Department of Health Care Administration

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Department of Health Care Administration

  1. 1. Revised 5/31/2010 Department of Health Care Administration Trinity University HCAD 5340: Health Care Strategic Planning and Marketing Spring Semester 2006 Thursdays, 9:00 a.m. – 12:00 p.m. CC 100 Course Instructor: Amer Kaissi, Ph.D.; Assistant Professor Contact Information: Department of Health Care Administration, Trinity University One Trinity Place - #58, San Antonio, Texas 78212-7200 Office Phone: 210-999-8132, Home Phone: 210-764-8326 Fax: 210-999-8108 E-mail: amer.kaissi@trinity.edu Website: http://www.trinity.edu/akaissi/ Office Hours: Monday, Tuesday, Wednesday: 9:00- 12:00 Thursday: 1:00-2:00 Or by appointment. Course Description: This course is designed to provide knowledge and skills pertaining to the functions of strategic planning and marketing in the health care setting. These will be applied to the health care manager whose responsibilities center upon management functions other than an assignment as a planning or marketing specialist. Areas to be covered include an analysis of strategic planning and marketing theory emphasizing strategic planning concepts in an era of regulation and competition and a marketing orientation to designing the services offered by the health care organization. The course will utilize (1) information from textbooks; (2) case analyses, which provide important insight into the workings of health care institutions; and (3) personal experiences of the instructor and class participants. The course also emphasizes written and verbal communication skill development. You will be expected to produce clear and concise business communications that indicate an ability to think critically through a situation and apply theories learned in class. 1
  2. 2. Revised 5/31/2010 Course objectives: Students effectively completing this course will have demonstrated the ability to apply strategic planning and marketing tools in health care organizations. More specifically, students should be able to: • Understand the processes involved in initiating the strategic planning process • Be able to conduct a competitor analysis. • Be able to define an organization’s distinctive competencies and competitive advantages, and identify strategies that build on these strengths. • Be able to design, manage, and support strategic planning processes in health care organizations. Be able to conduct the information-gathering and analytic tasks that inform strategy formulation. • Master conceptual and analytic tools for assessing environmental, market, and internal factors that should be considered in strategy formulation. Be able to identify strategies that “fit” different situations. • Think strategically about the decisions health care organizations must make to be successful. • Develop and evaluate strategic alternatives for health care organizations. • Critically analyze the marketing process and how it is related to strategic planning. • Understand the role and the purpose of marketing activities within health care organizations. Course Materials: Required: - Textbook: “Strategic Management of Health Care Organizations,” 4th edition, by Peter M. Ginter, Linda E. Swayne, and W. Jack Duncan, Blackwell Publishing, 2002. - Additional readings: A file including all additional book readings will be made available on the first day of class. You are responsible for making copies for yourself. Recommended: - “Service Line Success: Eight Essential Rules,” by E. Preston Gee, ACHE Management Series, Health Administration Press, 2004. - “Essentials of Health Care Marketing,” by Eric N. Berkowitz, Jones and Bartlett Publishers, 2004. Teaching methods: It is important to recognize that we learn in different ways. Some students learn best in small group discussions. Others learn best while listening to a lecture. Still others find learning most helpful when they analyze a case study. In this class we will use multiple teaching methods with the expectation that one of them will be particularly applicable to your mode of learning. 2
  3. 3. Revised 5/31/2010 Grading: Assignments (2 at 15% each) 30 % Leading Class Discussion 10 % Midterm Exam 25 % Marketing project paper 15 % Marketing project presentation 15 % Preparation/contribution 5% Total 100 % If you wish to contest a grade for a reason that you think is valid, you have to do so in writing. Please prepare a formal letter addressed to me, in which you explain why you think the grade is unfair or inadequate. This procedure will guarantee that you will receive a prompt response to your letter and an explanation of why the grade was changed or not. Assignments: There are 2 required assignments for this class. The assignments are available at the end of the syllabus (see pages 15-16) and each assignment will be graded based on a specific grading form (see pages 18-19). Marketing Project (Paper and Presentation) You will work in groups of five for this paper. You are highly encouraged to start working on this project from the beginning of the second part of the course. You have to decide on a topic by March 2nd (Session 7) and the paper itself is due on April 27th (Session 13). Please see page 16 for the guidelines for this project, and page 19 for the evaluation criteria. The findings of the paper will be presented to the class at the end of the semester (April 27th). The presentation should include the use of appropriate visual aids. The bulk of the presentation should focus on discussing the market research survey and advertisement. The group doing the presentation will have 15 minutes to present, followed by 15 minutes of questions and discussion. Each group is expected to prepare handouts to be distributed in class to facilitate note taking for other students (handouts should include the research survey presented). You will be penalized for exceeding the time limit and are urged to practice the presentation to be sure that you stay within the time limit. All members of the group should take part in the presentation and will receive the same grade (see page 21). Midterm Exam: The midterm exam will cover materials from sessions 1-7. Since this is a graduate level program, it is expected that students will move beyond mere rote memorization of information to synthesis and analysis of the course content. The exam will include essay questions designed to integrate the concepts in the assigned reading, class discussions and the case analyses. The exam will be held in-class with closed books and closed notes. Leading Class Discussion: Five case studies (different from the ones used for assignments) will be assigned during the semester. For each case, a group of 5 students will be selected to lead the discussion 3
  4. 4. Revised 5/31/2010 and facilitate activities. Discussion questions specific to each case will be provided. The group will be responsible for briefing the class on the case, discussing the questions, coming up with additional issues for discussion, and, if applicable, updating the class on the organization/market in question. Discussion leaders should meet in advance to decide on strategies and questions. Please see pages 10-14 for a detailed list of requirements for each case. Please see page 22 for the evaluation criteria. Preparation/Contribution: This class will be taught in an environment of peer-learning and collaboration as professionals and colleagues. In this environment of mutual contribution, you are expected to be on time, attend class and come prepared for active participation. Since our sessions will be interactive, you presence and participation will be vital to the success of the class. If you expect to be late or to miss a session, it is your responsibility to contact me in advance. My policy on unjustified absence/lateness is summarized as follows: - For each unjustified absence, one grade point will be deducted from your final grade - For each unjustified lateness, half a grade point will be deducted from your final grade Examples of unjustified absences: missing class to attend a wedding, a birthday party, or to go shopping. Examples of unjustified lateness: coming to class late because of traffic, problems finding a parking spot, or failing to wake up on time. Because our class activities are dependent on the assigned readings, you are also expected to complete the readings before they are discussed in class. Failure to constructively contribute to class will be a disservice both to you and to your classmates. The evaluation form for class preparation/contribution is available at the end of this syllabus (see page 23). Late Work Policy: All works and exams are due on the day assigned. Exceptions will be made only for reasons that are beyond your control. Examples of exceptional circumstance: Serious illness impacting a significant portion of the time you had to do the assignment or death in the family. Examples of things that are generally not exceptions: Coming down ill the night before an assignment that was handed out much earlier or conflicts with work. If you do have conflicts with work, please notify me as soon as possible so we can work out arrangements. If you miss an exam because of an exception, please arrange a retake. Exams missed without an exception receive a grade of zero. Assignments handed out late will result in a one letter-grade reduction for each day late. Students’ evaluations of the Instructor: During the last class period, you will be requested to formally evaluate the instructor. I kindly ask you to take these evaluations seriously as feedback will be used to improve the course and as results are considered for promotion decisions. Moreover, I will conduct an informal evaluation halfway through the semester to detect possible problems and address them. 4
  5. 5. Revised 5/31/2010 Academic Integrity: Trinity University’s policy on academic integrity and the penalties for violations will be followed with no exception. Please refer to the Student Handbook. Course Calendar: Session # Date Topic description Readings Due 1 1/19 Syllabus Chapters 1 & 2 Introduction to Strategic Management & External Environment 2 1/26 Market Analyses Chapter 3 Market Reports 3 2/02 Internal Analyses & Directional Chapters 4 & 5 Strategies Case 2* 4 2/9 Developing Strategies Chapter 6 Assignment # 1 : Case 15 5 2/16 Service Line Management Case 11* Guest Speaker: Preston Gee 6 2/23 Evaluating Strategies Chapter 7 Assignment # 2: Case 13* 7 3/2 Strategy Implementation Chapter 10 Topics for Case 18 Marketing Project TBD Midterm Exam 8 3/9 Marketing Process & Marketing Chapter 1- “Essentials” Research 3/16 Spring Break- No Class 9 3/23 Marketing Research (cont’d) Chapter 5- “Essentials” Case 9 3/30 ACHE Congress- No Class 10 4/6 Marketing Mix Chapter 7- “Health Care Market Guest Speaker: Deborah Dahlke Strategy” 11 4/13 Customers’ Behavior Chapter 4- “Essentials” Case 5 12 4/20 Market Segmentation Chapter 6- “Essentials” 13 4/27 Presentations Marketing Project * These cases are from the new edition of the book and will be provided to you in a package to copy. 5
  6. 6. Revised 5/31/2010 Course Outline: Session 1, January 19th: Syllabus; Introduction to Strategic Management & External Environment Readings: 1) Chapter 1: The Nature of Strategic Management, pp. 3-49. 2) Chapter 2: Understanding and Analyzing the External Environment, pp. 50-91. ---------------------------------------------------------------------------------------------------------- Session 2, January 26th: Market Analyses Reading: 1) Chapter 3: Service Area Competitor Analyses, pp. 92-136. Prepare: Market Reports’ Presentation • Short Case (To be distributed in class): “Unearth Unflattering Info? ” ---------------------------------------------------------------------------------------------------------- Session 3, February 2nd: Internal Analyses and Directional Strategies Readings: 1) Chapter 4: Internal Environmental Analyses and Competitive Advantage , pp. 137-174. 2) Chapter 5: Directional Strategies, pp. 175-208. Prepare for discussion: Case 2: Methodist Healthcare: Managing for the Future (from packet). Short Case (To be distributed in class): “No Ladies Allowed” ---------------------------------------------------------------------------------------------------------- Session 4, February 9th: Developing Strategies Reading: 1) Chapter 6: Developing Strategic Alternatives, pp. 211-263. Due Assignment # 1: Case 15: Wills Eye Hospital: A Specialty Hospital Survivor, pp. 797-814. Short Case (To be distributed in class): “Fast-Food Financials” ---------------------------------------------------------------------------------------------------------- 6
  7. 7. Revised 5/31/2010 Session 5, February 16th: Service Line Management Guest Lecturer: Mr. E. Preston Gee, MBA, Senior Managing Director, Phase 2 Consulting, Austin, TX Prepare for discussion: Case 11: HMA and its Riverview Regional Medical Center Facility (from packet) ---------------------------------------------------------------------------------------------------------- Session 6, February 23rd: Evaluating Strategies Reading: 1) Chapter 7: Evaluation of Alternatives and Strategic Choice, pp. 264-312. Due Assignment # 2: Case 13: Emanuel Medical Center: Crisis in the Health Care Industry (from packet). Short Case (To be distributed in class): “Say ah! or nah! to a spa?”” ---------------------------------------------------------------------------------------------------------- Session 7, March 2nd: Strategy Implementation Reading: 1) Chapter 10: Implementing Strategy through Unit Actions Plan, pp. 397-424. Prepare for discussion: Case 18: The Premier Healthcare Alliance Emerges, pp 851-875. Short Case (To be distributed in class): “Centura Healthcare” Due: Topics for Marketing Project. ---------------------------------------------------------------------------------------------------------- Midterm Exam: covers sessions 1-7 (Date to Be Determined). ---------------------------------------------------------------------------------------------------------- Session 8, March 9th: Marketing Process & Marketing Research Reading: 1) “Essentials of Health Care Marketing,” Chapter 1: The Meaning of Marketing, pp. 3-38. ---------------------------------------------------------------------------------------------------------- 7
  8. 8. Revised 5/31/2010 March 16th: No Class, Spring Break ---------------------------------------------------------------------------------------------------------- Session 9, March 23rd: Marketing Research (cont’d) Reading: 1) “Essentials of Health Care Marketing,” Chapter 5: Marketing Research, pp. 135-166. Prepare for discussion: Case 9: Helicopter Emergency Medical Services at the Medical College of Georgia Hospital and Clinics, pp. 712-720. ---------------------------------------------------------------------------------------------------------- March 30th: No Class, ACHE Congress ---------------------------------------------------------------------------------------------------------- Session 10, April 6th: Tactics and Marketing Mix: The Four P’s Guest Speaker: Mrs. Deborah Vollmer Dahlke, Vice President of Business Development, Chief Business Development Officer, Cancer Therapy & Research Center (CTRC) Reading: 1) “Health Care Market Strategy: From Planning to Action,” Chapter 7: Determining Market Actions, pp. 159-213. ---------------------------------------------------------------------------------------------------------- Session 11, April 13th: Customers’ Behavior Reading: 1) “Essentials of Health Care Marketing,” Chapter 4: Buyer Behavior, pp. 101-134 Prepare for discussion: Case 5: The University of Texas Health Center at Tyler, pp. 639-654. ---------------------------------------------------------------------------------------------------------- Session 12, April 20th: Market Segmentation Reading: 1) “Essentials of Health Care Marketing,” Chapter 6: Market Segmentation, pp. 167-198 ---------------------------------------------------------------------------------------------------------- Session 13, April 27th: Presentations 8
  9. 9. Revised 5/31/2010 Due: Marketing project Market Reports (Session # 3; January 26th) You will work in groups of 4-5 to prepare a market presentation on one of the following markets: - Boston, Massachusetts - Miami, Florida - Phoenix, Arizona - Orange County, California - Little Rock, Arkansas - Syracuse, New York - Greenville, South Carolina - Lansing, Michigan - Northern New Jersey - Seattle, Washington - Cleveland, Ohio - Indianapolis, Indiana A market report will be provided to you. You are responsible for summarizing this report (two slides) and updating the market’s information with some additional research on your own (two slides). The presentation should answer the following question: “If I was a healthcare manager in this market, what environmental issues/trends would I watch out for?” Each group will have a maximum of 10 minutes to present its findings. This exercise will not be graded. 9
  10. 10. Revised 5/31/2010 Case 2- Discussion Guidelines (Session #3; February 2nd) Please note that this case is available in the packet. In preparing “Case 2: Methodist Healthcare: Managing for the Future,” the discussion leaders should consider the following questions: 1) What are the most important environmental factors that Methodist Healthcare should incorporate into its strategic plan? 2) Develop a list of critical success factors for Methodist Healthcare and explain your choices. 3) What are your strategic recommendations for Methodist Healthcare? In addition to the above questions, each discussion leader should prepare an additional question that is relevant to the case. The group is also responsible for briefing the class on the case and, if applicable, updating the class on the current situation of the organization in question. The format in which the questions are discussed is left to the group. Suggested formats include a PowerPoint presentation with open discussion, an informal presentation with open discussion, a role play, etc… Creativity is encouraged, and the format chosen should be designed to achieve maximum participation from the class. Regardless of the format, the activity should last a maximum of one hour. 10
  11. 11. Revised 5/31/2010 Case 11- Discussion Guidelines (Session # 5; February 16th) Please note that this case is available in the packet. In preparing “Case 11: HMA and its Riverview Regional Medical Center Facility” the discussion leaders should consider the following questions: 1) Please develop a SWOT analysis for RRMC. What strategic alternatives are suggested by the analysis? 2) What new services or products can be developed with existing resources? 3) What services need to be promoted or strengthened to control out-migration from the primary service area? 4) What should RRMC do to counter its image problem in the community because of its decision to close the Women’s Pavilion? In addition to the above questions, each discussion leader should prepare an additional question that is relevant to the case. The group is also responsible for briefing the class on the case and, if applicable, updating the class on the current situation of the organization in question. The format in which the questions are discussed is left to the group. Suggested formats include a PowerPoint presentation with open discussion, an informal presentation with open discussion, a role play, etc… Creativity is encouraged, and the format chosen should be designed to achieve maximum participation from the class. Regardless of the format, the activity should last a maximum of one hour. 11
  12. 12. Revised 5/31/2010 Case 18- Discussion Guidelines (Session #7; March 2nd) Please note that this case is available in your book. In preparing “Case 18: The Premier Healthcare Alliance Emerges,” the discussion leaders should consider the following questions: 1) Please develop a stakeholder map for Premier. Is it more or less intricate than that of other healthcare organizations? 2) What should be the mission of the new Premier alliance? 3) Please use an extended BCG portfolio matrix to suggest strategic alternatives for Premier. In addition to the above questions, each discussion leader should prepare an additional question that is relevant to the case. The group is also responsible for briefing the class on the case and, if applicable, updating the class on the current situation of the organization in question. The format in which the questions are discussed is left to the group. Suggested formats include a PowerPoint presentation with open discussion, an informal presentation with open discussion, a role play, etc… Creativity is encouraged, and the format chosen should be designed to achieve maximum participation from the class. Regardless of the format, the activity should last a maximum of one hour. 12
  13. 13. Revised 5/31/2010 Case 9- Discussion Guidelines (Session #9; March 23rd) Please note that this case is available in your book. In preparing Case 9:“Helicopter Emergency Medical Services at the Medical College of Georgia Hospital and Clinics,” the discussion leaders should consider the following questions: 1) One student can be assigned to each of the following roles at MCG: - Hospital administrator - Physician - Financial director - Marketing director - Community representative Each role should develop strong arguments for sponsoring or not sponsoring a HEMS, and if the decision is made to sponsor the service, whether or not to enter into joint sponsorship (with UH or another local hospital). Arguments should be based on cost, mission, occupancy rates, managerial issues, population data, competition, and image considerations. 2) What would be the marketing effectiveness of HEMS for MCG? 3) Based on your analyses, why do you think there is a strong growth in helicopter ambulatory services throughout the US? In addition to the above questions, each discussion leader should prepare an additional question that is relevant to the case. The group is also responsible for briefing the class on the case and, if applicable, updating the class on the current situation of the organization in question. The format in which the questions are discussed is left to the group. Suggested formats include a PowerPoint presentation with open discussion, an informal presentation with open discussion, a role play, etc… Creativity is encouraged, and the format chosen should be designed to achieve maximum participation from the class. Regardless of the format, the activity should last a maximum of one hour. 13
  14. 14. Revised 5/31/2010 Case 5- Discussion Guidelines (Session #11; April 14th) Please note that this case is available in your book. In preparing Case 5:“The University of Texas Health Center at Tyler,” the discussion leaders should consider the following questions: 1) In competing for paying customers (those covered by some form of insurance), what advantages and disadvantages does UTHCT have versus its two major competitors? 2) What is UTHCT’s financial situation? Has it improved or deteriorated in recent years? 3) Should UTHCT attempt to expand its service offerings to match those of the two competing institutions or should it remain narrowly focused? 4) Does the fact that UTHCT has historically focused on pulmonary problems- especially tuberculosis- and operates as a teaching hospital, reduce or increase its appeal to paying clients? Why? In addition to the above questions, each discussion leader should prepare an additional question that is relevant to the case. The group is also responsible for briefing the class on the case and, if applicable, updating the class on the current situation of the organization in question. The format in which the questions are discussed is left to the group. Suggested formats include a PowerPoint presentation with open discussion, an informal presentation with open discussion, a role play, etc… Creativity is encouraged, and the format chosen should be designed to achieve maximum participation from the class. Regardless of the format, the activity should last a maximum of one hour. 14
  15. 15. Revised 5/31/2010 Guidelines for Assignment # 1- Case 15 (Due Session # 4, February 9th) Please note that this case is available in your book. Please answer the following questions related to “Case15: Wills Eye Hospital: A Specialty Hospital Survivor:” 1) Please provide a brief SWOT analysis for Wills Eye Hospital (you can use a table format). 2) How has the implementation of the mission statement of Wills Eye Hospital changed over the past decade? Are these changes consistent with the hospital’s original mission? 3) How important is it for Wills Eye Hospital to form a strategic alliance? What are some of the possible partners? What would the hospital offer to its partners? What would the possible partners offer to the hospital? 4) What are other strategic alternatives available to Wills Eye Hospital? What are the pros and cons of each alternative? The page limit is six double-spaced pages, Font 12, exclusive of any appendices. See page 18 for the complete criteria that will be used for the evaluation and grading of this assignment. 15
  16. 16. Revised 5/31/2010 Guidelines for Assignment # 2- Case 13 (Due Session # 6, February 23rd) Please note that this case is available in the packet. Please answer the following questions related to “Case 13: Emanuel Medical Center: Crisis in the Health Care Industry:” 1) What are the most important operational issues President Moen should address? 2) Please discuss the strategic alternatives available to Emanuel Medical Center. 3) What strategic option would you recommend to President Moen? The page limit is six double-spaced pages, Font 12, exclusive of any appendices. See page 19 for the complete criteria that will be used for the evaluation and grading of this assignment. 16
  17. 17. Revised 5/31/2010 Guidelines for Marketing Project (Due Session # 13, April 27th) Topics related to actual organizations: • HEB in San Antonio opening “RediClinic” inside an HEB Plus store in collaboration with Methodist Healthcare System. • Christus Santa Rosa in San Antonio opening a “Family Health Center”. • Northeast Baptist Hospital in San Antonio opening a new and expanded Women’s Services floor. • Northeast Baptist Hospital in San Antonio opening a new and expanded Cardiovascular Center • North Central Baptist Hospital in San Antonio opening a separate Emergency Room for children. • Southeast Baptist Hospital in San Antonio opening a new Cath Lab Center. • Covenant Healthcare opening a “hospital-clinic” hybrid in Southern Milwaukee. • Brooklyn Lutheran Medical Center in New York opening new unit to appeal to Chinese Community. • Any other service of interest to you (subject to instructor’s approval) Topics not related to actual organizations: • Hospital starting a fitness center. • Assisted Living facility opening a new unit geared to patients of Hispanic origin only. • Large health plan offering “Health Savings Account” plan. • Hospital starting sport medicine center. • Hospital offering an alternative medicine program. • Any other service of interest to you (subject to instructor’s approval) Please address the following issues: 1) Provide detailed background information on the new service selected. 2) Conduct a detailed marketing research for that service including: a) Problem recognition b) Objectives c) Research design: sources of data d) Data collection method(s) and sampling design (assuming that primary data sources are needed). e) Please design a short (2-3 pages) survey that can be used in your research. 3) Please describe some of the tactics that you would use in relation to this new service (Product/service; Price, Place and Promotion). 4) Please design an advertisement for this new service (billboard, newspaper, magazine, or radio), including the rationale for your choice. 17
  18. 18. Revised 5/31/2010 The page limit is sixteen double-spaced pages (including the survey), Font 12, exclusive of any appendices. See page 21 for the complete criteria that will be used for the evaluation and grading of this assignment. 18
  19. 19. Revised 5/31/2010 HCAD 5340: Strategic Planning and Marketing Evaluation of Assignment # 1 Name: Date: Elements of Evaluation Grade 1. Answers are logical, deep and /80% comprehensive 2. Paper is well-planned, well-written, and /10% logically organized. 3. Paper makes accurate use of relevant /10% concepts and theories. Comments: Grade: 19
  20. 20. Revised 5/31/2010 HCAD 5340: Strategic Planning and Marketing Evaluation of Assignment # 2 Name: Date: Elements of Evaluation Grade 1. Answers are logical, deep and /80% comprehensive 2. Paper is well-planned, well-written, and /10% logically organized. 3. Paper makes accurate use of relevant /10% concepts and theories. Comments: Grade: 20
  21. 21. Revised 5/31/2010 HCAD 5340: Strategic Planning and Marketing Evaluation of Marketing Project Paper Name: Date: Elements of Evaluation Grade 1 Appropriate background information is /20% provided 2. Marketing research is adequate and /30% logical 3. Survey developed is adequate /20% 4. Tactics used are appropriate. /20% 5. Advertisement is well designed. /20% 6. Paper is well-planned, well-written, and 10% logically organized Comments: Grade: 21
  22. 22. Revised 5/31/2010 HCAD 5340: Strategic Planning and Marketing Evaluation of Marketing Project Presentation Name: Date: Elements of Evaluation Grade 1. Main points are critically summarized /30% and well-presented. 2. Survey & advertisement are presented /30% and well discussed 3. Presentation is clear (audience can follow /20% the presentation, materials are clear, presenter speaks clearly and slowly). 4. Response to questions is appropriate. /20% Comments: Grade: 22
  23. 23. Revised 5/31/2010 HCAD 5340: Strategic Planning and Marketing Evaluation of Leading Class Discussion Name: Date: Elements of Evaluation Grade 1. Discussion questions are well addressed /30% 2. Additional questions are interesting and /30% relevant 3. Class participation is maximized /20% 4. Response to questions is appropriate. /20% Comments: Grade: 23
  24. 24. Revised 5/31/2010 HCAD 5340: Strategic Planning and Marketing Evaluation of Class Preparation/Contribution Name: Date: Elements of Evaluation Grade 1. Always appeared alert and engaged /50% 2. Participated in class discussions and contributed to others’ learning /50% Comments: Grade: 24

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