upon being co-opted as a British colony in the early 20th century to fuel a flailing textile industry, the fertile lands of Sudan were transformed into cotton plantations, thus beginning the insidious process of subjugating the Sudanese people through division and demarcation. The modern colonial scholar Mahmood Mamdani has observed that British colonial governance was about identity formation †¦ (because) the colonial political objective involved more than just redefining the relationship between colonial power and subject; it involved reshaping the very self-consciousness of the colonized, how they thought of themselves, their self-identity (Mamdani, 2009), and this concept of ensuring obedience through the removal and reshaping of identity lies at theShow MoreRelatedCritical Analysis of the Challenges Faced by Au in Achieving Continental Unity2727 Words   |  11 Pagesphysically, and economically, going beyond the material and affecting the lives of thousands of women, children, and men. AU therefore, came at a time when it was most desired. The African continent needed a powerful organ that cans unit different regions, races, tribes and people from different religious background and creed. AU has become the best hope that the African continent i s hanging its hopes on. There are a number of challenges that are facing the AU. One of the challenges facing the AU’s, is itsRead MoreOne Significant Change That Has Occurred in the World Between 1900 and 2005. Explain the Impact This Change Has Made on Our Lives and Why It Is an Important Change.163893 Words   |  656 Pagesgenerations to be among the processes that distinguish that era, not only from those proceeding it but from the rest of human history altogether. The essay by Gabrielle Hecht and Paul Edwards provides a nuanced interweaving of analyses of the nuclear arms race, debates over nuclear power as a major energy source, and the communications revolution made possible by computer technologies that did so much to shape the cold war standoff between the Soviet and American superpowers and the transition to a new

Evolution Of Lincoln s Policy On Slavery Essay - 1573 Words

Evolution of Lincoln’s policy on slavery in the United States. Abraham Lincoln was the great man of his generation just as well as he is considered a great man in history today. He made a huge difference that impacts us greatly today still. He is one of the main reasons to why we do not have slavery around anymore, along with some help of other people back then that supported him. Even though, racism still exist today it is not as horrifying and sickening as to how it was before back in the 1800s. Considering the fact that Abraham Lincoln ended slavery, in order to have achieve this he created many policies to permanently put slavery to a final end. Some of these policies were: The Gettysburg Address, the Thirteenth Amendment, Emancipation Proclamation, and so on. Slavery was a serious problem that needed a solution and he just so happened to be the type of man that never quit to achieve what he wanted or thought what was right until he achieved his goal. This is a great quality that he had and some of the reasons to why this man was and is gre atly respected and appreciated before and today. He detested how unequal African Americans’ were being treated by the people that supported slavery and thought it was the right thing because African Americans’ were only three-fifths of a person. He did not like how the people of the black race did not have all the rights as of the white race, which is why he created the thirteenth amendment. Abraham Lincoln would make speeches andShow MoreRelatedThe Struggle Of The Civil War1684 Words   |  7 Pagespublished in 1996. Mcpherson decided to split Battle Cry Of Freedom into five different parts and each of those parts tying back to his five themes established in the preface of the book. 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The Evolution1206 Words   |  5 PagesThe Evolution of Democracy in the Early Republic The evolution of democracy from the time of President Thomas Jefferson to President Andrew Jackson can be depicted as a minimal change in conceptually agrarian viewpoints and strong supporters of equality for the common man. While the two men essentially shared many of the same beliefs and ideas, there was a noticeable difference to how they acted on them and spoke out about them. As the nation s third president, Jefferson organized the national governmentRead MoreSummary : Does Freedom Ring? 1802 Words   |  8 PagesFreedom Ring? Mrs. Levin Belleville West Outline Intro Past issues Slavery Women Rights LGBT Minorities Unborn Conclusion Does Freedom Ring? America is known as â€Å"the land of the free and the home of the brave,† yet some people can object to this statement and say, ‘America is not free for me’! Our country’s history shows that freedom may not be free for all of us. With issues in our past, such as slavery, women s rights, and present-day controversies, i.e. the fight for equal rightsRead MorePolitical Parties And The Democratic Party2072 Words   |  9 Pagesrestore what is established and traditional, and to minimize change. This means that Republicans want a free market capitalism, limited government, strong national defense, opposing regulation and labor unions, and they support socially conservative’s policies. On the other hand, the Democratic Party was created in 1828 and is considered the oldest political party in the United States of America. The donkey symbolizes that Democratic people are smart and brave. The Democrats believe in social liberalismRead More The Reconst ruction of the Union After the Civil War Essay2103 Words   |  9 PagesUnion began under President Lincoln before the end of the war, and carried on by President Johnson after the assassination of President Lincoln. 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Outsourcing Trends Health Services Professionals Free Essays

string(108) " quality and bring the programs under local control to align the program with their own mission and values\." [pic] MGT 6220 – Health Care Human Resource Management Outsourcing Trends – Health Services Professionals Fall 2012 Research Paper Anthony Edens Thomas Grumley Outsourcing Trends – Health Services Professionals In today’s healthcare environment, hospitals are facing increasing pressure to reduce costs, increase efficiency and improve the quality of patient care. Although some of the details of the impending changes may not be perfectly defined, the industry is certain that changes are inevitable. Going forward, there will be an increased focus on quality; penalties for re-admissions, medical errors and hospital acquired infections (Buser, 2010). We will write a custom essay sample on Outsourcing Trends: Health Services Professionals or any similar topic only for you Order Now Several factors, such as aging populations, new treatments, low patient financial responsibility and misalignment of incentives have forced the Government to reconsider current Medicare reimbursement arrangements (Kaplan, Porter, 2011). For example, fee for service, which reimburses providers and hospitals based on the procedure performed, are not based on the desired outcome which should be good patient health. Therefore, the incentive for the provider could be to perform more of the higher reimbursement procedures and not to focus on decreasing the costs of business. Unfortunately, this has lead to a cycle of increasing costs for the government and payers, who are now looking for ways to decrease reimbursement and align incentives with quality while reducing re-admissions. Decreasing reimbursement will force hospitals that are not currently focused on cost control to rethink the existing strategies. In light of this, hospitals will need to concentrate on expense control, staffing productivity and service line efficiency. Crucially, hospitals will need to focus on effective alignment with physician practices and hospitalists. One consideration that continues to arise is whether to outsource certain functions from an employment model to one involving outsourcing, and one which will be discussed at length in the following pages. The current climate is signaling a clear increase in the trend to outsource a multitude of functions, for both large and small hospitals. In Modern Healthcare’s 33rd Annual Outsourcing Survey, 42 firms reported a 14% increase in the number of healthcare clients from 2009 to 2010. The following year’s survey, reported that among the top 20 outsourcing firms there was a reported 13. 1% growth from 2010 to 2011. The top 5 services which are currently outsourced are laundry, housekeeping, clinical/diagnostic equipment maintenance, hospital based emergency departments and food services (Kutscher, 2012). Additionally, the outsourcing of back office functions continues to increase. For example, firms providing accounts receivable functions reported a 21% increase in 2010 and firms providing medical record services reported a 6% increase in 2010 and an 8% increase in 2011 (Kutscher, 2012; Daly, 2011). Also related to the back office functions is effective revenue cycle management. When considering the tightening of the current and future reimbursement environment, the ability for a hospital to successfully collect monies owed and to reduce bad debt will be crucial. For example, in May of 2011, Conifer, a subsidiary of for-profit hospital chain Tenet Healthcare Corp. , Dallas announced that it closed on a deal to provide revenue management services to 56 hospitals (Kutscher, 2012). Another area of explosive growth is in the IT sector. Part of the reason is that there is a federal mandate which requires hospitals and physician practices to show â€Å"meaningful use† of electronic records. Not only are there financial incentives for implementing electronic health records early, there are financial penalties for those that have not implemented a system over the next few years. Robust growth can also be seen among the firms that provide diagnostic equipment maintenance. In Modern Healthcare’s 33rd Annual Outsourcing Survey, these firms saw 12. 6% growth from 2009 to 2010 and the following year’s survey showed a 16. % increase. This is due to the fact the medical equipment is growing increasingly more complex and that specialized firms are able to adhere to strict maintenance schedules, provide detailed documentation and track repair costs. One of the largest areas of growth is in the outsourcing of anesthesia services. From 2009 to 2010, the growth among survey respondents was 147% to a total of 2 22 contracts. One of the reasons for this is that anesthesia services can operate as a self contained unit within a hospital. This works more efficiently than if each physician would bring in their own team by providing both consistency and cost effectiveness. However, there are concerns regarding outsourcing hospital services. Reasons for hesitation among hospital executives can be corporate culture, patient privacy and regulatory compliance. There are definite security and compliance concerns related to the outsourcing of electronic medical records. For instance, while Indian insurance and pharmaceutical companies have had success, gaining market share from U. S hospitals may prove to be difficult. As soon as it leaves the confines of the U. S. , it’s not subject to the same rigorous laws as we are,† says George Conklin, chief information officer of Christus Health (Sharma, 2010). Here, we are going to focus on outsourcing the hospitalist and revenue cycle functions and show some of the advantages and limitations of each. The number of hospitals that have hospitalist programs continues to gro w, and today 2/3rd of all hospitals use a hospitalist program. Additionally, the demand for these providers currently outweighs the supply with a total of 31,000 covering the country’s demand of 40,000 (Buser, 2010). One of the reasons for this increasing demand is it allows those physicians with busy outpatient practices to concentrate on those practices and for the providers in the hospitalists programs to concentrate on the inpatients. Additionally, hospitalists can focus their attention to the details of inpatient management due to their more consistent practice patterns and expertise which all helps to reduce average length of stay and increase patient health and satisfaction. Hospitals can choose from either employing and managing the group of hospitalists directly or using a 3rd party vendor such as TeamHealth or EmCare to outsource the service. For instance, a hospital may choose to employ a group of hospitalists directly if it’s looking to ensure quality and bring the programs under local control to align the program with their own mission and values. You read "Outsourcing Trends: Health Services Professionals" in category "Papers" However, crucial to the success of this is effective leadership and expertise. In some instances, employing hospitalists directly may require abundant investment in IT systems and other tools which will require large amounts of capital dollars that some smaller hospitals may not have access to. In these instances a hospital may choose to outsource this function to take advantage of the large economies of scale and expertise a large vendor may be able to offer. For instance, in the article â€Å"Hospital Medicine’s Management Shuffle† by Bonnie Darves, Martin Buser, MPH, who is the co-founder of the hospitalist consulting firm Hospitalist Management Resources LLC, attributes the decisions to outsource to rapid growth of programs in which the hospital did not have the proper infrastructure and financial support to carry on with the program. Additionally, by outsourcing the practice the hospital reduces its regulatory risks as well as administrative and recruiting burdens. For example, in 2007 Hospital Specialists of Georgia, turned over management services to Cogent, a prominent and large vendor of hospitalist programs. At the time the group was handling a third of the medical center’s admissions and could not increase that without support. Without available capital, the company was not able to meet the growing demands of IT, especially as quality and performance measurement started to become more prevalent. (Darves, 2007). Using a 3rd party vendor whose expertise lies in focus and efficiency, and especially when combined with firms who bundle ED and hospitalist services, hospitals can reduce patient wait times and reduce the number of patients who leave the ER prior to triage or treatment. Ultimately this acts to increase the overall volumes of the hospital. Additionally, for 2012, CMS (Centers for Medicare and Medicaid Services) created two new critical measurements which measure, in minutes, the time from ED arrival to ED departure for patients admitted from the ED to the facility and from the admit decision time to the time of departure from the ED for patients admitted to inpatient status. Improving these times has a multitude of positive effects on the facility. For example, this can reduce the ED length of stay, increase the ED capacity, improve the admission process and ultimately improve the patient outcome. Conversely, some may argue that quality and alignment with the hospital are better achieved when providers are employed directly. For example, Kadlec Medical Center of Richland Washington decided that in 2006 it would discontinue its arrangement with a large vendor and bring its program in-house. The hospital wanted more control over the number of hospitalists as well as the scope and quality of services (Darves, 2007). However, the data suggests that quality does not suffer when outsourcing a hospitalist program. This is why we recommend outsourcing in the case of a hospitalist program. In a 2009 survey released by the Medical Group Management Association, the data shows that a hospitalist from a large vendor sees, on average, more than 19% more patients per day than a hospitalist employed by the hospital. Patrick Hays FACHE and C. Thomas Smith explain in their article â€Å"Why the Independent Hospitalist Practice is here to Stay,† that this does not imply an adverse effect on the quality of the healthcare, and is instead the result of a focused effort where other hospital assignments are not competing for attention. An increase in focus and expertise can lead to early detection and better diagnosis of disease which ultimately leads to less expensive and less complex treatments, and importantly, to fewer re-admissions. Outsourcing the hospitalist practice is also cost effective. A 3rd party hospitalist vendor can usually integrate its existing software with the hospitals and reduce training and orientation costs that could come with having to learn a new EMR system. In addition to IT and recruiting costs, there can also be costs associated with billing, accounting, legal, regulatory, marketing and quality control. Should a hospital choose to employ the physicians and experience rapid growth without the proper infrastructure, these costs can quickly deteriorate the earnings of the group. Regulatory and legal costs can be especially problematic. For instance, Stark and Anti-Kickback Laws limit what a hospital can pay to an employed physician and require that each contract be put under scrutiny to ensure fair market value scrutiny to guarantee there are no conflicts of interest between the physician, hospital and patient. To make certain a hospital is not violating these serious and complex laws, it would need to employ and increase its legal department’s infrastructure to include a department specifically designated to physician contracts, a cost many small hospitals may not be able to afford. With so many reasons for a hospital to use a 3rd party vendor, hospitals may become increasingly interested in avoiding the employment model. John Donahue, CEO of Cogent HMG expects a â€Å"dramatic ramp up of hospitalist consolidation† in the coming years because of the new quality requirements the government is demanding the hospitals meet. The large hospitalist companies already have effective ways to measure this as well as reduce length of stay and complications resulting from hospital stays (Robeznieks, 2012). Another step firms are taking to convince hospital executives that outsourcing is the right choice is using local contractors and simultaneously offering a national support model. For example, Radisphere, an Ohio based radiology outsourcing firm, uses local radiologists who work with a network of offsite subspecialists offering continuous access to consultations. In summary, outsourcing hospitalist services can provide hospitals, large and small, a cost effective and efficient means to provide quality patient care. With an ever increasing focus on quality, using a group focused physicians with hospital expertise who do not have competing private practices can increase patient satisfaction, increase hospital capacity and volumes all while helping the hospital achieve its goals while creating and maintaining a good quality reputation in the community. Let us not forget, however, that the presence of Human Resources should be critical in this decision. The head of Human Resources needs to understand the dynamics of the business and the challenges that lay ahead should the company choose to outsource an existing function or in-source a function currently delegated to a 3rd party firm. For instance, if a decision is made to outsource an existing department there will need to be a roadmap for the existing employees. Ask questions such as, â€Å"Will there be a severance package or can these employees be transitioned or transferred to open positions in other areas of the company? Furthermore, there needs to be discussions regarding the reliability of the outsourcing firm and a contingency plan should the firm go out of business or discontinue the relationship. Are there alternative companies that could provide similar services if this situation were to arise? Will the chosen firm be able to meet the projected volume needs to the hospital? Additionally, even if the hospitalist function is outsourced, communication from management and H R will remain important so that those in these new positions still feel supported and motivated. HR needs to work closely with the firm providing the services so that boundaries, objectives and targets are clear. In a situation where an outsourced function is brought in-house, HR needs to ensure that the current management infrastructure can accommodate the new positions. Especially in the case of employing hospitalists, contracts as well as compensation and benefit packages need to be created. Another example of where opportunities lie for outsourcing departments is in office functions such as revenue cycle management. In recent years, hospitals have steadily warmed to the idea of outsourcing functions which were previously kept in-house, such as business processes and information technology. However, a host of factors–including the passage of the Patient Protection and Affordable Care Act, the faltering economy and the increasing emphasis on quality and performance improvement–have pushed that trend into overdrive (McKinney, 2010). In order to remain competitive and stay afloat, hospitals and other healthcare organizations are desperately looking deeper into business functions to determine the areas that may be better off outside the walls. Faced with a potential flood of new patients and lean budgets, hospitals are carefully considering each department to determine which functions can be turned over to contractors, and more areas are fair game than ever before†, says Reggie Hill, a partner at Waller Lansden Dortch Davis, Nashville (McKinney, 2010). Although housekeeping, food services, and diagnostic equipment maintenance are among the most common outsourced services, revenue cycle management is becoming increasingly popular. Because of the perception that there will continue to be cuts in reimbursement and new reimbursement models, hospitals are looking for ways to cut expenses and maximize revenue,† Hill says. â€Å"If an outsourcing agreement looks like it will accomplish those goals, it’s going to be something a hospital will want to take advantage of. † In particular, there has been continued growth in the number of organizations that are seeking out revenue-cycle management services, Hill says. â€Å"There are vendors that have shown they can add value, and more hospitals are giving it a try† (McKinney, 2010). Although more organizations are looking into the use of a vendor, it is important to consider all variables before determining the best option. Outsourcing the revenue cycle function does not fit all business models. Factors such as practice size, legal compliance, training ability, cost savings, quality, and efficiency should be studied carefully in order to realize the maximum return on investment. Companies that fit the outsourcing model and execute the transition properly can realize the greatest rewards. Conversely, outsourcing may be the downfall of an organization if these factors are not considered. When a company commits to outsourcing, cost savings tend to dominate and labor rates are a large contributing factor. In search of satisfaction, many companies are looking to offshore vendors. Offshore outsourcing companies might save hospitals even more money in labor costs because employees in countries such as India often work for much less money than U. S. staffers (Mantone, 2003). Managing a department outside of the organization’s walls has its other cost saving advantages. Having fewer internal employees reduces the need for back office space which will generate savings in rent. With a billing service, billing and collection activities occur off-site and therefore it may be possible for a hospital to reduce its current overhead costs or convert existing office space to a revenue generation, patient services area (Schechter, 2000). Furthermore, cost savings with outsourcing may also be realized in more subtle ways such as an adaptation of superior processes. The demand for standardization in revenue cycle management is on the rise. Despite growth in the industry, the floundering economy has made some providers skittish about first-time outsourcing deals†, Zambuto says. Another motivating factor that is convincing many to take the plunge is the need for standardization, he says. Outsourcing to a vendor can help ensure processes are done the same way each time at every location, which reduces the probability of errors, he says (McKinney, 2010). With this standardization comes an increased revenue flow. Many companies are careless with collections and spend unnecessary time, money, and resources on correcting mistakes. Re-billing and managing overpayments can become costly due to the increased hours of operation and additional wages paid to employees working these claims. If the billing can be done quickly and accurately the first time, these costs will not have to be wasted in order to generate the same amount of revenue. For example, Marshall McHenry, MD, a Cincinnati internist, chose to outsource billing when he started his own private practice. â€Å"He pays an outside billing service 6% of collections or about $20,000 to $22,000 annually, he said. In contrast, an in-house biller would have cost $30,000, including benefits, and a billing system would have cost several thousand, if not tens of thousands of dollars, Dr. McHenry estimates. Also, had he hired a biller, he would have had to factor in training and vacation time, and figure out how to avoid down time that could have seriously hurt his practice† (Chin, 2003). Additionally, this higher level of quality requires ongoing employee training which may become not only time consuming, but expensive. The billing service is responsible for hiring, training and supervising staff. They also are responsible for coverage when any of their employees are out of the office. And they are responsible for acquiring and maintaining all necessary computer software and hardware as well as addressing other technology-related issues (Schechter, 2000). The relief of these burdens will allow management to focus more on its core competencies. Typically, a revenue-cycle outsourcing firm takes over some or all of a hospital’s business office functions, which can include everything from patient registration, accounts receivable, billing and coding. They consolidate those functions into larger offices that serve many providers. The end result, outsourcing companies say, is a more efficient model that leaves more operating revenue for hospitals. Those types of business arrangements will likely continue as cash-strapped hospitals see the potential for big savings, says Dean William Harvey, a partner at the law firm Vinson Elkins in Dallas (McKinney, 2010). Richard Garnick, chairman and CEO of Anthelio Healthcare Solutions, credits the â€Å"incredible† cost pressures on hospitals for the growth in his company’s revenue-cycle management services. In the case of federal healthcare programs, Garnick has seen his client hospitals grow increasingly concerned that possible across-the-board cuts to Medicare and Medicaid could push them into the red. Those concerns have led some of Garnick’s core clients at community hospitals to replace their in-house back office staff with his employees to reduce the cost of those functions by 30% to 35%. â€Å"That gap will potentially allow that hospital to survive,† he says about one recent client (Daly, 2011). Success with outsourcing has also been achieved by Marc D. Grobman, DO, a solo internist at Internal Medicine and Primary Care in Wilmington, DE when he chose to use Health Care Practice Management Inc. as a billing service. He says he is getting 98% of money due compared with 75% when he was part of the hospital network. â€Å"At first using a billing service was a virtual necessity. Now I see no reason to bring it in-house because it’s working out so well,† Dr. Grobman says. He also thinks he gets more expert billers through outsourcing, which in turn means he leaves less money on the table. Dr. McHenry contends that he gets about 10% more — $35,000 to $40,000 a year — than he would have had he hired someone to handle billing. Because it’s a specialized skill, it can be hard to find good billers in the local labor pool, he added (Stevens, 2007). On the contrary, outsourcing does have its drawbacks, and most notably, a reduced sense of control is inevitable. Outsourcing firms are responsible for these functions which prevents the hospital from easily maintaining close management of operations. â€Å"The downside is you can lose control,† said Louis Korman, MD, one of Dr. Weinstein’s partners. â€Å"You can be taken. There are a lot of people who think that doctors’ practices are just money mills they can take advantage of† (Chin, 2003). Additionally, an absence of direct management may result in poor customer service. Third party billing firms may be required to deal with patients directly and it is difficult for the hospital or physician practice to monitor this interaction closely. Many physicians believe that they are able to maintain better relationships with patients when billing functions are kept in-house. Without this strong patient – provider relationship, a healthcare organization may not be able to survive. Moreover, a third party revenue cycle management firm may not hold the same work ethics as the healthcare entity which may result in subpar performance. A vital piece to the success of any billing department is legal compliance and these performance standards must be met. But revenue management outsourcing has its share of pitfalls, most notably legal compliance, he adds. Providers need to be confident in a contractor’s ability to manage the billing requirements of Medicare and other programs, while successfully complying with the Health Insurance Portability and Accountability Act of 1996 (McKinney, 2010). Dissatisfaction with an outsourcer’s performance led Detroit Medical Center in February to sue to dissolve a 10-year, $300 million contract with Provider HealthNet Services, Dallas. Detroit Medical said the outsourced operation failed to achieve timely completion of medical records and had not delivered on a plan to train employees and organize the department for computerized records. Provider HealthNet said uncooperative and obstructive action by Detroit Medical officials caused the performance problems (Morrissey, 2003). A company’s decision whether or not to outsource a department will inevitably require the presence of Human Resources. One advantage of outsourcing the revenue cycle management team is the distance that it creates between management and the frontline employees. In some cases, this disconnect is desired by the hospital because it relieves the duty of having to deal with employee issues. If an employee of a hospital is not performing, the management team will have to carefully follow HR policies and document progression of failing performance before termination may occur. This can not only be time consuming, but it can hinder productivity until the change may be made. Utilizing a vendor will allow the hospital to simply request that a replacement be made for a certain employee without having to follow any HR policies. â€Å"While the net cost of farming out billing is unknowable, Dr. Schwartz does believe that whatever it is, it’s worth the peace of mind it gives him. † An outsource service insulates us from the kinds of problems that could get us into financial trouble,† he says. There are some advantages† to not having him on staff, Dr. Weinstein said. â€Å"The biggest one is that if he’s not doing a good job, I don’t have to worry about firing him. I just have to say to the company, ‘Hey, this guy is not doing a good job. I want somebody else. ‘ They have to worry about firing him, and firing high-level people is not easy to do† (Stevens, 2007). Although some hospitals may find this Ã¢â‚¬Ë œpeace of mind’ to be worth a potential added cost, there are some disadvantages that an HR department may face with outsourcing a business function. Whenever a hospital chooses to outsource a department or other function, it will unavoidably have to endure a layoff of some magnitude. A layoff or employee termination will most certainly involve a strong HR presence. No matter the level of expertise of the HR department, this process is never easy to manage. In some cases, a layoff may be necessary involving employees who have been part of an organization for years. Relationships have developed between the employees and management team which can make this event even more difficult. However, if the business decision to outsource is made, many times a layoff is most likely unavoidable. Additionally, this will create a loss of jobs in the community. â€Å"Also it can be a â€Å"hard sell† because outsourcing hospitals are â€Å"taking jobs from the local community and putting them elsewhere,† Johnston says. â€Å"It’s not that big of a deal when the office has 10 people,† he says. â€Å"But when there are 100, 200 people in the office it becomes a big deal† (Mantone, 2003). This event can also create a negative image for the hospital which may not be beneficial for its reputation. This challenge must be closely managed by the HR department. In conclusion, outsourcing can be an effective way to increase the efficiency and lower the costs of an organization. In the case of using a 3rd party hospitalist firm, it uses a focused group of physicians who not only help to decrease costs but improve patient care and decrease re-admissions. Also, with improved patient care there comes a decrease in the average length of stay which is obviously great for the patient but also enables the hospital to increase its capacity for additional patient services. It can be advantageous to a hospital to use a 3rd party outsourcing firm so long as the goals and expectations are clearly outlined and defined within the contract terms with the firm providing these services. Another example of an opportunity to take advantage of the focus of a 3rd party firm is in the realm of the revenue cycle function. Advantages such as decreased overhead costs, increased expertise and augmented standardization are ways in which a hospital can improve its overall collections, decrease its net accounts receivable days and lower the amount of money spent to do so. Outsourcing does not necessarily imply going overseas, as mentioned in the hospitalist example above, patient care mostly depends on human interaction in most services and so the local community economy remains intact. In the end, HR needs to be well versed in the goals of the company and be able to contribute to the decision by offering perspective on future labor needs, compensation and benefit costs or savings and strategic alignment with the hospital’s strategies and mission. â€Å"References† Buser, M. , (2010, December). Hospitalist Programs in the Age of Healthcare Reform. Journal of Healthcare Management, 55:6, 378-380. Chin, T. , (2003, August 11). The Doctor is Outsourcing: To Hire or Not to Hire. American Medical News, Retrieved November 15, 2012 from http://www. ama-assn. org/amednews/2003/08/11/bisa0811. htm Daly, R. , (2011, September 5). Under Pressure. Modern Healthcare, Vol. 41 Issue 36, S1-S4. Darves, B. , (2007, May). Hospital Medicine’s Management Shuffle. Today’s Hospitalist. Retrieved November 10, 2012 from http://www. todayshospitalist. com/index. php? b=articles_readcnt=64. html Hays, P. , Smith, C. Thomas. , (2010, October). Why the Independent Hospitalist Practice is here to Stay. Physician Future. Retrieved November 18, 2012 from http://www. physicianfuture. com/news/physician-news/why-the-independent-hospitalist-practice-is-here-to-stay. html Kaplan, R. , Porter, M. , (2011, September). How to Solve the Cost Crisis in Health Care. Harvard Business Review, 48-49. Kutscher, B. , (2012, September 3). Expertise on Call. Modern Healthcare, Vol. 42 Issue 36, 20-27. Mantone, J. , (2003, November 24). Letting Someone Else Do It Better. Modern Healthcare, Vol. 33 Issue 47, S10 McKinney, M. , (2010, September 20). Outsourcing Sees Stimulus Effect: Health Reform, Ailing Economy Prompt a Closer Look at Use of Contractors. Modern Healthcare, Vol. 40 Issue 38, pS1-S5, 5p. Morrissey, J. , (2003, May 12). Not Paying Off: Baylor, EDS Terminate Revenue Management Deal. Modern Healthcare, Vol. 33 Issue 19, p3, 1/2p. Robeznieks, A. , (2012, April 2). Partnering up: As Consolidation Begins to Sweep through Healthcare, Hospitalists Expect to See the Trend Accelerate in their Sector. Modern Healthcare, Vol. 42, Issue 14. Schechter, K. , (2000, July 24). Compare Costs, Benefits of Billing Service vs. In-House. American Medical News, Retrieved from http://www. ama-assn. org/amednews/2000/07/24/bica0724. htm Sharma, A. , Worthen, B. , (2010, November). Qualms Arise Over Outsourcing of Electronic Medical Records. The Wall Street Journal. Retrieved November 29, 2012 from http://online. wsj. com/article/SB10001424052748704865104575588252907738276. html Stevens, L. , (2007, April 16). The Ins and Outs of Billing: Pros and Cons of Outsourcing. American Medical News, Retrieved November 15, 2012 from http://www. ama-assn. org/amednews/2007/04/16/bisa0416. htm How to cite Outsourcing Trends: Health Services Professionals, Papers

Analysis Of Maltese Falcon Essay Research Paper free essay sample

Analysis Of Maltese Falcon Essay, Research Paper I don t remember if Gutman said it in the film about the Falcon being coated by lacquer to obfuscate that it s truly made of gold and gems. I think it was implied that nil is what they truly seem to be. This is what I believe Dashiell Hammett was seeking to pass on through his novel, The Maltese Falcon. In this paper I will compose about why I believe what is Hammett seeking to convey through his dramatis personae of characters. These characters are unlike the image and stereotype dramatis personae upon their functions. Sam Spade International Relations and Security Network T precisely the typical ( stereotyped? ) chief character or instead a detective character ( I think for any chief character. ) By his looks/appearance, He [ Spade ] looked instead cheerily like a blond Satan ( p. 3 ) . Proposing he is non beatific looking like Lashkar-e-Taibas say Humphrey Bogard ( an indicant that the film isn T true to the novel ) . The movie ruined the dry un-charming hero concept the novel have and so make I as one of my first illustration of the things-are-not-what-they-seemed-theory-for-Hammett s message. Spade is indurate, covetous, and portions a similarity with Mike from The House of Games. Why I think Mike and Spade are similar? For one thing Brigid O Shaughnessy gave Spade a talk/speech about him utilizing her reasonably much the same thing Ford asked Mike in the airdrome. Brigid s remark ( p. 211-212 ) You ve been playing with me? Merely feigning you cared-to trap me like this? You didn t-care at all? You didn t-don t-I-love-me? Ford s You used me # 8230 ; address is strikingly similar to Brigid s including the reaction from Mike/Spade. The two work forces both refused to demo sympathy and they did both had sex with their respective victims # 8230 ; er adult females except Mike ends up dead and Brigid ends up in gaol. Ford and Mike and Spade and Brigid portion many similarities from the two adult fe males being used and the work forces victimizing these adult females. We know what Mike did already and Spade used his diabolic appeal to acquire Brigid to work out the instance. He conned her into giving him money, win his trust, and played with her feelings. The comparing between Mike and Spade is to demo that Spade is more of a con work forces than a detective which I hope are ( normally ) depicted as observant, straight-arrow, gentlemen. Spade is a proto-badass character. I think Hammett is seeking to convey that heroes aren t ever good. Brigid O Shaughnessy ( whom I will mention as Brigid because her last name is long ) is a complex character in which that she appears to be a typical damsel-in-distress but say to be a beautiful and unreliable adult female whose truenesss shift at the bead of a dime. ( backcover ) Yet Brigid is demure and gentle throughout the novel. In the film nevertheless she seemed blunt unlike her really diffident fresh opposite number. She was less diffident in the film and she said why she needed Spade and Archer s aid right off wereas in the novel she said Could you- ? I thought-I-that is- quietly. I think due to the adult females s motion that happened late so they decided to do Brigid less diffident. Brigid s character is unlike the usual damsel-in-distress femal e function though she her idiosyncrasy is. Brigid s not damsel-in-distress features are elusive. Brigid s unreliable Acts of the Apostless were mentioned but she was neer shown moving it outright. These Acts of the Apostless were besides obscure that it hardly makes you believe of Brigid any lupus erythematosus. When I read the book I didn t see how Brigid is unreliable. Brigid lied but that doesn T seem unreliable at all possibly because I think it was written in a manner as if she is stating a bantam white prevarication. Her so called perfidy are obfuscated by her demure idiosyncrasy as if to soften them. In the terminal of the novel/film when she revealed that she killed Miles she said it in a manner that it was an guiltless accident and goes on with her You used me†¦ address to do it look like the victim. Brigid s lines were written in a manner they it makes her look exploited and regretful that we are inclined to be sympathetic of what a anguished psyche she is that we can t aid but non recognize that she is a manipulative enchantress! I must state that Brigid is a good written character. Hammettt wrote her in a manner that we the reader think she is what she is: a hapless victimized miss when she is truly subtly pull stringsing our judgement of her, doing us believe she s inexperienced person. That s really unreliable! Casper Gutman is really much like Santa Claus in a manner that he seems reasonably and quiet all the clip. Gutman neer lost his pique one time but even if he did his face ever stayed reasonably. In my sentiment Gutman is the supporter of the novel/film because he is the originator of the whole black bird caper. He has deadly subordinates: Wilmer and ( possibly ) Cairo. Gutman doesn t seem like a bad cat because of the manner he s portrayed as Santa-like. It seems like he is the antonym of spade. Spade is the good cat who looks bad and Gutman is a bad cat who looked nice. I think Hammett neer truly established who s good and bad. Gutman neer threatened Spade with his life to acquire the falcon. Gutman hired Spade and Spade merely didn t agree with them that much. So Gutman is non precisely an adversary. I don t even think there is an adversary who try to do the supporter s life snake pit except possibly Dundy. Dundy nevertheless isn t the bad cat but the cat who doesn T trust a shady character which is typical presents in narratives with a supporter like Spade. In decision, I think Hammett wants us to recognize that everything International Relations and Security Network t black and white, there are sunglassess of grey or so the expression goes. Not all good things are good and non all bad things are bad. Meaning we can t merely based everything with stereotypes and visual aspects for they are lead oning. Through it all it s how good or bad a individual is inside that determines whether they are so good and bad. This nevertheless can non be seen, you ll have to cognize this individual before you can happen out. Spade seemed indurate as I said but he has a devoted trueness to Miles. He didn T show he cared for Miles but he did in the terminal when he put his feelings for Brigid aside to convey his spouse s slayer to justness. Of class Spade besides did this because he doesn T privation to be Brigid s sap but like I said nil is clear.

A comparison and contrast whether Aunt Sylvie would raise the girls better or the state in the the novel Housekeeping, by Marilynne Robinson. Includes three intext citations and 3 works cited.

A comparison and contrast whether Aunt Sylvie would raise the girls better or the state in the the novel Housekeeping, by Marilynne Robinson. Includes three intext citations and 3 works cited. Matthew S. BurkholderMrs. Cindy LaCom4/5/2005The novel Housekeeping, by Marilynne Robinson, takes place in the fictional town of Fingerbone. Fingerbone is a dreary little town that is prone to flooding and misfortune. The story begins by explaining how their grandfather was killed in a train wreck. More hardship comes when their mother borrows their neighbor's car and drives it off a cliff. After their mothers suicide Lily and Nora come to help raise the main character Ruthie, and her sister Lucille. Not soon after the grandmothers feel they are ill suited to raise two young girls and send for their Aunt Sylvie to come live with them. The girls soon discover their aunt is a lot different than the average resident of Fingerbone. She has an unnecessary supply of newspapers and tin cans, and she doesn't like to turn the lights on in the house. She also adopts a number of stray cats and takes a midday nap on a park bench in town square.English: Ruthie Foster @ Liri Blues 2010 Italiano:.. .Even stranger she carries crackers in her pocket for the make-believe children in the woods and disappears into the mountains for days at a time. Her lack of responsibility has a splitting effect on the sisters own relationship. Ruthie is a tall and awkward teenager. She never seems to fit in at school, and badly wants to follow Sylvie's free-spiritedness. But the younger Lucille wants stability and has the need to belong. Lucille tries to help her older sister change, but is met with resistance from Ruthie. Lucille decides she has had enough and goes to live with a teacher from school. Unfortunately the townspeople of Fingerbone this that Aunt Sylvie is a bad influence and that she should get her act together. But Ruthie and Sylvie cannot conform, and so they...

Marx on Class. essays

Marx on Class. essays The propertied class and the class of the proletariat present the same human self-alienation. But the former class finds in this self alienation its confirmation and its good, its own power...the class of the proletariat feels annihilated in its self alienation, it sees in its own powerlessness... This extract is taken from Karl Marx, The Holy Family (1845). It was written at a time of upheaval in Karl Marxs life. Just after he was editor of the Rheinische Zeitung at Cologne in 1842. He worked there until his extreme radical views led to the suppression of the paper, and Marx went to Paris, where he met Engels and collaborated with him in works of political philosophy. Engels was a (German philosopher) the son of a factory owner who, went on to supervised his father's business in Manchester and wrote influential essays on the social and political conditions in Britain in the 1840s, including The Condition of the Working Class in England (1845), that influenced Marxs work on class at the time. Other influences at the time would have been Feuerbach on whom he wrote a thesis on in 1845. Feuerbach had a materialistic out look on history. He held to the philosophical theory that only physical matter is real and that all phenomena and processes can be explained by reference to it. Related to this is the doctrine that political and social change is triggered by change in the material and economic basis of society. Also Hegel, Marx also based his theory of dialectical materialism on Hegel's work such as The Phenomenology of Mind (1807), which describes the progression of the human mind from consciousness through self-consciousness, reason, spirit, and rel igion to absolute knowledge although he later then rejected aspects of the philosophy claiming it was to abstract. In the gobbet statement Marx is saying that the property owner class (the aristocracy, the upper class) and the class of the masses (the working cl...

Traveling to Foreign Country Essay Example | Topics and Well Written Essays - 750 words

Traveling to Foreign Country - Essay Example This has given me a different perspective on traveling to a new land. The anxiety that I felt upon moving to America mostly centered on my children. As an adult, I knew that small changes could be dealt with and that time tends to heal most wounds. But my anxiety for my children was immense. I did not want them to be at a disadvantage because they were new in this country. I wanted them to learn the language and social skills they would need to be successful. I needed to find work right away, so that meant finding a good day care for the children. As I approached the first day care center that would grant me an interview, my heart was pounding with nervousness. I had faced much more stressful situations in my homeland, but so much was weighing on this decision. At least that is what I thought at the time. The large brick building was a Christian church that had a day care center on the bottom level. Entering the day care center door, I could smell the strong smells of plastic and dis infectant. Janice, the director greeted me warmly. She shook me by the hand and spoke very loudly and slowly. Too loudly. I immediately felt dumb and wondered if I had made a good choice. As it turns out, Janice was a lovely person. She gave me a walking tour of the day care center, where children of all colors were engaged in play. Everything was neat, clean and child sized. The workers were playing with the children. Janice stopped talking so loudly when I made it clear through my speech that I was OK at understanding English. By the end of my visit, I no longer felt dumb. My children were enrolled in a day care center that was clean and affordable. Janice became the first friend I made in America. My anxiety concerning my children slowly began to slip away. My next task was to purchase transportation for my family. This experience left me confused and not nearly as satisfied as the day care experience. Actually, in many ways the experiences started in a similar way. I entered a b uilding full of conflicting smells. Walking into the dealership, I could smell an odd combination of roasting hotdogs, coffee, motor oil and the unmistakable smell of tires. The food odors came from a lounge area inhabited by noisy children and bored parents waiting to have their cars serviced. The other, more expected smells were from the cars in the showroom. Lawrence, the salesman greeted me and began talking very fast. He wanted to know about my family, my job, my homeland and me. He thought it was wonderful that I had just moved to America, explaining his parents had moved from Belgium when he was a small child. Finally, he started to talk about cars. I told him the amount of money I could spend but he said that was not the most important consideration. He explained that in America, cars were more than transportation. He said cars are a way of telling people about you. I honestly did not understand what he meant. He continued this way for some time, talking fast and showing me one bright, shiny car after another. I began to grow impatient. I had not come to look at cars I could not afford. I just needed to find a car that could get me to work and the kids to day care. Finally, I let Lawrence know that I was running out of time and I needed to see some cars I could afford. He began to talk about how easy the financing was and how low my payments could be each month. Every figure he suggested was more than I could afford. Lawrence grew persistent when I gathered my

Organisational Behaviour and Human Resource Management BEM2004 Essay

Organisational Behaviour and Human Resource Management BEM2004 - Essay Example It makes every effort to ensure that its products are preferred by consumers and that its public relations are accomplished without difficulties. Ethical business practice prolongs the life of an organization and promotes consumer satisfaction among other stakeholders. This paper evaluates whether business ethics is an oxymoron justifying the arguments through ethical theories that include; virtue ethics, deontology, utilitarianism and Marxism. Business Ethics Businesses are compelled to remain flexible due to the inconsistency of the contemporary operating environments. Each competitor strives to acquire a greater market share than other players, which sometimes leads to negligence in regard to corporate ethics. Various situations require to be dealt with differently and sometimes managers are perplexed regarding what business ethics necessitates in certain circumstances. In some instances, acting morally may be costly or may be hindered by obstacles. For these reasons, Velasquez (2 002) observes that referring to ‘business ethics’ as an oxymoron precisely identifies ethics as a challenge. On the other hand, as presented in the definition of ethics, if an organization is to remain ethical in its operations, it has to observe the laid out values and principles. In other words, no matter how pressing the situation is, ethical values have to be adhered to for business ethics to be accomplished. In essence, many organizations avoid being perfectionists in business ethics even though they insist on ethical standards when dealing with stakeholders. This makes them escape the unintentional negative consequences of fanatical business ethics (DesJardins, 2008). Various ethical theories portray business ethics as an oxymoron. For example, virtue ethics is a theory that sheds light on the boundary between balanced decision making and unethical behavior in business (West, 2003). Sometimes financial managers are faced with the dilemma of determining the appropr iate step to take when the business is faced with challenges, yet the set business values have to be adhered to. The right decision that may save a company from collapsing may be regarded as unethical in a different perspective if the common values are not observed. Rather than being restricted to a set of conceptual rules, a manager maintains his/her professional role and appraises an ethically thought-provoking decision within that role. In other words, he/she is not bound by what is believed to be ethical while acting for the good of the organization (Maximiano, 2003). For instance, the finance director in a company X realizes that the organization will incur losses owing to an abrupt change in exchange rates. The company maintains corporate social responsibility and runs a philanthropic community program which is among its core values that costs 10% of its proceeds. The manager is faced with the dilemma of suspending the program to minimize the company’s expenditure or to retain the program. The first alternative will lead him to disregard the company’s ethical values. However, as a professional, his work is to ensure that the company does not incur a loss. The manager has to make an ethically charged decision and suspend the program until the operating environment regains normalcy. According to virtue ethics, he will be regarded as a good manager due to his intelligence that helps in maintaining efficiency and profitability, while on the other hand he is

Payola Essay Example | Topics and Well Written Essays - 500 words

Payola - Essay Example Payola goes back to the 1920s and the days of vaudeville and continued through the 1940s with the big band era (Hornberger). Paying a station to play a record was legal as long as the disc jockey notified the listeners that the airtime was purchased. This was often overlooked for decades until the era of rock and roll. Up until 1950, the American Society of Composers Authors and Publishers (ASCAP) controlled nearly all the music in the dancehalls, hotels, radio, and theaters. Their offices were in New York City and the directors had total control of the content. They would not allow membership for 'black' or 'hillbilly' artists (DiMaggio 608). Several networks split from ASCAP due to their rates and racist policies and in 1939 they formed Broadcast Music Inc. (BMI). After World War II BMI set about signing the black and hillbilly artists that ASCAP had refused to work with. This core of musical outcasts would form the genesis of rock and roll. Teenagers were hungry for rock and the 45-RPM record made it accessible. By the early 1950s major BMI labels were turning out 100 new singles a week (Cartwright). DJs, suffocated with new recordings, would be paid by the record companies to promote a record. This was nothing new or unusual in the business.

Case Study On A Patient With Pulmonary Tuberculosis

Case Study On A Patient With Pulmonary Tuberculosis The case that is about to be discussed here revolves around a patient diagnosed with pulmonary tuberculosis. The patient that was clerked, Mrs A, was a 61 year old woman. She was a Malay housewife. Her Body Mass Index value of 26.0 kg/m2 based on her height of 1.58 m and weight of 65 kg indicated that she fell into the overweight range. The patient was admitted to the Accident Emergency mode transferred in from another hospital via an ambulance. She presented symptoms such as shortness of breath(SOB) and her respiratory rate was 20 breaths per minute. She appeared pale and weak and her blood glucose levels were low (2.1 mmol/l) and her blood pressure values indicated she was hypertensive with a value of 152/93 mmHg. Upon physical examination, mild leg swelling was observed. Based on her past medical history, patient was diagnosed with pulmonary tuberculosis for the past 3 months, hypertension for the past 5 years, diabetes for the past 5 years and advanced renal failure for the past 6 months. Upon enquiry, she was seen to be a non-smoker and a non alcoholic. Patient lived with her daughter. Several investigations were performed to evaluate the patients condition. A positive sputum smear test indicated that the patients tuberculosis was still active. Upon renal function assessment, creatinine clearance was calculated and a value of 5.5 ml/min indicated Stage 5 renal failure. Her potassium and urea levels were also above range based on Table 1. Upon haematology assessment, her low blood sugar levels indicated hypoglycaemia and patients haemoglobin count was also low signifying anemia. Chest X ray was conducted on this patient and minor lesions at the apical segments of the upper lobe were seen. This is a typical radiographic representation of patients with tuberculosis. Table 1: Results of the investigations performed Laboratory Test Readings Normal range Sputum Smear Test Positive Renal Function Creatinine, Cr Urea Potassium, K+ 912 ÃŽÂ ¼mol/l 37.8 mmol/l 5.5 mmol/l 44-80 ÃŽÂ ¼mol/l 1.7 8.5 mmol/l 3.5 5.0 mmol/l Haematology Assessment Blood Sugar Level Haemoglobin 2.1 mmol/l 9.8 g/dl 4.5 6.0 mmol/l 13.5 18 g/dl Table 2 provides details about patients drug history giving information about patients drugs and their respective doses. Upon interview, patient informed that she had not been purchasing any over the counter medications. She also has no known drug allergy. Table 2 : Drug History and their respective doses and their indication Drug Dose Duration Indication Rifampicin 300 mg OD 2 months Anti TB Isoniazid 200 mg OD 2 months Anti TB Pyrazinamide 750 mg OD 2 months Anti TB Ethambutol 600 mg OD 2 months Anti TB Pyridoxine 20 mg OD 2 months Treatment of neuropathy Gliclazide 40 mg OD 5 years Anti diabetic Prazosin 2 mg TDS 5 years Anti Hypertensive Furosemide 80 mg OD 5 years Anti Hypertensive Nifedipine 20 mg TDS 5 years Anti Hypertensive Based on the investigations performed, the patient was diagnosed to be suffering from pulmonary tuberculosis and diabetes mellitus. Patients daily condition was monitored and appropriate management was undertaken to control the patients condition. Patients overall progress is tabulated in the table 3 and the observation is recorded. Table 3 : Patients clinical progress and management Day Clinical Progress Management 1 Hypoglycemia = 2.1 mmol/L AFB test positive Chest X ray performed SOB Hyperkalaemia ( 5.5 mol/L) Anemic ( 9.8 g/dL) BP : 152/93 mmHg Strict fluid intake IV Dextrose 10%/24 hours Refer to chest physician Lesions at upper lobes NPO2 to resolve SOB Start on Calcium polystyrene Start Ferrous (IV) sulphate Start antihypertensives Monitor input output 2 AFB test +ve Blood Sugar Level = 3.0 mmol/L BP : 140/90 mmHg Start TB regimen (EHRZ) Continue IV Dextrose 10% Monitor Blood Glucose Continue antihypertensives 3 Blood Sugar level = 3.2 mmol/L Severe renal impairment ( CrCl =5.6 ml/min ) Chest X ray done time to time BP : 130/70 mmHg Continue dextrose infusion Send patient for dialysis Lesions still present Continue antihypertensives 4 No SOB Hypoglycaemia resolved = 5.5 mmol/L AFB +ve BP : 130/75 mmHg Remove nasal prongs Stop Dextrose. Monitor blood glucose Continue TB regimen 6 K+ level in normal range ( 4.5 mmol/L) Blood Sugar level = 6.0 mmol/L CrCl = 7.7 ml/min BP : 130/65 mmHg Stop Calcium polystyrene. Monitor blood glucose Send patient for dialysis 8 Hyperglycemia = 11.1 mmol/L BP : 125/75 mmHg Start on Insulin DM counselling 13 AFB -ve DXT = 10.2 mmol/L BP : 120/70 mmHg Transfer out of isolation Continue insulin. Monitor blood glucose Based on patients presentation and results from investigations performed on day 1, patient was started on dextrose and her blood glucose levels were regularly monitored. Based on patients previous history, a sputum smear test was ordered and two consecutive positive results resulted in the patient being referred to the chest physician. A chest X ray was performed and lesions in the apical segment were present. To resolve patients SOB, patient was started on Nasal Prongs at 3L/min. To control her hyperkalemia, patient was given calcium polystyrene sulphonate powder. Patient was also started on ferrous sulphate infusion to help her cope with her anaemia. A strict fluid intake was imposed on patient to resolve her leg swelling and this was monitored through an input output chart. Her blood pressure (BP) levels were also elevated and patient was given antihypertensives such as nifedipine, prazosin and furosemide to control her BP. On day 2, her sputum smear remained positive and patient was commenced on the intial phase therapy for tuberculosis which consists of isoniazid, rifampicin, pyrazinamide and ethambutol. There was not much improvement in her blood glucose levels and patient was remained on the dextrose infusion. Moving on to day 3, not much improvement was observed and due to patients deteriorating renal function, patient was sent for peritoneal dialysis. By day 4, patient could breath normally and no shortness of breath was seen. Nasal prongs were removed. When her blood glucose levels were monitored, the results indicated patient was within the normal range and dextrose was withheld. Blood glucose levels were still monitored to prevent sudden drops and increase in blood glucose. Her potassium levels were within range by day 6 and calcium polystyrene sulphonate was stopped and potassium levels were monitored as well. Patient suffered from a hyperglycemia episode on day 8 and the patient was given biphasic insulin to treat this condition. By this day, her BP was also in the normal range but the antihypertensives were still continued. On day 13, patient was transferred out of the isolation ward as her sputum smear test produced negative results. Patients condition for tuberculosis was still being monitored. Her blood glucose levels were still in the high range and patient was to be continued on insulin. To summarize this case, patients active tuberculosis state should be managed well to ensure patient does not suffer from further complications that might arise in the future. Patients history was well noted and this helped in treating the patient in early stages. Adequate investigations were performed to assist the healthcare professional team to diagnose the patient and also to manage the patient. Patient was admitted for a long period but the appropriate management that was undertaken resulted in improvement in patients condition. Further care for the patient would improve the patients quality of life in the future Pathophysiology and Incidence Tuberculosis (TB) is an infectious disease that has plagued many nations across the world. Based on the report by World Health Organization (WHO), almost 9.4 million cases of TB were reported 3. It is highly common of those with TB to contract the Human Immunodeficiency Virus (HIV) and a prevalence of almost 1.7 million deaths from TB among HIV-negative people was recorded around the globe 3. In the United Kingdom, an increasing trend in TB incidence has been reported and this is shown in Figure 1. In 2008, a rate of 14 per 100 000 population in the UK were reported to be suffering from TB 4. Malaysia on the other hand has a higher record of TB cases with 103 per 100 000 population being reported in 2007. Table 1 summarizes some of the data obtained from World Health Organization 3. Figure 1: Number of TB cases reported in the UK from 2000 to 2008 4 Table 1: Statistics displaying number of TB cases in Malaysia in 2007 3 All In HIV + people Incidence All forms of TB (per 100 000 population) 103 17 Mortality All forms of TB (per 100 000 population) 121 8.3 Multi-drug Resistant TB (MDR-TB) MDR-TB among new cases (%) 0.1 Notified relapse cases (per 100 000 pop/yr) 61 The bacteria that is responsible for this disease is the acid fast bacilli aerobic bacterium Mycobacterium tuberculosis 1. A key feature that enables this bacterium to survive would be its unique cell wall. Mycolic acids are linked covalently to arabinogalactan that provides a barrier to host defense mechanism. Antigens such as lipoarabinomannan present on the exterior of the cell wall facilitate the survival of the organism within macrophages 1. Tuberculosis is spread usually spread within droplets containing the microorganism that are produced when an infected person coughs, sneezes or even talks 1,2. Figure 1 gives a schematic impression of the progression of the disease. The inhaled droplets are initially trapped by dendritic cells that act to expel any foreign particles out. Most mycobacteria are able to surpass this defense mechanism and travels further to the alveoli where it gets ingested by macrophages 1. It then undergoes intracellular replication that might take duration o f 4 to 6 weeks. Cytokines are further released during this period and this attracts T lymphocytes that are involved in mediating a cell immune response. The next natural defense system step would be the formation of granuloma that contains the activated T lymphocytes and macrophages. These nodular lesions disable further spread of the disease as the environment within restricts the growth of the bacilli and a latent period occurs 1. For less immunocompetent individuals, the granuloma will not be able to contain the bacilli and the active disease takes form 1. Figure 1: Image depicting the progress of tuberculosis 2 The diagnostic tests available are summarized in Table 2. TB can be divided to latent and active and to diagnose each different test has been recommended. For latent TB, Mantoux test can be carried out and those with positive results can be considered for QuantiFERON TB test 5. To diagnose active pulmonary TB, a chest X-ray would be taken followed by multiple sputum samples that are sent for smear test 5. Table 2: Diagnostic tests available for tuberculosis 1 Variable Purpose Time required for results Sputum smear Detect acid fast bacilli Sputum culture Identify M tuberculosis 3-6 weeks with solid media, 4-14 days with high-pressure liquid chromatography Tuberculin skin test/ Mantoux Detect exposure to mycobacteria 48 72 hours QuantiFERON TB-test Measure immune reactivity to M tuberculosis 12 24 hours Chest radiography Visualize lobar infiltrates with cavitation Minutes The drugs that are commonly used in tuberculosis are isoniazid, rifampicin, pyrazinamide and ethambutol. Rifampicin is a bactericidal agent that inhibits RNA synthesis by binding to the ß subunit of RNA polymerase. It can be given via oral administration and can even be distributed to the central nervous system due to its lipophilicity. Metabolism of this drug occurs in the liver and it is usually excreted in the urine. Isoniazid is a bactericidal pro-drug that inhibits ketoenoylreductase enzyme, InhA, that is responsible in synthesizing mycolic acids. Isoniazid can be administered orally, intramuscularly or intravenously and is acetylated in the liver and subsequently excreted in the urine. Pyridoxine 10 mg is given concurrently to minimize this risk. Pyrazinamide is another prodrug that is activated by nicotinamidase to pyrazinoic acid. This component at low pH carries proton into the cell and collapses the proton motive force present in the mycobacterium which results in cell d eath. It is only bactericidal against non growing bacilli forms.. Ethambutol works by binding to arabinosyl transferase enzyme and inhibits the polymerization of the cell wall arabinan component. Table 3 gives the details of the dose and side effects reported with the administration of the tuberculosis drugs. Table 3: Tuberculosis drugs with their respective doses and side effects 6,7 Drug Dose Side effects Isoniazid 5 -8 mg/kg (max 300 mg) Peripheral neuropathy, hepatotoxicty Rifampicin 10 15 mg/kg (max 600 mg) Nausea, vomiting, thrombocytopenia, orange discolouration of urine Pyrazinamide 20 40 mg/kg ( max 1.5 g 50 kg) Nausea , vomitting, hyperuricemia Ethambutol 15 25 mg/kg Neuropathy, red green color blindness Evidence based medication review Treatment for Tuberculosis In the past three decades, no new drugs have been discovered in fighting TB. The 4 drugs have been the gold standard in treating TB The chemotherapy regimen available for tuberculosis therapy can be divided to the initial phase and the continuation phase. In the initial phase, drugs such as rifampicin, isoniazid, pyrazinamide and ethambutol are used 6. These drugs act to decrease the amount of bacteria present and also prevent resistance from emerging from the strains. This regimen is usually for 2 months. The continuation phase would consist of drugs such as isoniazid and rifampicin. Isoniazid was the first drug to be introduced into combating tuberculosis back in the 1950s. Rifampicin , an antibiotic, was later added to the market and was added to the isoniazid regimen in 1967. This resulted in shortening the duration of treatment from 12 months to a 6 to 9 month treatment 9. Addition of pyrazinamide to the regimen decreased the chemotherapy duration further. Clinical studies have indicated that a pyrazinamide containing short course regimen had a sputum negative conversion rate of 70-95% in the first two months compared to the treatment without pyrazinamide 11. The relapse rates recorded from these studies also were only 4%. A clinical study conducted in East Africa compared the four 6-month daily regimens that comprised of Streptomycin, Isoniazid and Rifampicin (SHR), Streptomycin, Isoniazid and Pyrazinamide (SHZ); Streptomycin, Isoniazid and thiacetazone (SHZ) and Streptomycin and Isoniazid (SH) 10. The SHZ regimen that was the most effective amongst all the regimens and the SHR regimen had the lowest relapse rate of 2% 30 months post treatment 10. No significant difference results were obtained from the treatment regimen that was carried out for 18 months 10. This study gives an impression of the efficacy of the isoniazid, rifampicin and pyrazinamide regimen when used together In a Poland study, the efficacy of the 4 different drug regimens containing rifampicin, isoniazid and ethambutol were assessed. During the initial phase, patients were given isoniazid 300 mg, rifampicin 600 mg and ethambutol 25 mg/kg 8. In the continuation phase the regimens given to patients comprised of rifampicin 600 mg, isoniazid 15mg/kg(Regimen A), isoniazid 15 mg/kg rifampicin 600 mg twice a week (Regimen B), Isoniazid 15kg/mg, rifampicin 600 mg ethambutol 50mg/kg once a week (Regimen C) and Isoniazid 15mg/kg, rifampicin 600 mg, ethambutol 50mg/kg twice a week (Regimen D) 8. The result of this study demonstrated that Regimen D had 47% of its patients displaying a significant change in their sputum result to a negative result compared to the other regimens. There were no significant differences in rates between all regimens by the end of the fifth month as all patients had their sputum converted to negative. This study had the limitation of not including pyrazinamide in its regi men but it can be seen that to achieve a quicker rate of sputum negative cultures a regimen containing ethambutol could be used in the continuation phase. A trial conducted by Jindani et al. assessed the effectiveness of daily dosing of the intial phase drugs compared to the intermittent thrice weekly dosing. The drugs that were assessed were isoniazid, rifampicin, pyrazinamide and ethambutol. The doses that were given to the patients were based on WHO recommendations. The outcome measured after 2 months had 77% of the patients with negative sputum cultures after their 2 month stint (p=0.001) 13. A similar study was conducted in Hong Kong with the difference being a 12 month follow up period. By the end of the second month, 94% of patient receiving the daily regimen had improved. 90% of those under the intermittent regimen also had improved by the second month. Over the long term follow up, more relapse cases were recorded but the values were not significant 14. Hypoglycemia Treatment Patient was hypoglycemic upon arrival and dextrose infusion was provided to restore the patients normal blood glucose range. Two forms of treatment are usually available for hypoglycemic attacks namely glucagon and dextrose infusion. A study compared the efficacy between both the options and it was observed that both were capable of treating hypoglycemia effectively. The only disparity observed was the recovery. Patients on dextrose infusion are capable of regaining consciousness by 4 minutes compared to 6 minutes for patients that were on glucagon ( p Table 4 : Results of 51 hypoglycemic patients treated with dextrose 10% and dextrose 50% 27 Dextrose 10% Dextrose 50% Median time needed to attain recovery (minutes) 8 8 Median total dose administered 10g ( p 25g (p Median post treatment blood sugar levels 6.2 mmol/l (p=0.003) 9.4 mmol/l (p=0.003) Diabetes Treatment Oral antidiabetic agents such as gliclazide in the patients drug history would not be sufficient for her to have proper control over her glycemic levels. It was reported that tuberculosis affects the hormonal secretion by interfering with endocrinal organs such as pancreas 15. Rifampicin reduces the concentration of gliclazide by inducing liver microsomal enzymes CYP 2C9 that rapidly eliminates gliclazide from circulating in the system 15,16,17. In a study by Park et al., patients given with 80 mg gliclazide had the concentration of the drug present in the body reduced by 70% on day 7. The elimination half life of the drug also increased 3 fold 17. All these contribute to the inability of the sulfonyluea to reduce the glucose levels in this patient. According to the stepwise approach in NICE guidelines, the next step to manage this patient would be to start the insulin regimen18. The type of insulin that was given was biphasic Mixtard insulin analogue that consists of a short acting analogue and also a long acting analogue. P.V. Rao reported that, due to the insulin resistance present in patients started on anti Tb therapy, the doses of insulin needed to manage these patients increase 15. It is well proven that insulin can achieve better HbA1c levels as a clinical trial by United Kingdom Prospective Diabetes Study (UKPDS) revealed that after 9 years monotherapy with insulin, 28% of patients achieved HbA1c levels below 7% and 42% patients achieved fasting plasma glucose levels below 7.8 mmol/l 19. Hypertension Treatment Patient was suffering from Stage 5 renal disease and the target for blood pressure in this patient would be 125/75 mm Hg 20. First line treatment for this patient would be loop diuretic, furosemide 20. They act by inhibiting the Na+/K+/2Cl- transporter on the ascending limb of loop of Henle which results in natriuresis and hence a fall in blood volume 21. This loop diuretic also performs its vasodilator actions via prostaglandin (PGE2 and prostacyclin) formation. This results in an increased blood flow in the medulla 21. In accordance to SIGN guidelines as well, long acting dihyrdopyridines such as nifedipine and ÃŽÂ ± blockers can be added as supplementary therapy 20. Nifedipine, a calcium antagonist acts by causing vasodilatation due to reduction in peripheral resistance. ÃŽÂ ± blockers such as prazosin block ÃŽÂ ±1 receptors and this results in vasodilation. A study by Vadasz displayed that Furosemide doses at 40 mg did not display any significant changes in systolic blood pressure. However, when the dose was increased to 60 mg, there was a significant reduction in blood pressure 21,22. A combined dose of 40 mg and 60 mg were effective in reducing the diastolic blood pressure. Based on this evidence, it is clear that furosemide on its own is not capable of decreasing blood pressure. When nifedipine was combined with diuretics it was observed that a statistically significant lower risk of cardiovascular events was observed compared to the non-statistically significant difference that was noted with nifedipine monotherapy 22. In another study by Psaty et al, nifedipine did not demonstrate an increase of risk in myocardial infarction compared to the other calcium channel blockers 25. Prazosins efficacy in lowering blood pressure was studied and the lowest effective dose that is capable of reducing blood pressure was noted to be 10mg 26. Doses below 10 mg per day did not significantly reduce the blood pressure compared to the placebo arm. Treatment of Anaemia Patient had very low haemoglobin levels and this was indicative of anaemia. NICE guidelines have recommended that in order to manage anemia, patients are usually given eryhtropoetin stimulating agents and also iron supplements to help produce haemoglobin 23. There has been no evidence in the use of iron supplements in patients with chronic kidney disease prior to treatment with erythropoietin. But it is recommended that the erythropoietin therapy should not be commenced in conditions of complete iron absence 23. In some conditions, where patients were in Stage 5 renal failure also diagnosed with other co-morbidities, treatment with erythropoietin stimulating agents is decided based on clinical judgment by the professional team if the patient were to benefit from the treatment 23. Treatment of Hyperkalaemia Patient was suffering from mild hyperkalemia and it was necessary that this was be treated before it progresses to severe hyperkalemia that might lead to adverse events such as cardiac arrest. A study compared the effectiveness between sodium polystyrene sulfonate and calcium polysterene sulfonate and it is noted that treatement with sodium increases sodium concentration in the body and this escalates the risk of hypertension 24. Treatment with calcium polystyrene sulfonate resulted in 50% decrease in potassium content and an additional advantage of increase in calcium concentration was observed as well 24. Conclusion Based on all the evidence provided for the patients condition, it is clear that the guidelines were adhered in treating the patients individual disease with some minor differences. Tuberculosis treatment for the initial phase was extended for more than 2 months due to the positive result obtained from sputum smear. Patient eventually achieved negative sputum smear and the patient was to be monitored before the patient was commenced on the continuous phase drugs. Effective treatment was undertaken to treat patients hypoglycemia condition, and based on the evidence gathered, dextrose 10% is the suitable treatment option for the patient. The antihypertensive regimen that was chosen was due to the patients renal failure. Nifedipine, prazosin and furosemide collectively controlled the blood pressure of the patient. Ferrous sulphate was chosen as her treatment compared to erythropoietin and this was based on the doctors clinical judgement. Her hyperkalemia which was treated with calcium su lfonate did benefit the patient as her potassium levels were within the normal range at the end of the treatment. PATIENT MEDICATION PROFILE PATIENT DETAILS Name Mrs A Consultant General Practitioner Address Kuala Lumpur Gender Female Weight 65 Height 158 Community Pharmacist Date of Birth (Age) 61 Known Sensitivities None Social History Non smoker Non Alcoholic PATIENT HOSPITAL STAY Presenting complaint in primary care / reason for admission Admission date April Low Sugar Level : 2.1 mmol/L Discharge Date Discharged to Not Known Shortness of breath RELEVANT MEDICAL HISTORY RELEVANT DRUG HISTORY Date Problem Description Date Medication Comments Feb Pulmonary Tuberculosis Feb Rifampicin 6 months Advanced Renal Failure Feb Isoniazid 5 years Hypertension Feb Pyrazinamide 5 years Diabetes Mellitus Feb Ethambutol Feb Pyridoxine 6 months Prazosin 6 months Nifedipine 6 months Furosemide Gliclazide RELEVANT NON DRUG TREATMENT Peritoneal Dialysis Prescribed Medication Start Stop Clinical/Laboratory Tests Date Result 1 Rifampicin Day 1 Sputum Smear Test Day 1 Positive 2 Isoniazid Day 1 Creatinine Day 1 912 Â µmol 3 Pyrazinamide Day 1 Urea Day 1 37.8 mmol/l 4 Ethambutol Day 1 Potassium Day 1 5.5 mmol/l 5 Pyridoxine Day 1 Blood Glucose Day 1 2.1 mmol/l 6 Prazosin Day 1 Blood Pressure Day 1 152/93 7 Nifedipine Day 1 Haemoglobin Day 1 9.8 g/dl 8 Furosemide Day 1 Chest Xray Day 1 Lesions in the apical segment 9 Dextrose Solution Day 1 Day 4 Blood Glucose Day 8 11.1 mmol/l 10 Ferrous sulphate Day 1 Sputum Smear Day 13 Negative 11 Calcium polystyrene sulphate powder Day 1 Day 6 12 Insulin Mixtard Day 8 CLINCIAL MANAGEMENT Diagnosis Pharmaceutical Need Pulmonary Tuberculosis Continue patient on intial phase drugs Hypoglycemia Start patient on dextrose Hypertension Continue antihypertensive treatment Hyperkalaemia Start calcium polystyrene sulphonate powder Anaemia Start ferrous sulphate Advanced Renal Failure Send patient for peritoneal dialysis PHARMACEUTICAL CARE PLAN Date Care Issue/Desired Output Action Output Sub therapeutic doses For Anti TB drugs Discussed with the pharmacist and patients diabetic condition was the reason for the dose regimen Doses were not changed Drug sensitivity testing was not performed Patient is diabetic and is more susceptible for MDR-TB No test was performed Management of patients compliance towards anti tuberculosis drugs -Patient might be hospitalised for a long period of time due to renal failure -DOTS scheme to be implemented upon discharge -Adequate patient education on the importance of completing the regimen is important Hospitalisation or DOTS scheme Renal failure Ethambutol excreted by kidney. Suggest change of medication to 2 Isoniazid + Rifampicin + Pyrazinamide -If treatment continued, monitoring essential Continue treatment as before and patient being monitored AFB test Another 2 samples should be taken for AFB tests before switching to the continuous phase Action yet to be taken Monitor drug toxicity Lab investigations on full blood count, liver function, serum uric acid, serum bilirubin, should be done to ensure no toxicity Eye examination for ethambutol side effects Scheduled appointments for patient Education on side effects of drugs To inform patient about anti Tb drugs side effect and advise patient not to stop the drug and side effects can be controlled ( PZA and arthralgia ) Counseling by pharm

Arthur Millers Death of a Salesman as Epic Tragedy Essay -- Death Sal

Arthur Miller's Death of a Salesman as Epic Tragedy   Ã‚  Ã‚   Aristotle's Poetics defines the making of a dramatic or epic tragedy and presents the general principles of the construction of this genre. Surprisingly, over the centuries authors have remained remarkably close to Aristotle's guidelines. Arthur Miller's twentieth century tragedy Death of a Salesman is an example of this adherence to Aristotle's prescription for tragedy. It is significant to test Aristotle's definition and requirements of tragedy by comparison and contrast, against a contemporary tragedy and to make observations with regard to what influence society and culture may have on the genre. This discussion however, will be confined to the realm of plot and the more notable aspects of the construction of the incidents in tragedy because of the complexity of this element. Aristotle's attention throughout much of Poetics is directed towards the requirements and expectations of plot.   Plot, 'the soul of tragedy', Aristotle says, must be an imitation of a noble and complete action. In Death of a Salesman, Miller does provide a complete action, that is it has what Aristotle identifies as a beginning, a middle, and an end. These divisible sections must, and do in the case of Death of a Salesman, meet the criterion of their respective placement. Whether Miller provides a nobel action, however, is an issue of culture. Willy Loman ultimately takes his own life so that his son Biff may benefit from the insurance money that he will receive. The question then, is according to our culture is his suicide noble? Since Willy's suicide is perpetrated for Biff's benefit, one could view this act as sacrifice. Sacrifice is in our culture, a pious and admirable quality, one of... ...ath of a Salesman' Twentieth Century Literature.   January, 1972. 19-24.   Rpt. in World Literary Criticism.   Ed. Frank Magill.   'Arthur Miller' Detroit: Gale Research, 1992.   2366-2368. Hayman, Ronald.   Arthur Miller.   New York: Frederick Ungar, 1972. Hoeveler, D. J.   'Ben's Influence.'   Arthur Miller?s Death of a Salesman: Modern Critical Interpretations.   Ed. Harold Blum.   Philadelphia: Chelsea House, 1988. 72-81. Magill, Frank.   'Death of a Salesman.'   Master Plots.   Englewood Cliffs: Salem, 1976.   1365-1368. Miller, Arthur.   Death of a Salesman.   New York: Penguin, 1949. ---.   Conversations With Arthur Miller.   Jackson: Mississippi UP, 1987. Parker, Brian.   'Point of View in Arthur Miller's Death of a Salesman.'   Arthur Miller: A Collection of Critical Essays.   Ed. Robert Corrigan.   Englewood Cliffs:   Prentice Hall, 1969.   98-107.