Health equity will gain increasing visibility, but little more
Michael Daley
Hs
Summary of the prediction
Health equity will acquire greater attention, but not that much. The COVID-19 epidemic brought to light and highlighted the fact that our country is experiencing a health equity catastrophe.
COVID-19 continues to unfairly impact low-income areas and ethnic minorities due to structural imbalances.
President Biden's health equity special team will be led by Yale University scholar Marcella Nunez-Smith, indicating that health equity will be a priority for the current regime.
Knowledge-based explanation
The process of discovering which health-related interventions are helpful in individuals or groups, how beneficial they are
And how well they can be implemented successfully for successful adoption is referred to as prevention science.
Policy changes are used in primary prevention efforts to enhance access to healthcare, needed pharmaceuticals, and nutritional meals.
Knowledge-based explanation
A health transition is a change in a general population’s state of health that typically happens in tandem with socioeconomic growth in developing countries. This health transition is needed for health equity.
According to a recent review of pharmacy data, African-American and Latino health plan participants perform worse on key indicators of treatment outcomes than Caucasians
Organizations SCAN Group and SCAN Health Plan, are working towards health equity
They are establishing company-wide objectives in order to better their results.
Scientific management
Integrating health equality concerns into policy and programmers, partnering with other areas to address disparities, interacting with community to ensure their initiatives to solve disparities, and recognizing the lowering of health disparities are all ways that public health can help to reduce health disparities.
Collaboration, policy reform advocacy, good management, and nursing teaching are all important parts of the medical staff's role in eliminating health inequities.
Relationship Between Scientific management theory and the prediction
The scientific management philosophy aimed to boost the effectiveness of each individual in an organization.
Public health care should be made accessible and affordable to low income individuals by setting up campaigns and initiatives to make sure they know where the services are provided
Equal treatment should be given to all. No discrimination
Doctors, nurses as well as other medical staff should make sure all the patients and people in their communities are getting equal treatment
References
Sachin H. (2020). Top 10 Healthcare Industry Predictions For 2021.Forbes.https://www.forbes.com/sites/sachinjain/2020/12/16/top-10-healthcare-industry-predictions for-the-year-2021/?sh=146b895d2d07
WHO. (2020). Equitable Access to Safe and Effective Vaccines .https://www.who.int/emergencies/diseases/novel-coronavirus-
McFarland A, ...
[GET]⚡BOOK✔ Jonas and Kovner's Health Care Delivery in the United States 11t...zolliparasnyut
Jonas and Kovner's Health Care Delivery in the United States is one of the stronger health policy texts on the market. Readers and instructors looking for an uptodate broadbased overview of US health policy should strongly consider using the book.The Journal of the American Medical Association (JAMA) (From reviews of the 10th Edition.)Health care managers practitioners and students must both operate as effectively as they can the daunting and continually evolving system at hand and identify opportunities for reform advances Health Care Delivery in the US has been an indispensable companion to those preparing to manage this balance. The present edition demonstrates once again why this volume has come to be so prized. It takes the long view charting recent developments in health policy and putting them sidebyside with descriptions and analysis of existing programs in the US and abroad.She
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The December edition of the Professional Diversity Network Jobs Index & Report focuses on the Healthcare sector and the position of the diverse employee and candidate in this rapidly growing segment of the US economy.
The life, medical, and health sciences represent a broad array of disciplines that generally involve the biology and health of people, plants, and animals. These fields, especially when the provision of medical care is included, make up an important and growing part of Michigan’s economy. Approximately 533,000 Michiganders were employed in one of these sectors in 2015, representing approximately one in eight jobs. Between 2011 and 2015, the sector added 21,000 jobs, with growth of 4.2 percent. While this growth is slower than the overall economy during this period, this slower growth is misleading. Michigan’s economy is still recovering from the sharp employment declines that occurred in the 2000s, a decline that the life, medical, and health sciences did not experience. Compared to its 2000 level, employment in the life, medical and health sciences is up 18.9 percent, while overall Michigan employment is still down 9.3 percent.1 The ability of the sector to grow while the rest of Michigan’s economy was contracting represents an important stabilizing force for the economy.
[GET]⚡BOOK✔ Jonas and Kovner's Health Care Delivery in the United States 11t...zolliparasnyut
Jonas and Kovner's Health Care Delivery in the United States is one of the stronger health policy texts on the market. Readers and instructors looking for an uptodate broadbased overview of US health policy should strongly consider using the book.The Journal of the American Medical Association (JAMA) (From reviews of the 10th Edition.)Health care managers practitioners and students must both operate as effectively as they can the daunting and continually evolving system at hand and identify opportunities for reform advances Health Care Delivery in the US has been an indispensable companion to those preparing to manage this balance. The present edition demonstrates once again why this volume has come to be so prized. It takes the long view charting recent developments in health policy and putting them sidebyside with descriptions and analysis of existing programs in the US and abroad.She
Building Patient-Centeredness in the Real World: The Engaged Patient and the ...EngagingPatients
This paper examines the separate but intertwined ethical, economic and clinical concepts of patientcenteredness and how ACOs provide a structure for turning those concepts into a functioning reality.
The December edition of the Professional Diversity Network Jobs Index & Report focuses on the Healthcare sector and the position of the diverse employee and candidate in this rapidly growing segment of the US economy.
The life, medical, and health sciences represent a broad array of disciplines that generally involve the biology and health of people, plants, and animals. These fields, especially when the provision of medical care is included, make up an important and growing part of Michigan’s economy. Approximately 533,000 Michiganders were employed in one of these sectors in 2015, representing approximately one in eight jobs. Between 2011 and 2015, the sector added 21,000 jobs, with growth of 4.2 percent. While this growth is slower than the overall economy during this period, this slower growth is misleading. Michigan’s economy is still recovering from the sharp employment declines that occurred in the 2000s, a decline that the life, medical, and health sciences did not experience. Compared to its 2000 level, employment in the life, medical and health sciences is up 18.9 percent, while overall Michigan employment is still down 9.3 percent.1 The ability of the sector to grow while the rest of Michigan’s economy was contracting represents an important stabilizing force for the economy.
1
Literature Review Assignment
STUDENT NAME
Class
Date
2
Part A: Annotated Bibliography
Article 1: Immigration as a Social Determinant of Health
Castañeda, H., Holmes, S. M., Madrigal, D. S., Young, M.-E. D., Beyeler, N., & Quesada, J.
(2015). Immigration as a Social Determinant of Health. Annual Review of Public
Health, 36(1), 375–392. doi: 10.1146/annurev-publhealth-032013-182419
Abstract
Although immigration and immigrant populations have become increasingly important foci in
public health research and practice, a social determinants of health approach has seldom been
applied in this area. Global patterns of morbidity and mortality follow inequities rooted in
societal, political, and economic conditions produced and reproduced by social structures,
policies, and institutions. The lack of dialogue between these two profoundly related
phenomena—social determinants of health and immigration—has resulted in missed
opportunities for public health research, practice, and policy work. In this article, we discuss
primary frameworks used in recent public health literature on the health of immigrant
populations, note gaps in this literature, and argue for a broader examination of immigration as
both socially determined and a social determinant of health. We discuss priorities for future
research and policy to understand more fully and respond appropriately to the health of the
populations affected by this global phenomenon.
Annotated Bibliography
The article reports on the importance of identifying social determinants and the effects of
socially determined structures among immigrant populations in the United States. The study
identifies ways in which immigrants health outcomes are based on biases due to using
3
information based on group behaviors instead of on an induvial case. The impact of migrant and
immigrant individuals, physical and mental health in these communities’ changes as social,
economic, and political policies take place. This article is helpful in that broadens the
immigration experience including more central factors than just language, income, or education
as the cause of all health related problems in this community. But to show factors of power
structures and the ability to put in place effective health interventions that respond to direct
causes of poor or declining health in these populations.
Article 2: Fear by Association: Perceptions of Anti-Immigrant Policy and Health Outcomes
Vargas, Edward & Sanchez, Gabriel & Juárez, Melina. (2017). Fear by Association: Perceptions
of Anti-Immigrant Policy and Health Outcomes. Journal of Health Politics, Policy and
Law. 42. 3802940. 10.1215/03616878-3802940.
Abstract
The United States is experiencing a renewed period of immigration and immigrant policy
activity as well as heightened enforcement of such policies. This intensified activity can affect
various aspects of im ...
The Academy White Paper was published in October 2014 as a means to tell the Academy’s story, the history of how AIHM came to be, and why its formation is timely and important.
What thanksgiving means for patients and providers?Jessica Parker
Thanksgiving is a federal holiday in the United States, celebrated on the fourth Thursday of November celebrating the harvest and other blessings of the past year. The word thanksgiving means giving of thanks to God, especially in a religious ceremony.
Hai,this is Anusha. am looking for a help with my research.docxJeanmarieColbert3
Hai,
this is Anusha. am looking for a help with my research papers. subject is homeland security and contemporary issues and the topics are
1.Border security is key to immigration reform??
2.walls won't keep us safe
may i get it done by Thursday evening. and also lemme know the amount for both the papers. am also attaching the paper rubric here
thank you.
.
Guys I need your help with my international law class, Its a course.docxJeanmarieColbert3
Guys I need your help with my international law class, It's a course on International Law but it's not in essence a law course but part of the concentration I'm in, which is International Relations (in the School of Humanities and Social Sciences) my essay question is the following:
Are the jurisdictions of states absolute and unlimited?
.
hare some memories of encounters with people who had very different .docxJeanmarieColbert3
hare some memories of encounters with people who had very different expectations of their children compared to your own (it doesn't matter if you have children or not, just think about what you would have expected in their place). We tend to think of these situations in terms of good parents and bad parents, but speculate about the possible role of culture. Are there ways to avoid problems when parents with different cultural standards mix?
.
Hacker or SupporterAnswer ONE of the following questionsQuestio.docxJeanmarieColbert3
Hacker or Supporter
Answer ONE of the following questions:
Question A
In a 2-4 page paper, critique the case of Julian Assange, who created the Web site Wikileaks. Is Assange a glorified hacker and threat to national and international security or is he a supporter for human rights and freedom of speech?
.
HA415 Unit 6Discussion TopicHealthcare systems are huge, compl.docxJeanmarieColbert3
HA415 Unit 6
Discussion Topic
Healthcare systems are huge, complex, and constantly changing as they respond to economic, technological, social, and historical factors. The availability of technology has a profound effect on the health care costs and the availability of medical care. Local, state and national policy makers have an impact on these systems. Explain what you would do to encourage and increase technological advances and availability and try to decrease costs for all the stakeholders involved.
Needs 250 -300 words paper, strictly on topic and original with a Scholar References. Please No Phagiarism!
.
HA410 Unit 7 AssignmentUnit outcomes addressed in this Assignment.docxJeanmarieColbert3
HA410 Unit 7 Assignment
Unit outcomes addressed in this Assignment:
● Identify significant standards for healthcare documentation.
● Understand important factors involved in regulations pertaining to paper and electronic health records.
Course outcomes addressed in this Assignment:
HS410-4: Compare standards and regulations for healthcare documentation.
Instructions:
Your boss is the Director of Medical Records at a large academic medical center. He is finding it difficult to monitor the ongoing legislative and policy changes related to Health Information Management. He has asked that you do the following:
1) Visit the AHIMA website (www.ahima,org) and visit the “Advocacy and Public Policy” tab.
2) From there, visit both the “Legislation” and “News and Alerts” menu options.
3) Prepare two pages report highlighting the two most important items your boss should be aware of.
4) Recommend a course of action for each.
Paper should be 600- 800 words length, strictly on topic, informative, and original with 2-3 scholar referencess. No repeatation of words. Please use and read the attached document and follow all the instructions and use the grading rubrics below to do this assignment.
NO PHARGIARIAM!!
Unit 7 Assignment Grading Rubrics:
Instructors: to complete the rubric, please enter the points the student earned in the green cells of column E. Then determine point deductions for writing, late policy, etc in the red cells to calculate the final grade.
Assignment Requirements
Points possible
Points earned by student
Student understands issues related to health information management.
0-40
Student can assess policy and news items impact health information management.
0-40
Student can make well supported recommendations to address current legislative and policy issues in health information management.
0-40
Student prepares a well-crafted report in APA format using the AHIMA website and other sources, as needed.
0-30
Total (Sum of all points)
150
0
*Writing Deductions (Maximum 30% from points earned):
Grammar/Punctuation/Spelling:
30%
Order of Ideas/Length requirement (if applicable):
30%
Format
10%
*Source citations
30%
Late Submission Deduction: (refer to Syllabus for late policy)
Adjusted total points
0
*If sources are not cited and work is plagiarized, grade is an automatic zero and further action may take place in accordance with the Academic Integrity Policy as described in the university catalog.
Final Percentage
0%
Feedback:
.
hacer oír salir suponer traer ver 1. para la clase a la.docxJeanmarieColbert3
hacer oír salir
suponer traer ver
1.
para la clase a las dos.
2.
Los fines de semana mi computadora a casa.
3.
que me gusta trabajar los sábados por la mañana.
4.
Por las mañanas, música en la radio.
5.
Cuando tengo hambre, un sándwich.
6.
Para descansar, películas en la televisión.
.
H07 Medical Coding IDirections Be sure to make an electronic c.docxJeanmarieColbert3
H07 Medical Coding I
Directions
: Be sure to make an electronic copy of your answer before submitting it to Ashworth College for grading. Unless otherwise stated, answer in complete sentences, and be sure to use correct English spelling and grammar. Sources must be cited in APA format. Your response should be two (2) to four (4) pages in length; refer to the "Assignment Format" page for specific format requirements.
Lesson 1, 2, 3, and 4 of this course has covered a wide variety of topics. Thus far, you have learned a great deal of information on health insurance, medical contracts, HIPAA, physician and hospital medical billing, and Medicare and Medicaid.
For this writing assignment, please explain why the following course objectives are important for medical billers and coder to understand:
1.
Understand the history and impact of health insurance on health care reimbursement process and recognize various types of health insurance coverage.
2.
Identify the key elements of a managed care contract and identify the role HIPAA plays in the health care industry.
3.
Recognize and explain the different components of physician and hospital billing and differentiate between the two types of services.
4.
Explain the difference between Medicare and Medicaid billing.
Please include at least 3 scholarly articles within your response. Overall response will be formatted according to APA style and the total assignment should be between 2-4 pages not including title page and reference page.
.
More Related Content
Similar to Health equity will gain increasing visibility, but little more
1
Literature Review Assignment
STUDENT NAME
Class
Date
2
Part A: Annotated Bibliography
Article 1: Immigration as a Social Determinant of Health
Castañeda, H., Holmes, S. M., Madrigal, D. S., Young, M.-E. D., Beyeler, N., & Quesada, J.
(2015). Immigration as a Social Determinant of Health. Annual Review of Public
Health, 36(1), 375–392. doi: 10.1146/annurev-publhealth-032013-182419
Abstract
Although immigration and immigrant populations have become increasingly important foci in
public health research and practice, a social determinants of health approach has seldom been
applied in this area. Global patterns of morbidity and mortality follow inequities rooted in
societal, political, and economic conditions produced and reproduced by social structures,
policies, and institutions. The lack of dialogue between these two profoundly related
phenomena—social determinants of health and immigration—has resulted in missed
opportunities for public health research, practice, and policy work. In this article, we discuss
primary frameworks used in recent public health literature on the health of immigrant
populations, note gaps in this literature, and argue for a broader examination of immigration as
both socially determined and a social determinant of health. We discuss priorities for future
research and policy to understand more fully and respond appropriately to the health of the
populations affected by this global phenomenon.
Annotated Bibliography
The article reports on the importance of identifying social determinants and the effects of
socially determined structures among immigrant populations in the United States. The study
identifies ways in which immigrants health outcomes are based on biases due to using
3
information based on group behaviors instead of on an induvial case. The impact of migrant and
immigrant individuals, physical and mental health in these communities’ changes as social,
economic, and political policies take place. This article is helpful in that broadens the
immigration experience including more central factors than just language, income, or education
as the cause of all health related problems in this community. But to show factors of power
structures and the ability to put in place effective health interventions that respond to direct
causes of poor or declining health in these populations.
Article 2: Fear by Association: Perceptions of Anti-Immigrant Policy and Health Outcomes
Vargas, Edward & Sanchez, Gabriel & Juárez, Melina. (2017). Fear by Association: Perceptions
of Anti-Immigrant Policy and Health Outcomes. Journal of Health Politics, Policy and
Law. 42. 3802940. 10.1215/03616878-3802940.
Abstract
The United States is experiencing a renewed period of immigration and immigrant policy
activity as well as heightened enforcement of such policies. This intensified activity can affect
various aspects of im ...
The Academy White Paper was published in October 2014 as a means to tell the Academy’s story, the history of how AIHM came to be, and why its formation is timely and important.
What thanksgiving means for patients and providers?Jessica Parker
Thanksgiving is a federal holiday in the United States, celebrated on the fourth Thursday of November celebrating the harvest and other blessings of the past year. The word thanksgiving means giving of thanks to God, especially in a religious ceremony.
Hai,this is Anusha. am looking for a help with my research.docxJeanmarieColbert3
Hai,
this is Anusha. am looking for a help with my research papers. subject is homeland security and contemporary issues and the topics are
1.Border security is key to immigration reform??
2.walls won't keep us safe
may i get it done by Thursday evening. and also lemme know the amount for both the papers. am also attaching the paper rubric here
thank you.
.
Guys I need your help with my international law class, Its a course.docxJeanmarieColbert3
Guys I need your help with my international law class, It's a course on International Law but it's not in essence a law course but part of the concentration I'm in, which is International Relations (in the School of Humanities and Social Sciences) my essay question is the following:
Are the jurisdictions of states absolute and unlimited?
.
hare some memories of encounters with people who had very different .docxJeanmarieColbert3
hare some memories of encounters with people who had very different expectations of their children compared to your own (it doesn't matter if you have children or not, just think about what you would have expected in their place). We tend to think of these situations in terms of good parents and bad parents, but speculate about the possible role of culture. Are there ways to avoid problems when parents with different cultural standards mix?
.
Hacker or SupporterAnswer ONE of the following questionsQuestio.docxJeanmarieColbert3
Hacker or Supporter
Answer ONE of the following questions:
Question A
In a 2-4 page paper, critique the case of Julian Assange, who created the Web site Wikileaks. Is Assange a glorified hacker and threat to national and international security or is he a supporter for human rights and freedom of speech?
.
HA415 Unit 6Discussion TopicHealthcare systems are huge, compl.docxJeanmarieColbert3
HA415 Unit 6
Discussion Topic
Healthcare systems are huge, complex, and constantly changing as they respond to economic, technological, social, and historical factors. The availability of technology has a profound effect on the health care costs and the availability of medical care. Local, state and national policy makers have an impact on these systems. Explain what you would do to encourage and increase technological advances and availability and try to decrease costs for all the stakeholders involved.
Needs 250 -300 words paper, strictly on topic and original with a Scholar References. Please No Phagiarism!
.
HA410 Unit 7 AssignmentUnit outcomes addressed in this Assignment.docxJeanmarieColbert3
HA410 Unit 7 Assignment
Unit outcomes addressed in this Assignment:
● Identify significant standards for healthcare documentation.
● Understand important factors involved in regulations pertaining to paper and electronic health records.
Course outcomes addressed in this Assignment:
HS410-4: Compare standards and regulations for healthcare documentation.
Instructions:
Your boss is the Director of Medical Records at a large academic medical center. He is finding it difficult to monitor the ongoing legislative and policy changes related to Health Information Management. He has asked that you do the following:
1) Visit the AHIMA website (www.ahima,org) and visit the “Advocacy and Public Policy” tab.
2) From there, visit both the “Legislation” and “News and Alerts” menu options.
3) Prepare two pages report highlighting the two most important items your boss should be aware of.
4) Recommend a course of action for each.
Paper should be 600- 800 words length, strictly on topic, informative, and original with 2-3 scholar referencess. No repeatation of words. Please use and read the attached document and follow all the instructions and use the grading rubrics below to do this assignment.
NO PHARGIARIAM!!
Unit 7 Assignment Grading Rubrics:
Instructors: to complete the rubric, please enter the points the student earned in the green cells of column E. Then determine point deductions for writing, late policy, etc in the red cells to calculate the final grade.
Assignment Requirements
Points possible
Points earned by student
Student understands issues related to health information management.
0-40
Student can assess policy and news items impact health information management.
0-40
Student can make well supported recommendations to address current legislative and policy issues in health information management.
0-40
Student prepares a well-crafted report in APA format using the AHIMA website and other sources, as needed.
0-30
Total (Sum of all points)
150
0
*Writing Deductions (Maximum 30% from points earned):
Grammar/Punctuation/Spelling:
30%
Order of Ideas/Length requirement (if applicable):
30%
Format
10%
*Source citations
30%
Late Submission Deduction: (refer to Syllabus for late policy)
Adjusted total points
0
*If sources are not cited and work is plagiarized, grade is an automatic zero and further action may take place in accordance with the Academic Integrity Policy as described in the university catalog.
Final Percentage
0%
Feedback:
.
hacer oír salir suponer traer ver 1. para la clase a la.docxJeanmarieColbert3
hacer oír salir
suponer traer ver
1.
para la clase a las dos.
2.
Los fines de semana mi computadora a casa.
3.
que me gusta trabajar los sábados por la mañana.
4.
Por las mañanas, música en la radio.
5.
Cuando tengo hambre, un sándwich.
6.
Para descansar, películas en la televisión.
.
H07 Medical Coding IDirections Be sure to make an electronic c.docxJeanmarieColbert3
H07 Medical Coding I
Directions
: Be sure to make an electronic copy of your answer before submitting it to Ashworth College for grading. Unless otherwise stated, answer in complete sentences, and be sure to use correct English spelling and grammar. Sources must be cited in APA format. Your response should be two (2) to four (4) pages in length; refer to the "Assignment Format" page for specific format requirements.
Lesson 1, 2, 3, and 4 of this course has covered a wide variety of topics. Thus far, you have learned a great deal of information on health insurance, medical contracts, HIPAA, physician and hospital medical billing, and Medicare and Medicaid.
For this writing assignment, please explain why the following course objectives are important for medical billers and coder to understand:
1.
Understand the history and impact of health insurance on health care reimbursement process and recognize various types of health insurance coverage.
2.
Identify the key elements of a managed care contract and identify the role HIPAA plays in the health care industry.
3.
Recognize and explain the different components of physician and hospital billing and differentiate between the two types of services.
4.
Explain the difference between Medicare and Medicaid billing.
Please include at least 3 scholarly articles within your response. Overall response will be formatted according to APA style and the total assignment should be between 2-4 pages not including title page and reference page.
.
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Guidelines:
1.
Paper consisting of 2,000-2,250 words; however, the reference page isn’t included as any part of the word count.
2.
Provide a thesis and/or main claim that is clear and comprehensive. This is the essence of the paper.
3.
APA formatting: in-text citations, headings, correct sentence structure, paragraph transition.
4.
Please apply the attached (4) readings to this homework.
5.
Address the following in the paper:
a.
Briefly describe the company
REI
using the Baldrige Performance Excellence framework.
b.
Using the Baldrige framework, outline
REI
organization's leadership structure and practices (
innovation, communication, and diversity
) chosen to study.
c.
Describe the evidence you find to identify that organization's leadership style (
servant and authentic
) by using specific references from the research literature to support your description.
d.
As a researcher of organizational leadership, how does the Baldrige framework help assess organizational leadership?
e.
Identify any
gaps
in assessment the framework does not address, and describe them with references from other sources.
.
Guidelines12-point fontCambria fontSingle space50 words ma.docxJeanmarieColbert3
Guidelines
12-point font
Cambria font
Single space
50 words maximum per section summarized (Be concise. I would prefer less than 50 words)
Sections to summarize-
(50 words summary for each topic )
Genetics Versus Epigenetics
Defining Epigenetics
DNA methylation
RNAi and RNA-directed Gene Silencing
From Unicellular to Multicellular Systems
.
HA425 Unit 2 discussion- Organizational Behavior and Management in H.docxJeanmarieColbert3
HA425 Unit 2 discussion- Organizational Behavior and Management in Health Care - Discussion
Discussion Topics
1.
Discuss the role and importance of organizational culture in promoting organizational change, organizational learning, and quality of healthcare.
2. Explain how teamwork is used in the CQI process and its impact on the process.
NO PHARGIARISM!!! Paper must be 500 words, strictly on topic, well detailed and original with 2-3 scholar referencsea. No repeatation.
.
GuidelinesPaper is based on one novel , Frankenstein. We ha.docxJeanmarieColbert3
Guidelines
Paper is based on one novel ,
Frankenstein
. We have
learned that one element crucial to horror stories is a monster. After reading the
entire novel , you will write a two- to three-page paper analyzing whether Victor Frankenstein or the
creation is the true monster in the novel.
You must pick one. Then state three
reasons/actions why he is the monster.
DO NOT:
o
Claim they are both monsters
o
Claim that neither is
o
Claim that there is no monster because Victor is hallucinating, has
a split personality, is dreaming, etc.
o
Claim that the real monster is abstract/philosophical--narcissism,
society, nature vs. nurture, etc
These are all innovative and great and may make a great essay but that's not
the assignment.
You must make a claim that Victor is the true monster
OR his creation is the true monster and support your claim.
Even though it is your interpretation of who the monster is, when you write
academic essays, you are really asserting a claim and attempting to convince
readers to agree with your stance. To do this effectively, it’s best to create a
more objective tone, pulling back on personal statements and writing in terms of
what Shelley intended and how readers in general perceive/infer the information.
In other words, avoid statements like: “I think the monster is really Victor
Frankenstein.” And use statements like: “After careful analysis of Shelley’s
characters, readers agree that Victor is the true monster of the novel.” Also, a
major pitfall to avoid: Do not claim that the monster is Victor then focus on the
creation in the body of the essay and why the creation is not the monster.
Throughout the semester, I have been posing questions on the Discussion Board
that you have been responsible for. You were then required in some weeks to
respond to a peer’s answers. The purpose of this is to cultivate interaction among
peers as you are working in such solitude when in an online environment.
However, I know that it is hard to routinely read a lot of what your peers have to
say. So this second paper is the one opportunity for you to truly HEAR several
angles of a discussion, much like in a traditional classroom, and assimilate the
opinions of your classmates.
For the essay, after you first come to your own observation about who the true
monster is then read through a handful of each of the four
Frankenstein
discussion threads (Storyline Shift, Victor Frankenstein, The Creation, and
Frankenstein Finale). Find a few posts that support your observation. You do not
need to read through all of the posts for each thread but read through enough to
help inform your selection. Throughout your essay you will need to
include at
least three quotes from two different threads (one per body
paragraph/reason).
These quotes need to support your claim. In other words, if
you claim that Victor is the monster, don’t include a quote by a peer that focuses
on the monster’s compassion. Also, be.
Guidelines1.Paper word count should be 1,000-1,250. Refer.docxJeanmarieColbert3
Guidelines:
1.
Paper word count should be 1,000-1,250. Reference page should not be counted in the word count.
2.
Following issues to be addressed in the paper:
a.
Discuss the conceptual differences between Transformational-Transactional Leadership and the visions of future developments in leadership Warren Bennis was predicting.
b.
Using the guidance of both leadership theorists and applied behavioral scientists, compose your basic definition of organizational leadership that is functional in organizations you know.
c.
Drawing from tenets of the Christian worldview related to organizational leadership, compare the key points of that guidance with two key elements (leadership and integrity) of organizational leadership.
d.
Support your comparisons with substantive documentation for each of the two key elements of current theories.
3.
Due date: No later than Wednesday, October 12, 2016 at noon (EST)
.
Guided Response Respond to at least two of your classmates. Ch.docxJeanmarieColbert3
Guided Response:
Respond to at least two of your classmates. Choose posts that address a different developmental period than you chose. Determine if the selected activity and toy is appropriate to the age group and is tied to Piaget’s theory. Provide feedback and suggestions for improvement.
Melissa Pieringer
An activity for the adolescent room: hypothetical problem solving
According to Piaget’s theory children 12 and over are in the formal operations stage of cognitive development. This is the final stage of cognitive development that takes place prior to adulthood. Children at this stage are developing abstract reasoning, deductive reasoning, and hypothetical thinking skills. Children at this stage are able to use hypothetico-deductive reasoning which involves forming a hypothesis, predicting a possible or likely outcome for a given scenario, and taking into consideration various factors that may influence the outcome (Mossler, 2014). At the formal operations stage children also develop the ability to think abstractly and weigh multiple potential outcomes for a given situation (Mossler, 2014). According to the Jean Piaget Society (2016), one of the best ways to promote the development of abstract thinking skills is to explore hypothetical topics, global issues, political issues, or social issues and allow children to come up with potential creative solutions to the problem (The Jean Piaget Society, 2016). A suggested hypothetical scenario to explore could be how humans could live in outer space (The Jean Piaget Society, 2016). Other present day issues to explore could include global warming, pollution, limited resources, war, poverty, famine, etc.
A toy or object for the adolescent room: art and crafting supplies
It is suggested that educators working with children at this stage use visual models such as charts, illustrations, and diagrams to keep children engaged in learning (The Jean Piaget Society, 2016). Furthermore, children should be encouraged to work creatively with a variety of materials. Art and crafting supplies could be used to create illustrations, diagrams, or posters demonstrating the solutions that they come up with to the topic or issue being explored. Therefore, I would request that a variety of art and crafting supplies be given to the adolescent room. Some ideas for materials could include the following:
· Poster paper or boards
· Paint
· Markers
· Colored pencils
· Crayons
· Scissors
· Glue or glue sticks
· Construction paper
· Old magazines
· Stencils
· Rulers
· String
References
Mossler, R. (2014).
Child and Adolescent Development
(2
nd
ed.) [Electronic ed.]. Retrieved
from:
https://content.ashford.edu/
The Jean Piaget Society. (2016). Educational implications of Piaget’s theory. Retrieved from:
http://piaget.weebly.com/educational-implications--activities.html
Christina Gutierrez
Cognitive De.
Guided ResponseReview the philosophies of education that your.docxJeanmarieColbert3
Guided Response:
Review the philosophies of education that your classmates chose and write a minimum 150-word response to at least two of them. Comment on whether you agree or disagree with their philosophies of education and their rational for them. Suggest additional ways in which the theories they have chosen could be applied to educational environments.
By:
Melissa
I have been in the classroom for over 12 years, and every day I learn something new. Every day I encounter a new student or discover something new about a student in my class that has been there the whole year. Every encounter is different, every child is different, and not one child thinks the same or learns the same. I discovered this early on in my teaching career, but I am constantly reminded how we cannot take for granted streamlined teaching in the classroom.
Teachers are not the only ones who teach in the classroom, the students in your classroom teach each other and teach you the teacher how to explain something differently and view things differently and reach the same destination to answer the same question correctly. I believe that being an effective teacher one must get to know students on a personal level. Not by reading their folders at the beginning of the year, but by asking open ended questions, listening to how they respond and how they express themselves either verbally or written expression. Teachers need to listen to their students not just hear them and move on, but take the child as a whole and help them reach another level in their education journey.
Special education is more than just accommodations; it is accommodating children to their needs and finding what works for them. Some need verbal cues to know that they are doing well and motivate them to keep working towards success, while others need positive written expression to push them over the hump and work to accomplish their goals. Most children with learning disabilities suffer from low self esteem and act up or become the class clown are constantly in trouble. They become the trouble makers or the ones always in trouble for not completing homework assignments, and because teachers only see this on the surface they push them off to one side of the classroom. What most general education teachers don’t see is how much they are asking for help.
Education should be used to empower every student and every teacher. Being an educator is more than just teaching to a test, it is planting the seed of enjoying the love for learning. We need to remember that we are educating our future.
By:
Katrina
Children learn best in an environment where they feel safe, especially younger children in an early childhood program. For toddlers the progressivism philosophy is one that works best. Toddlers cannot sit still for long periods of time and they need things that are developmentally appropriate. They need activities that allow them to use all of their senses. As they are touching and seeing while list.
Guided Response When responding to your peers, suggest ways to.docxJeanmarieColbert3
Guided Response:
When responding to your peers, suggest ways to continue to strengthen the contribution listed, so that this influence remains strong in our education system today. Describe why you believe this contribution should continue to be a part of our current education system. Respond to at least two peers.
BY: Tiffany Futch
Improved teaching means teachers were taught to teach on more of a professional level by actual people qualified to teach. Normal schools broadened their curricula to the training of secondary school teachers, requirement of the completion of high school to be admitted to college for teacher training, teachers must have a bachelor’s degree. “High school completion was seldom required for admission, and the majority of instructors did not hold a college degree themselves.” (Diener, 2008). Society has come a long way when it comes to teaching, and who is qualified to teach. Higher education is required more than ever in today’s society, and all of these examples have helped with the success of the way teachers complete their degrees today.
When it comes to teaching in the 21
st
century, full time teachers are required to have a minimum of a four year bachelor’s degree. Technology helps play a role in the success of teachers and students in and out of the classroom. Like the rest of the class we are all completing our degree in an online program. When it comes to teaching in the classroom teachers can use computers and other devices to help children excel, and outside of the classroom, the students can utilize the internet to help them with projects, and even communicate with other students to help with projects.
Webb. L. D. (2014). History of American education: Voices and perspectives. San Diego, CA: Bridgepoint Education, Inc.
BY:Christine Rodriguez
Teacher training is very important for teachers because they should be able to teach multiple subjects and be qualified in what they are teaching. Strengthening of the normal school curriculum and standards was needed in order for the school system to get better. In the 1900's schools exploded from 50 to almost 350, but with the low academic levels, teacher and students were not able to teach or learn at a college level. Teachers did not have, at this point, a college degree themselves. As the population kept increases and there was a higher demand for education, everyone began to need a high school diploma to be admitted for a college degree.
University enter teacher training: "Teacher training at the college or university level, typically consisted of one or two courses in the "science and art" of teaching, had been offered at a limited number of institutions as early as the 1830s, and the universities had always been institutions for the education of those who taught in the Latin grammar schools, academies, and high schools" (Webb, 2014).
This did not qualify them as teachers when they took these courses, but it did make them becom.
Guided Response As you read the responses of your classmates, con.docxJeanmarieColbert3
Guided Response:
As you read the responses of your classmates, consider how their negative educational experience could have been changed to support student learning. Respond to at least two of your classmates’ posts. Provide additional suggestions for them in creating their own positive, stimulating learning environment. Be sure to respond to any queries or comments posted by your instructor.
Melissa Cagno
The biggest negative experience that I have had is with a previous employer, and it was my first day as a preschool teacher in a facility nearby. On my first day, I walked into a situation that made a huge impact on the way I viewed this facility. When I started that day, I was told that I would not be in “my classroom” that I would be filling in for a teacher that was out that day. I didn’t have an issue with that fact and was actually up for the challenge. But when I entered the classroom I noticed there were no rules, no structure, no lesson plans and the classroom was complete chaos. I managed to create some spur of the moment lessons and engaged in music as much as possible. Then when it was time for lunch, and I went to serve it, it was pure sugar and very unhealthy. I left for the day feeling defeated, tired, frustrated and stressed and nowhere to turn. I expressed my concerns throughout the day along with a lot of severe health issues to the owner and was brushed off. I care a lot about the children’s safety and their learning environment, and I felt like I was drowning. Needless to say, I ended up moving on from that position because I felt helpless and without a direction to improve anything.
I have had several positive experiences throughout my educational background. The classrooms were always welcoming, warm and inviting and it showed that the teachers cared about their classrooms and their students. Those classrooms made me excited about becoming a teacher and gave me something to work towards in the future.
“The foundation for successful learning and a safe and secure classroom climate is the relationship that teachers develop with their students (Sousa, Tomlinson, 2011)”. The teacher-student relationship is something that should be built on from day one. If the students do not trust or know you, they will feel uneasy and unsafe in the classroom environment. It is so important to form the relationship with your students to ensure communication and safety of your students. Another way to provide a positive learning environment is with your attitude. If you have a positive and fun attitude, it will show through your lessons and your students will enjoy being in your class every day which will affect how they learn. Lastly, the organization is a big key to a positive and stimulating learning environment. If your classroom is packed full of stuff or the students, do not know where materials are it can cause frustrations for you and your students.
I firmly believe there are no stupid questions! I want to ensure my stude.
Guided ResponseReview several of your classmates’ posts and res.docxJeanmarieColbert3
Guided Response:
Review several of your classmates’ posts and respond to at least two of your peers original posts. Please keep in mind that this assignment can be a sensitive subject and that people’s past experiences may have shaped their views. Choose one point from your peer’s post that made an impact on you and explain why this particular comment resonated with you. Share your thoughts on the disadvantages and advantages of segregation with your peers.
BY:
Tiffany
Bradley
When preparing for this week’s discussion post I was a little at awe, I personally had never heard of the little rock nine. And I’m not that far from Arkansas. The Little Rock Nine was a group of nine African American students that were enrolled in Little Rock Central High School in 1957. However, their enrollment was engaged by the Little Rock Crisis. Which the students were initially prevented from entering the racially segregated school by Orval Faubus, the Governor of Arkansas. When President Dwight D. Eisenhower done an intervention, the students were then allowed to attend the school. The nine students were Ernest Green, Elizabeth Eckford, Jefferson Thomas, Terrance Roberts, Thelma Mothershed, and Melba Pattillo Beals. (https://en.wikipedia.org/wiki/Little_Rock_Nine)
Personally, if I was in the situation that these nine students experienced I would have been lost, afraid, and felt like something was wrong with me. A child of any race should not have to be put in this situation to feel unwanted or that they are unwelcome because they are of a different color. Many times however that is not the case. And this was the case for these nine children. My reaction would have been a sense of sadness, and anger. I don’t believe I would not have made a seen, simply out of fear of being hurt. I would have wanted to stand up for myself as well as my peers of the same color. Nowadays, if the situation would arise that an African American child was not allowed into a while school, yes I would stand up. And voice my opinion. It should not matter the color of a child’s skin. They should be allowed to receive the proper education. Without first having to go through turmoil. This situation I’m sure was emotionally devastating for these nine children. Who simply just wanted to get an education. (Webb. L. D. (2014). History of American education: Voices and perspectives. San Diego, CA: Bridgepoint Education, Inc.)
De facto segregation, I believe does not have a detrimental effect on students nowadays. Some adults that were raised to racial, still are. But if children are taught not to be that way. Then most of the time children learn to except another student of a different minority. Where I live we have a lot of white and minority students. Which none are treated differently. They are all in school for the same reason to get an education. My own personal beliefs are we are all children of God, and just because we are different races, does not mean.
Guided ResponseYou must reply to at least one classmate. As y.docxJeanmarieColbert3
Guided Response:
You must reply to at least one classmate
. As you reply to your classmates, attempt to extend the conversation by examining their claims or arguments in more depth or by responding to the posts that they make to you. Keep the discussion on target and try to analyze things in as much detail as you can. For instance, you might consider sharing additional ways that information literacy skills can help them be critical consumers of information. Discuss similarities in how you and your classmates connected with the infographic or article
.
Guided ResponseRespond to at least one classmate that has been .docxJeanmarieColbert3
Guided Response:
Respond to at least one classmate that has been assigned a different position from you and offer a rebuttal. Be sure to provide evidence from the literature to support your opposition. Also, respond to your original post and provide your own opinion of inclusion based on the evidence from the research and the responses of your classmates. Did your thinking change after reading your classmates’ viewpoints? Share your concerns about working with students with special needs in the regular classroom.
BY:
Mallory Johnson
What is inclusion?
Inclusion is an educational environment in which all students are grouped together in the same classroom regardless of their intelligence level hence the phrase used, “Least Restrictive Environment”. This practice means that an increasing number of regular classroom teachers are called upon to teach exceptional children in regular classrooms, sometimes also termed inclusive classrooms (LeFrançois, G. 2011).
IDEA was established for children with learning disabilities and has been mandated as a part of every educational facility.
As defined by the American Psychological Association, “The Individuals with Disabilities Education Act (IDEA) ensures that all children with disabilities are entitled to a free appropriate public education to meet their unique needs and prepare them for further education, employment, and independent living.”
Not every student learns equally; however, every student should be given the equal opportunity to do so regardless of their learning abilities. With that, inclusion provides an environment where not only students will learn together, but regular students will respect and build friendships with students with learning disabilities. While I never had the change to experience this firsthand, this type of environment will enhance friendships and students helping one another. I think that when a child is included in something, their self confidence improves and they will strive to work harder.
Second, inclusion allows students to understand one another and learn from each other as far as customs and courtesies and attitudes. Students are vulnerable to imitate what they see whether it be good or bad. According to the text, one of the benefits of inclusion is the learning of socially appropriate behaviors by students with disabilities as a result of modeling the behavior of other students.
Lastly, inclusive classrooms provide students with learning disabilities access to general learning like the rest of their peers. They will learn the same information instead of the curriculum being adjusted which may omit valuable information. In this case, these students may be learning information that could be too easy depending on where they stand knowledge wise. For others, the adjustment may hinder learning more challenging information some could be ready for.
Individuals with Disabilities Education Act (IDEA). (n.d.). Retrieved July 17, 2016, from http://www.apa.org/about/.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Introduction to AI for Nonprofits with Tapp Network
Health equity will gain increasing visibility, but little more
1. Health equity will gain increasing visibility, but little more
Michael Daley
Hs
Summary of the prediction
Health equity will acquire greater attention, but not that much.
The COVID-19 epidemic brought to light and highlighted the
fact that our country is experiencing a health equity catastrophe.
COVID-19 continues to unfairly impact low-income areas and
ethnic minorities due to structural imbalances.
President Biden's health equity special team will be led by Yale
University scholar Marcella Nunez-Smith, indicating that health
equity will be a priority for the current regime.
Knowledge-based explanation
The process of discovering which health-related interventions
are helpful in individuals or groups, how beneficial they are
And how well they can be implemented successfully for
successful adoption is referred to as prevention science.
Policy changes are used in primary prevention efforts to
enhance access to healthcare, needed pharmaceuticals, and
nutritional meals.
2. Knowledge-based explanation
A health transition is a change in a general population’s state of
health that typically happens in tandem with socioeconomic
growth in developing countries. This health transition is needed
for health equity.
According to a recent review of pharmacy data, African-
American and Latino health plan participants perform worse on
key indicators of treatment outcomes than Caucasians
Organizations SCAN Group and SCAN Health Plan, are working
towards health equity
They are establishing company-wide objectives in order to
better their results.
Scientific management
Integrating health equality concerns into policy and
programmers, partnering with other areas to address disparities,
interacting with community to ensure their initiatives to solve
disparities, and recognizing the lowering of health disparities
are all ways that public health can help to reduce health
disparities.
Collaboration, policy reform advocacy, good management, and
nursing teaching are all important parts of the medical staff's
role in eliminating health inequities.
3. Relationship Between Scientific management theory and the
prediction
The scientific management philosophy aimed to boost the
effectiveness of each individual in an organization.
Public health care should be made accessible and affordable to
low income individuals by setting up campaigns and initiatives
to make sure they know where the services are provided
Equal treatment should be given to all. No discrimination
Doctors, nurses as well as other medical staff should make sure
all the patients and people in their communities are getting
equal treatment
References
Sachin H. (2020). Top 10 Healthcare Industry Predictions For
2021.Forbes.https://www.forbes.com/sites/sachinjain/2020/12/1
6/top-10-healthcare-industry-predictions for-the-year-
2021/?sh=146b895d2d07
WHO. (2020). Equitable Access to Safe and Effective Vaccines
.https://www.who.int/emergencies/diseases/novel-coronavirus-
McFarland A, MacDonald E (2019) Role of the nurse in
identifying and addressing health inequalities. Nursing
Standard. doi: 10.7748/ns.2019.e11341
Pauly, B.(., MacDonald, M., Hancock, T. et al. Reducing health
inequities: the contribution of core public health services in
BC. BMC Public Health 13, 550 (2013).
https://doi.org/10.1186/1471-2458-13-550
4. Daniel B. McLaughlin
John R. Olson
Healthcare
Operations
Management
T h i r d E d i T i o n
AUPHA/HAP Editorial Board for Graduate Studies
Nir Menachemi, PhD, Chairman
Indiana University
LTC Lee W. Bewley, PhD, FACHE
University of Louisville
Jan Clement, PhD
Virginia Commonwealth University
Michael Counte, PhD
St. Louis University
Joseph F. Crosby Jr., PhD
Armstrong Atlantic State University
5. Mark L. Diana, PhD
Tulane University
Peter D. Jacobson, JD
University of Michigan
Brian J. Nickerson, PhD
Icahn School of Medicine at Mount Sinai
Mark A. Norrell, FACHE
Indiana University
Maia Platt, PhD
University of Detroit Mercy
Debra Scammon, PhD
University of Utah
Tina Smith
University of Toronto
Carla Stebbins, PhD
Des Moines University
Cynda M. Tipple, FACHE
Marymount University
Health Administration Press, Chicago, Illinois
Association of University Programs in Health Administration,
Washington, DC
7. Title: Healthcare operations management / Daniel B.
McLaughlin and John R. Olson.
Description: Third edition. | Chicago, Illinois : Health
Administration Press; Washington, DC :
Association of University Programs in Health Administration,
[2017] | Includes bibliographical
references and index.
Identifiers: LCCN 2016046001 (print) | LCCN 2016046925
(ebook) | ISBN 9781567938517
(alk. paper) | ISBN 9781567938524 (ebook) | ISBN
9781567938531 (xml) | ISBN
9781567938548 (epub) | ISBN 9781567938555 (mobi)
Subjects: LCSH: Medical care—Quality control. | Health
services administration—Quality control. |
Organizational effectiveness. | Total quality management.
Classification: LCC RA399.A1 M374 2017 (print) | LCC
RA399.A1 (ebook) | DDC 362.1068—
dc23
LC record available at https://lccn.loc.gov/2016046001
The paper used in this publication meets the minimum
requirements of American National
Standard for Information Sciences—Permanence of Paper for
Printed Library Materials, ANSI
Z39.48-1984. ∞ ™
Acquisitions editor: Janet Davis; Project manager: Joyce Dunne;
Cover designer: James Slate;
Layout: Cepheus Edmondson
Found an error or a typo? We want to know! Please e-mail it to
[email protected], mentioning
the book’s title and putting “Book Error” in the subject line.
For photocopying and copyright information, please contact
Copyright Clearance Center at
8. www.copyright.com or at (978) 750-8400.
Health Administration Press Association of University Programs
A division of the Foundation of the American in Health
Administration
College of Healthcare Executives 1730 M Street, NW
One North Franklin Street, Suite 1700 Suite 407
Chicago, IL 60606-3529 Washington, DC 20036
(312) 424-2800 (202) 763-7283
To my wife, Sharon, and daughters, Kelly and Katie, for their
love and support
throughout my career.
—Dan McLaughlin
To my father, Adolph Olson, who passed away in 2011. Your
strength as you
battled cancer inspired me to change and educate others about
our healthcare
system.
—John Olson
The first edition of this book was coauthored by Julie Hays.
During the final
stages of the completion of the book, Julie unexpectedly died.
As Dr. Christopher
Puto, dean of the Opus College of Business at the University of
St. Thomas, said,
“Julie cared deeply about students and their learning
experience, and she was
an accomplished scholar who was well respected by her peers.”
This book is a final
9. tribute to Julie’s accomplished career and is dedicated to her
legacy.
—Dan McLaughlin
and John Olson
vii
BRIEF CONTENTS
Preface
...............................................................................................
.......xv
Part I Introduction to Healthcare Operations
Chapter 1. The Challenge and the Opportunity
.................................. 3
Chapter 2. History of Performance Improvement
............................. 17
Chapter 3. Evidence-Based Medicine and Value-Based
Purchasing .... 45
Part II Setting Goals and Executing Strategy
Chapter 4. Strategy and the Balanced Scorecard
................................ 71
Chapter 5. Project Management
....................................................... 97
10. Part III Performance Improvement Tools, Techniques, and
Programs
Chapter 6. Tools for Problem Solving and Decision Making
........... 135
Chapter 7. Statistical Thinking and Statistical Problem Solving
........ 167
Chapter 8. Healthcare Analytics
..................................................... 203
Chapter 9. Quality Management: Focus on Six Sigma
..................... 221
Chapter 10. The Lean Enterprise
...................................................... 255
Part IV Applications to Contemporary Healthcare Operations
Issues
Chapter 11. Process Improvement and Patient Flow
......................... 281
Chapter 12. Scheduling and Capacity Management
........................... 323
Chapter 13. Supply Chain Management
............................................ 345
Chapter 14. Improving Financial Performance with Operations
Management ................................................................. 369
11. viii B r i e f C o n t e n t s
Part V Putting It All Together for Operational Excellence
Chapter 15. Holding the Gains
......................................................... 391
Glossary
...............................................................................................
.. 411
Index
...............................................................................................
...... 419
About the Authors
................................................................................... 437
ix
DETAILED CONTENTS
Preface
...............................................................................................
.......xv
Part I Introduction to Healthcare Operations
Chapter 1. The Challenge and the Opportunity
.................................. 3
Overview .......................................................................... 3
The Purpose of This Book ................................................. 3
The Challenge ................................................................... 4
The Opportunity .............................................................. 6
A Systems Look at Healthcare ........................................... 8
An Integrating Framework for Operations Management
12. in Healthcare .............................................................. 12
Conclusion ...................................................................... 15
Discussion Questions ...................................................... 15
References ....................................................................... 15
Chapter 2. History of Performance Improvement
............................. 17
Operations Management in Action .................................. 17
Overview ........................................................................ 17
Background..................................................................... 18
Knowledge-Based Management ....................................... 20
History of Scientific Management .................................... 22
Project Management ....................................................... 26
Introduction to Quality ................................................... 27
Philosophies of Performance Improvement ...................... 34
Supply Chain Management .............................................. 38
Big Data and Analytics .................................................... 40
Conclusion ...................................................................... 41
Discussion Questions ...................................................... 41
References ....................................................................... 42
Chapter 3. Evidence-Based Medicine and Value-Based
Purchasing .... 45
Operations Management in Action .................................. 45
x D e t a i l e d C o n t e n t s
Overview ........................................................................ 45
Evidence-Based Medicine ................................................ 46
Tools to Expand the Use of Evidence-Based Medicine ..... 54
Clinical Decision Support ................................................ 59
The Future of Evidence-Based Medicine and Value
13. Purchasing .................................................................. 62
Vincent Valley Hospital and Health System and Pay for
Performance ............................................................... 63
Conclusion ...................................................................... 64
Discussion Questions ...................................................... 64
Note ............................................................................... 64
References ....................................................................... 65
Part II Setting Goals and Executing Strategy
Chapter 4. Strategy and the Balanced Scorecard
................................ 71
Operations Management in Action .................................. 71
Overview ........................................................................ 71
Moving Strategy to Execution ......................................... 72
The Balanced Scorecard in Healthcare ............................ 75
The Balanced Scorecard as Part of a Strategic
Management System ................................................... 76
Elements of the Balanced Scorecard System ..................... 76
Conclusion ...................................................................... 93
Discussion Questions ...................................................... 93
Exercises ......................................................................... 94
References ....................................................................... 94
Further Reading .............................................................. 95
Chapter 5. Project Management
....................................................... 97
Operations Management in Action ................................. 97
Overview ........................................................................ 97
Definition of a Project ..................................................... 99
Project Selection and Chartering ................................... 100
Project Scope and Work Breakdown .............................. 107
Scheduling .................................................................... 113
Project Control ............................................................. 117
14. Quality Management, Procurement, the Project
Management Office, and Project Closure .................. 120
Agile Project Management ............................................ 124
Innovation Centers ........................................................ 125
xiD e t a i l e d C o n t e n t s
The Project Manager and Project Team ......................... 126
Conclusion .................................................................... 129
Discussion Questions .................................................... 129
Exercises ........................................ ............................... 129
References ..................................................................... 130
Further Reading ............................................................ 130
Part III Performance Improvement Tools, Techniques, and
Programs
Chapter 6. Tools for Problem Solving and Decision Making
........... 135
Operations Management in Action ................................ 135
Overview ...................................................................... 135
Decision-Making Framework ......................................... 136
Mapping Techniques ..................................................... 138
Problem Identification Tools ......................................... 143
Analytical Tools ............................................................. 153
Implementation: Force Field Analysis ............................ 162
Conclusion .................................................................... 163
Discussion Questions .............................................. ...... 163
Exercises ....................................................................... 164
References ..................................................................... 165
Chapter 7. Statistical Thinking and Statistical Problem Solving
........ 167
15. Operations Management in Action ................................ 167
Overview: Statistical Thinking in Healthcare .................. 167
Foundations of Data Analysis ......................................... 169
Graphic Tools ................................................................ 169
Mathematical Descriptions ............................................ 174
Probability .................................................................... 178
Confidence Intervals and Hypothesis Testing ................. 185
Simple Linear Regression............................................... 192
Conclusion .................................................................... 198
Discussion Questions .................................................... 199
Exercises ....................................................................... 199
References ..................................................................... 201
Chapter 8. Healthcare Analytics
...................................................... 203
Operations Management in Action ................................ 203
Overview ...................................................................... 203
What Is Analytics in Healthcare? .................................... 203
Introduction to Data Analytics ...................................... 205
xii D e t a i l e d C o n t e n t s
Data Visualization ......................................................... 209
Data Mining for Discovery ............................................ 214
Conclusion .................................................................... 217
Discussion Questions .................................................... 218
Note ............................................................................. 218
References .................................................................... 219
Chapter 9. Quality Management—Focus on Six Sigma
................... 221
Operations Management in Action ................................ 221
Overview ...................................................................... 221
Defining Quality ........................................................... 222
16. Cost of Quality .............................................................. 223
The Six Sigma Quality Program ......................... ............ 225
Additional Quality Tools ............................................... 240
Riverview Clinic Six Sigma Generic Drug Project .......... 245
Conclusion .................................................................... 250
Discussion Questions .................................................... 250
Exercises ....................................................................... 250
References ..................................................................... 253
Chapter 10. The Lean Enterprise
...................................................... 255
Operations Management in Action ................................ 255
Overview ...................................................................... 255
What Is Lean? ............................................................... 256
Types of Waste .............................................................. 257
Kaizen ........................................................................... 259
Value Stream Mapping .................................................. 259
Additional Measures and Tools ...................................... 261
The Merging of Lean and Six Sigma Programs .............. 274
Conclusion .................................................................... 276
Discussion Questions .................................................... 276
Exercises ....................................................................... 277
References ..................................................................... 277
Part IV Applications to Contemporary Healthcare Operations
Issues
Chapter 11. Process Improvement and Patient Flow
......................... 281
Operations Management in Action ................................ 281
Overview ...................................................................... 281
Problem Types .............................................................. 282
Patient Flow .................................................................. 283
17. xiiiD e t a i l e d C o n t e n t s
Process Improvement Approaches ................................. 284
The Science of Lines: Queuing Theory ......................... 292
Process Improvement in Practice ................................... 304
Conclusion .................................................................... 318
Discussion Questions .................................................... 319
Exercises ....................................................................... 319
References ..................................................................... 320
Further Reading ............................................................ 321
Chapter 12. Scheduling and Capacity Management
........................... 323
Operations Management in Action ................................ 323
Overview ...................................................................... 323
Hospital Census and Rough-Cut Capacity Planning ...... 324
Staff Scheduling ............................................................ 326
Job and Operation Scheduling and Sequencing Rules .... 330
Patient Appointment Scheduling Models ....................... 334
Advanced-Access Patient Scheduling .............................. 337
Conclusion .................................................................... 341
Discussion Questions .................................................... 341
Exercises ....................................................................... 341
References ..................................................................... 342
Chapter 13. Supply Chain Management
............................................ 345
Operations Management in Action ................................ 345
Overview ...................................................................... 345
Supply Chain Management ............................................ 346
Tracking and Managing Inventory ................................. 347
Demand Forecasting ..................................................... 349
Order Amount and Timing ........................................... 354
Inventory Systems ......................................................... 362
Procurement and Vendor Relationship Management ...... 364
Strategic View ............................................................... 364
18. Conclusion .................................................................... 365
Discussion Questions .................................................... 366
Exercises ....................................................................... 366
References ................................... .................................. 368
Chapter 14. Improving Financial Performance with Operations
Management ................................................................. 369
Operations Management in Action ................................ 369
Overview: The Financial Pressure for Change ................ 369
xiv D e t a i l e d C o n t e n t s
Making Ends Meet on Medicare and the Pressure of
Narrow Networks ..................................................... 370
Conclusion .................................................................... 386
Discussion Questions .................................................... 386
Exercises ....................................................................... 387
Note ............................................................................. 387
References ..................................................................... 387
Part V Putting It All Together for Operational Excellence
Chapter 15. Holding the Gains
......................................................... 391
Overview ...................................................................... 391
Approaches to Holding Gains ........................................ 391
Which Tools to Use: A General Algorithm ..................... 397
Data and Statistics ......................................................... 404
Operational Excellence .................................................. 405
The Healthcare Organization of the Future ................... 407
Conclusion .................................................................... 408
Discussion Questions .................................................... 408
Case Study .................................................................... 409
19. References ..................................................................... 410
Glossary
...............................................................................................
.. 411
Index
...............................................................................................
...... 419
About the Authors
................................................................................... 437
xv
PREFACE
This book is intended to help healthcare professionals meet the
challenges and
take advantage of the opportunities found in healthcare today.
We believe that
the answers to many of the dilemmas faced by the US healthcare
system, such
as increasing costs, inadequate access, and uneven quality, lie
in organizational
operations—the nuts and bolts of healthcare delivery. The
healthcare arena is
filled with opportunities for significant operational
improvements. We hope that
this book encourages healthcare management students and
working profession-
als to find ways to improve the management and delivery of
healthcare, thereby
increasing the effectiveness and efficiency of tomorrow’s
healthcare system.
20. Many industries outside healthcare have successfully used the
programs,
techniques, and tools of operations improvement for decades.
Leading health-
care organizations have now begun to employ the same tools.
Although numer-
ous other operations management texts are available, few focus
on healthcare
operations, and none takes an integrated approach. Students
interested in
healthcare process improvement have difficulty seeing the
applicability of the
science of operations management when most texts focus on
widgets and
production lines rather than on patients and providers.
This book covers the basics of operations improvement and
provides
an overview of the significant trends in the healthcare industry.
We focus on
the strategic implementation of process improvement programs,
techniques,
and tools in the healthcare environment, with its complex web
of reimburse-
ment systems, physician relations, workforce challenges, and
governmental
regulations. This integrated approach helps healthcare
professionals gain an
understanding of strategic operations management and, more
important, its
applicability to the healthcare field.
How This Book Is Organized
We have organized this book into five parts:
21. 1. Introduction to Healthcare Operations
2. Setting Goals and Executing Strategy
3. Performance Improvement Tools, Techniques, and Programs
xvi P r e f a c e
4. Applications to Contemporary Healthcare Operations Issues
5. Putting It All Together for Operational Excellence
Although this structure is helpful for most readers, each chapter
also stands
alone, and the chapters can be covered or read in any order that
makes sense
for a particular course or student.
The first part of the book, Introduction to Healthcare
Operations,
begins with an overview of the challenges and opportunities
found in today’s
healthcare environment (chapter 1). We follow with a history of
the field
of management science and operations improvement (chapter 2).
Next, we
discuss two of the most influential environmental changes
facing healthcare
today: evidence-based medicine and value-based purchasing, or
simply value
purchasing (chapter 3).
In part II, Setting Goals and Executing Strategy, chapter 4
highlights the
importance of tying the strategic direction of the organization to
operational
initiatives. This chapter outlines the use of the balanced
22. scorecard technique
to execute and monitor these initiatives toward achieving
organizational objec-
tives. Typically, strategic initiatives are large in scope, and the
tools of project
management (chapter 5) are needed to successfully manage
them. Indeed, the
use of project management tools can help to ensure the success
of any size
project. Strategic focus and project management provide the
organizational
foundation for the remainder of this book.
The next part of the book, Performance Improvement Tools,
Tech-
niques, and Programs, provides an introduction to basic
decision-making and
problem-solving processes and describes some of the associated
tools (chapter
6). Most performance improvement initiatives (e.g., Six Sigma,
Lean) follow
these same processes and make use of some or all of the tools
discussed in
chapter 6.
Good decisions and effective solutions are based on facts, not
intuition.
Chapter 7 provides an overview of data collection processes and
analysis tech-
niques to enable fact-based decision making. Chapter 8 builds
on the statistical
approaches of chapter 7 by presenting the new tools of advanced
analytics and
big data.
Six Sigma, Lean, simulation, and supply chain management are
23. specific
philosophies or techniques that can be used to improve
processes and systems.
The Six Sigma methodology (chapter 9) is the latest
manifestation of the use of
quality improvement tools to reduce variation and errors in a
process. The Lean
methodology (chapter 10) is focused on eliminating waste in a
system or process.
The fourth section of the book, Applications to Contemporary
Health-
care Operations Issues, begins with an integrated approach to
applying the
various tools and techniques for process improvement in the
healthcare environ-
ment (chapter 11). We then focus on a special and important
case of process
improvement: patient scheduling in the ambulatory setting
(chapter 12).
xviiP r e f a c e
Supply chain management extends the boundaries of the
hospital or
healthcare system to include both upstream suppliers and
downstream custom-
ers, and this is the focus of chapter 13. The need to “bend” the
healthcare
cost inflation curve downward is one of the most pressing issues
in healthcare
today, and the use of operations management tools to achieve
this goal is
addressed in chapter 14.
24. Part V, Putting It All Together for Operational Excellence,
concludes
the book with a discussion of strategies for implementing and
maintaining the
focus on continuous improvement in healthcare organizations
(chapter 15).
Many features in this book should enhance student
understanding and
learning. Most chapters begin with a vignette, called Operations
Management in
Action, that offers a real-world example related to the content
of that chapter.
Throughout the book, we use a fictitious but realistic
organization, Vincent
Valley Hospital and Health System, to illustrate the various
tools, techniques,
and programs discussed. Each chapter concludes with questions
for discussion,
and parts II through IV include exercises to be solved.
We include abundant examples throughout the text of the use of
various
contemporary software tools essential for effective operations
management.
Readers will see notes appended to some of the exhibits, for
example, that
indicate what software was used to create charts, graphs, and so
on from the
data provided. Healthcare leaders and managers must be experts
in the appli-
cation of these tools and stay current with the latest versions.
Just as we ask
healthcare providers to stay up-to-date with the latest clinical
advances, so too
25. must healthcare managers stay current with basic software tools.
Acknowledgments
A number of people contributed to this work. Dan McLaughlin
would like to
thank his many colleagues at the University of St. Thomas Opus
College of
Business. Specifically, Dr. Ernest Owens provided guidance on
the project man-
agement chapter, and Dr. Michael Sheppeck assisted on the
human resources
implications of operations improvement. Dean Stefanie Lenway
and Associate
Dean Michael Garrison encouraged and supported this work and
helped create
our new Center for Innovation in the Business of Healthcare.
Dan would also like to thank the outstanding professionals at
Hennepin
County Medical Center in Minneapolis, Minnesota, who
provided many of the
practical and realistic examples in this book. They continue to
be invaluable
healthcare resources for all of the residents of Minnesota.
John Olson would like to thank his many colleagues at the
University
of St. Thomas Opus College of Business. In addition, he would
like to thank
the Minnesota Hospital Association (MHA). Attributing much
of his under-
standing of healthcare analytics to working with the highly
professional staff
26. xviii P r e f a c e
of the MHA, he wishes to acknowledge Rahul Korrane, Tanya
Daniels, Mark
Sonneborn, and Julie Apold (now with Optum) as true agents
for change in
the US healthcare system.
The dedicated employees of the Veterans Administration have
helped
John embrace the challenges that confront healthcare today—in
particular
Christine Wolohan, Lori Fox, Susan Chattin, Eric James, Denise
Lingen, and
Carl (Marty) Young of the continuous improvement group, who
are helping
to create an organization of excellence. John acknowledges their
dedication to
serving US veterans and the amazing, high-quality service they
deliver.
John and Dan also want to thank the skilled professionals of
Health
Administration Press for their support, especially Janet Davis,
acquisitions edi-
tor, and Joyce Dunne, who edited this third edition.
Finally, this book still contains many passages that were written
by Julie
Hays and are a tribute to her skill and dedication to the field of
operations
management.
Instructor Resources
27. This book’s Instructor Resources include PowerPoint slides; an
updated
test bank; teaching notes for the end-of-chapter exercises; Excel
files and
cases for selected chapters; and new case studies, for most
chapters,
with accompanying teaching notes. Each of the new case studies
is one to
three pages long and is suitable for one class session or an
online learning
module.
For the most up-to-date information about this book and its
Instructor
Resources, visit ache.org/HAP and browse for the book’s title
or author
names.
This book’s Instructor Resources are available to instructors
who adopt
this book for use in their course. For access information, please
e-mail
[email protected]
Student Resources
Case studies, exercises, tools, and web links to resources are
available at
ache.org/books/OpsManagement3.
PART
INTRODUCTION TO
HEALTHCARE OPERATIONS
28. I
CHAPTER
3
THE CHALLENGE AND THE OPPORTUNITY
The Purpose of This Book
Excellence in healthcare derives from
four major areas of expertise: clinical
care, population health, leadership,
and operations. Although clinical
expertise, the health of a population,
and leadership are critical to an orga-
nization’s success, this book focuses
on operations—how to deliver high-
quality health services in a consistent,
efficient manner.
Many books cover opera-
tional improvement tools, and some
focus on using these tools in health-
care environments. So why have we
devoted a book to the broad topic
of healthcare operations? Because we
see a need for organizations to adopt
an integrated approach to operations
improvement that puts all the tools
in a logical context and provides a
road map for their use. An integrated
29. approach uses a clinical analogy: First,
find and diagnose an operations issue.
Second, apply the appropriate treat-
ment tool to solve the problem.
The field of operations research
and management science is too deep
to cover in one book. In Healthcare
Operations Management, only those
tools and techniques currently being
deployed in leading healthcare organi-
zations are covered, in part so that we
may describe them in enough detail
1
O V E RV I E W
The challenges and opportunities in today’s complex healthcare
delivery systems demand that leaders take charge of their opera -
tions. A strong operations focus can reduce costs, increase
safety—for
patients, visitors, and staff alike—improve clinical outcomes,
and allow
an organization to compete effectively in an aggressive
marketplace.
In the recent past, success for many organizations in the US
healthcare system has been achieved by executing a few critical
strate-
gies: First, attract and retain talented clinicians. Next, add new
30. technol-
ogy and specialty care services. Finally, find new methods to
maximize
the organization’s reimbursement for these services. In most
organiza-
tions, new services, not ongoing operations, were the key to
success.
However, that era is ending. Payer resistance to cost
increases and a surge in public reporting on the quality of
health-
care are forces driving a major change in strategy. The passage
of
the Affordable Care Act (ACA) in 2010 represented a
culmination
of these forces. Although portions of this law may be repealed
or
changed, the general direction of health policy in the United
States
has been set. To succeed in this new environment, a healthcare
enterprise must focus on making significant improvements in its
core operations.
This book is about improvement and how to get things done.
31. It offers an integrated, systematic approach and set of
contemporary
operations improvement tools that can be used to make
significant
gains in any organization. These tools have been successfully
deployed
in much of the global business community for more than 40
years and
now are being used by leading healthcare delivery
organizations.
This chapter outlines the purpose of the book, identifies
challenges that healthcare systems currently face, presents a
systems
view of healthcare, and provides a comprehensive framework
for the
use of operations tools and methods in healthcare. Finally,
Vincent
Valley Hospital and Health System (VVH), the fictional
healthcare
delivery system used in examples throughout the book, is
described.
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t4
32. to enable students and practitioners to use them in their work.
Each chap-
ter provides many references for further reading and deeper
study. We also
include additional resources, case studies, exercises,
and tools on the companion website that accompanies
this book.
This book is organized so that each chapter builds on the
previous one
and is cross-referenced. However, each chapter also stands
alone, so a reader
interested in Six Sigma can start in chapter 9 and then move to
the other
chapters in any order he wishes.
This book does not specifically explore quality in healthcare as
defined
by the many agencies that have as their mission to ensure
healthcare quality,
such as The Joint Commission, the National Committee for
Quality Assurance,
the National Quality Forum, and some federally funded quali ty
improvement
organizations. In particular, The Healthcare Quality Book:
Vision, Strategy,
and Tools (Joshi et al. 2014) delves into this perspective in
depth and may be
considered a useful companion to this book. However, the
systems, tools, and
techniques discussed here are essential to completing the
operational improve-
ments needed to meet the expectations of these quality
assurance organizations.
33. The Challenge
Health spending is projected to grow 1.3 percent faster per year
than the gross
domestic product (GDP) between 2015 and 2025. As a result,
the health share
of GDP is expected to rise from 17.5 percent in 2014 to 20.1
percent by 2025
(CMS 2015). In addition, healthcare spending is placing
increasing pressure
on the federal budget. In its expenditure report summary, the
Centers for
Medicare & Medicaid Services (CMS 2015) notes that “federal,
state and local
governments are projected to finance 47 percent of national
health spending
by 2024 (from 45 percent in 2014).”
Despite the high cost, the value delivered by the system has
been ques-
tioned by many policymakers. For example, unexplained quality
variations in
healthcare were estimated in 1999 to result in 44,000 to 98,000
preventable
deaths every year (IOM 1999). And those problems persist. A
2010 study of
hospitals in North Carolina showed a high rate of adverse
events, unchanged
over time even though hospitals had sought to improve the
safety of inpatient
care (Landrigan et al. 2010).
Clearly, the pace of quality improvement is slow. “National
Healthcare
Quality Report, 2009,” published by the Agency for Healthcare
Research
34. and Quality (AHRQ), reported: “Quality is improving at a slow
pace. Of
the 33 core measures, two-thirds improved, 14 (42%) with a rate
between 1%
and 5% per year and 8 (24%) with a rate greater than 5% per
year. . . . The
Agency for
Healthcare
Research and
Quality (AHRQ)
A federal agency
that is part of
the Department
of Health and
Human Services.
It provides
leadership and
funding to identify
and communicate
the most effective
methods to deliver
high-quality
healthcare in the
United States.
On the web at
ache.org/books/OpsManagement3
C h a p t e r 1 : T h e C h a l l e n g e a n d t h e O p p o r t
u n i t y 5
median rate of change was 2% per year. Across all 169
measures, results were
35. similar, although the median rate of change was slightly higher
at 2.3% per
year” (AHRQ 2010).
These problems were studied in the landmark work of the
Institute of
Medicine (IOM), Crossing the Quality Chasm: A New Health
System for the 21st
Century. The IOM (2001) panel concluded that the knowledge
to improve
patient care is available, but a gap—a chasm—separates that
knowledge from
everyday practice. The panel summarized the goals of a new
health system in
terms of six aims, as described in exhibit 1.1.
Although this seminal work was published more than a decade
ago, its
goals still guide much of the quality improvement effort today.
Many healthcare leaders are addressing these issues by
capitalizing on
proven tools employed by other industries to ensure high
performance and
quality outcomes. For major change to occur in the US health
system, however,
these strategies must be adopted by a broad spectrum of
healthcare providers
and implemented consistently throughout the continuum of
care—in ambula-
tory, inpatient, acute, and long-term care settings—to undergird
population
health initiatives.
The payers for healthcare must engage with the delivery system
to find
36. new ways to partner for improvement. In addition, patients need
to assume
strong financial and self-care roles in this new system. The
ACA and subsequent
health policy initiatives provide many new policies to support
the achievement
of these goals.
Although not all of the IOM goals can be accomplished through
opera-
tional improvements, this book provides methods and tools to
actively change
the system toward accomplishing several aspects of these aims.
Institute of
Medicine (IOM)
The healthcare
arm of the
National Academy
of Sciences; an
independent,
nonprofit
organization
providing unbiased
and authoritative
advice to decision
makers and the
public.
1. Safe, avoiding injuries to patients from the care that is
intended to help
them
2. Effective, providing services based on scientific knowledge
to all who
could benefit, and refraining from providing services to those
37. not likely
to benefit (avoiding underuse and overuse, respectively);
3. Patient centered, providing care that is respectful of and
responsive to
individual patient preferences, needs, and values, and ensuring
that
patient values guide all clinical decisions;
4. Timely, reducing wait times and harmful delays for both
those who
receive and those who give care;
5. Efficient, avoiding waste of equipment, supplies, ideas, and
energy; and
6. Equitable, providing care that does not vary in quality
because of per-
sonal characteristics such as gender, ethnicity, geographic
location, and
socioeconomic status.
EXHIBIT 1.1
Six Aims for
the US Health
System
Source: Information from IOM (2001).
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t6
The Opportunity
While the current US health system presents numerous
38. challenges, opportuni-
ties for improvement are emerging as well. A number of major
trends provide
hope that significant change is possible. The following trends
represent this
groundswell:
• Informatics systems are maturing, and big data and analytics
tools are
becoming ever more powerful.
• Automation, robots, and the Internet of Things will begin to
replace
human labor in healthcare.
• Supply chains and the relationships among health plans,
healthcare
systems, and individual providers are changing through
mergers,
partnerships, and acquisitions.
• Primary care is being redesigned with new provider models
and new
tools, such as telemedicine and mobile applications.
• Medicine itself is undergoing rapid change with the adoption
of
precision medicine tools, such as pharmacogenomics, to
individualize
patient treatments.
• A new emphasis on population health accountability and
management
will lead to healthier environments and lifestyles.
Evidence-Based Medicine
39. The use of evidence-based medicine (EBM) for the delivery of
healthcare in
the United States is the result of 40 years of work by some of
the most progres-
sive and thoughtful practitioners in the nation. The movement
has produced
an array of care guidelines, care patterns, and shared decision-
making tools
for caregivers and patients.
The impact of EBM on care delivery can be powerful. Rotter
and col-
leagues (2010) reviewed 27 studies worldwide including 11,938
patients and
assessed the use of clinical pathways. They found that the cost
of care for patients
whose treatment was delivered using the pathways was $4,919
per admission
less than for those who did not receive pathway-centered care.
Comprehensive resources are available to healthcare
organizations that
wish to emphasize EBM. For example, the National Guideline
Clearinghouse
(NGC 2016) is a comprehensive database of more than 4,000
evidence-based
clinical practice guidelines and related documents. NGC is an
initiative of
AHRQ, which itself is a division of the US Department of
Health and Human
Services. NGC was originally created in partnership with the
American Medical
Association and American Association of Health Plans, now
America’s Health
Insurance Plans.
40. Evidence-based
medicine (EBM)
The conscientious
and judicious
use of the best
current evidence in
making decisions
about the care of
individual patients.
C h a p t e r 1 : T h e C h a l l e n g e a n d t h e O p p o r t
u n i t y 7
Big Data and Analytics
Healthcare delivery has been slow to adopt information
technologies, but
many organizations have now implemented electronic health
record (EHR)
systems and other automated tools. Although implementation of
these systems
Evidence-Based Medicine (EBM)
The Institute of Medicine has been a leading advocate for
comparative effec-
tiveness research, the National Academy of Sciences’
concomitant deploy-
ment of EBM. The IOM Roundtable on Value and Science-
Driven Healthcare
has set a “goal that by the year 2020, 90 percent of clinical
decisions will be
supported by accurate, timely, and up-to-date clinical
information and will
reflect the best available evidence” (IOM 2011, 4; emphasis in
original).
41. To achieve this end, the IOM Roundtable recommends a
sophisticated
set of processes and infrastructure, which it describes as follows
(IOM 2011, 10).
Infrastructure Required for Comparative Effectiveness
Research: Common
Themes
• Care that is effective and efficient stems from the integrity of
the
infrastructure for learning.
• Coordinating work and ensuring standards are key components
of the
evidence infrastructure.
• Learning about effectiveness must continue beyond the
transition from
testing to practice.
• Timely and dynamic evidence of clinical effectiveness
requires bridging
research and practice.
• Current infrastructure planning must build to future needs and
opportunities.
• Keeping pace with technological innovation compels more
42. than a head-
to-head and time-to-time focus.
• Real-time learning depends on health information technology
investment.
• Developing and applying tools that foster real-time data
analysis is an
important element.
• A trained workforce is a vital link in the chain of evidence
stewardship.
• Approaches are needed that draw effectively on both public
and private
capacities.
• Efficiency and effectiveness compel globalizing evidence and
localizing
decisions.
In short, EBM is the conscientious and judicious use of the best
cur-
rent evidence in making decisions about the care of individual
patients.
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t8
has sometimes been organizationally painful, EHRs are now
43. becoming mature
enough to have a substantial positive impact on operations.
In addition, data science computer engineering has evolved to
provide
significant new tools in the following areas:
• Big data storage and retrieval—high volume, high velocity,
and high
variety of data types
• New analytical tools for reporting and prediction
• Portable and wearable devices
• Interoperabilty of devices and databases
Chapter 8 describes a set of analytical tools to fully utilize
these new resources.
Active and Engaged Consumers
Consumers are assuming new roles in their own care through the
use of health
education and information and by partnering effectively with
their healthcare
providers. Personal maintenance of wellness though a healthy
lifestyle is one
essential component. Understanding one’s disease and treatment
options and
having an awareness of the cost of care are also important
responsibilities of
the consumer.
Patients are becoming good consumers of healthcare by finding
and
considering price information when selecting providers and
treatments. Many
employers now offer high-deductible health plans with
44. accompanying health
savings accounts (HSAs). This type of consumer-directed
healthcare is likely
to grow and increase pressure on providers to deliver cost-
effective, customer-
sensitive, high-quality care. In addition, the ACA provides new
tools for employ-
ers to motivate their employees financially to engage in healthy
lifestyles.
The healthcare delivery system of the future will support and
empower
active, informed consumers.
A Systems Look at Healthcare
The Clinical System
To participate in the improvement of healthcare operations,
healthcare leaders
must understand the series of interconnected systems that
influence the delivery
of clinical care (exhibit 1.2).
In the patient care microsystem, the healthcare professional
provides
hands-on care to the patient. Elements of the clinical
microsystem include
• the team of health professionals who provide clinical care to
the patient,
• the tools that the team has at its disposal to diagnose and treat
the
patient (e.g., imaging capabilities, laboratory tests, drugs), and
Health savings
account (HSA)
45. A personal
monetary account
that can only be
used for healthcare
expenses. The
funds are not
taxed, and the
balance can be
rolled over from
year to year. HSAs
are normally
used with high-
deductible health
insurance plans.
Consumer-directed
healthcare
In general,
the consumer
(patient) is well
informed about
healthcare prices
and quality and
makes personal
buying decisions
on the basis of
this information.
The health
savings account
is frequently
included as a key
component of
consumer-directed
healthcare.
Patient care
46. microsystem
The level of
healthcare
delivery that
includes providers,
technology,
and treatment
processes.
C h a p t e r 1 : T h e C h a l l e n g e a n d t h e O p p o r t
u n i t y 9
• the logic for determining the appropriate treatments and the
processes
to deliver that care.
Because common conditions (e.g., hypertension) affect a large
number
of patients, clinical research has been conducted to determine
the most effec-
tive ways to treat these patients. Therefore, in many cases, the
organization
and functioning of the microsystem can be optimized. Process
improvements
can be made at this level to ensure that the most effective, least
costly care is
delivered. In addition, the use of EBM guidelines can help
ensure that the
patient receives the correct treatment at the correct time.
The organizational infrastructure also influences the effective
delivery
of care to the patient. Ensuring that providers have the correct
tools and skills
47. is an important element of infrastructure.
The EHR is one of the most important advances in the clinical
micro-
system for both process improvement and the wider adoption of
EBM.
Another key component of infrastructure is the leadership
displayed by
senior staff. Without leadership, progress and change do not
occur.
Finally, the environment strongly influences the delivery of
care. Key
environmental factors include market competition, government
regulation,
demographics, and payer policies. An organization’s strategy is
frequently influ-
enced by such factors (e.g., a new regulation from Medicare, a
new competitor).
Many of the systems concepts regarding healthcare delivery
were ini-
tially developed by Avedis Donabedian. These fundamental
contributions are
discussed in depth in chapter 2.
Organization
Level C
Microsystem
Level B
Patient
Level A
48. Environment
Level D
EXHIBIT 1.2
A Systems View
of Healthcare
Source: Ransom, Joshi, and Nash (2005). Based on Ferlie, E.,
and S. M. Shortell. 2001. “Improving
the Quality of Healthcare in the United Kingdom and the United
States: A Framework for Change.”
Milbank Quarterly 79 (2): 281–316.
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t10
System Stability and Change
Elements in each layer of this system interact. Peter Senge
(1990) provides a
useful theory for understanding the interaction of elements in a
complex system
such as healthcare. In his model, the structure of a system is the
primary mecha-
nism for producing an outcome. For example, the presence of an
organized
structure of facilities, trained professionals, supplies,
equipment, and EBM care
guidelines leads to a high probability of producing an expected
clinical outcome.
No system is ever completely stable. Each system’s
performance is modi-
fied and controlled by feedback (exhibit 1.3). Senge (1990, 75)
defines feedback
as “any reciprocal flow of influence. In systems thinking it is an
49. axiom that every
influence is both cause and effect.” As shown in exhibit 1.3,
increased salaries
provide an incentive for employees to achieve improvement in
performance
level. This improved performance leads to enhanced financial
performance
and profitability for the organization, and increased profits
provide additional
funds for higher salaries, and the cycle continues. Another
frequent example in
healthcare delivery is patient lab results that directly influence
the medication
+
+
+
–
–
Employee
motivation
Salaries
Financial
performance,
profit
Add or
reduce staff
50. Actual
staffing
level
Compare actual to
needed staff based
on patient demand
EXHIBIT 1.3
Systems with
Reinforcing
and Balancing
Feedback
C h a p t e r 1 : T h e C h a l l e n g e a n d t h e O p p o r t
u n i t y 11
ordered by a physician. A third example is a financial report
that shows an
over-expenditure in one category that prompts a manager to
reduce spending
to meet budget goals.
A more complete definition of a feedback-driven operational
system
includes an operational process, a sensor that monitors process
output, a feed-
back loop, and a control that modifies how the process operates.
Feedback can be either reinforcing or balancing. Reinforcing
feedback
prompts change that builds on itself and amplifies the outcome
51. of a process,
taking the process further and further from its starting point.
The effect of rein-
forcing feedback can be either positive or negative. For
example, a reinforcing
change of positive financial results for an organization could
lead to increases
in salaries, which would then lead to even better financial
performance because
the employees are highly motivated. In contrast, a poor
supervisor could cause
employee turnover, possibly resulting in short staffing and even
more turnover.
Balancing feedback prompts change that seeks stability. A
balancing
feedback loop attempts to return the system to its starting point.
The human
body provides a good example of a complex system that has
many balancing
feedback mechanisms. For example, an overheated body
prompts perspiration
until the body is cooled through evaporation. The clinical term
for this type
of balance is homeostasis. A treatment process that controls
drug dosing via
real-time monitoring of the patient’s physiological responses is
an example of
balancing feedback. Inpatient unit staffing levels that determine
where in a
hospital patients are admitted is another. All of these feedback
mechanisms are
designed to maintain balance in the system.
A confounding problem with feedback is delay. Delays occur
when
52. interruptions arise between actions and consequences. In the
midst of delays,
systems tend to “overshoot” and thus perform poorly. For
example, an emer-
gency department might experience a surge in patients and call
in additional
staff. When the surge subsides, the added staff stay on shift but
are no longer
needed, and unnecessary expense is incurred.
As healthcare leaders focus on improving their operations, they
must
understand the systems in which change resides. Every change
will be resisted
and reinforced by feedback mechanisms, many of which are not
clearly visible.
Taking a broad systems view can improve the effectiveness of
change.
Many subsystems in the total healthcare system are
interconnected.
These connections have feedback mechanisms that either
reinforce or balance
the subsystem’s performance. Exhibit 1.4 shows a simple
connection that origi-
nates in the environmental segment of the total health system.
Each process
has both reinforcing and balancing feedback.
This general systems model can be converted to a more
quantitative
system dynamics model, which is useful as part of a predictive
analytics system.
This concept is addressed in more depth in chapter 8.
53. H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t12
An Integrating Framework for Operations Management in
Healthcare
The five-part framework of this book (illustrated in exhibit 1.5)
reflects our view
that effective operations management in healthcare consists of
highly focused
strategy execution and organizational change accompanied by
the disciplined
use of analytical tools, techniques, and programs. An
organization needs to
understand the environment, develop a strategy, and implement
a system to
effectively deploy this strategy. At the same time, the
organization must become
adept at using all the tools of operations improvement contained
in this book.
These improvement tools can then be combined to attack the
fundamental
challenges of operating a complex healthcare delivery
organization.
Introduction to Healthcare Operations
The introductory chapters provide an overview of the
significant environmental
trends healthcare delivery organizations face. Annual updates to
industrywide trends
can be found in Futurescan: Healthcare Trends and Implications
2016–2021 (SHSMD
and ACHE 2016). Progressive organizations tend to review
these publications care-
fully, as they can use this information in response to external
forces by identifying
54. either new strategies or current operating problems that must be
addressed.
Business has aggressively used operations improvement tools
for the
past 40 years, but the field of operations science actually began
many centuries
ago. Chapter 2 provides a brief history.
Healthcare operations are increasingly driven by the effects of
EBM and
pay for performance; chapter 3 offers an overview of these
trends and how
organizations can effect change to meet current challenges and
opportunities.
Setting Goals and Executing Strategy
A key component of effective operations is the ability to move
strategy to
action. Chapter 4 shows how the use of the balanced scorecard
and strategy
maps can help accomplish this aim. Change in all organizations
is challenging,
and the formal methods of project management (chapter 5) can
deliver effec-
tive, lasting improvements in an organization’s operations.
Payers want
to reduce
costs for
chemotherapy
New payment
method for
chemotherapy
is created
55. Environment Organization Clinical microsystem Patient
Changes are made in
care processes and
support systems to
maintain quality
while reducing costs
Chemotherapy
treatment needs to
be more efficient to
meet payment
levels
EXHIBIT 1.4
Linkages Within
the Healthcare
System:
Chemotherapy
C h a p t e r 1 : T h e C h a l l e n g e a n d t h e O p p o r t
u n i t y 13
Performance Improvement Tools, Techniques, and Programs
Once an organization has its strategy implementation and
change management
processes in place, it needs to select the correct tools,
techniques, and programs
to analyze current operations and develop effective adjustments.
Chapter 6 outlines the basic steps of problem solving, which
56. begins
by framing the question or problem and continues through data
collection
and analyses to enable effective decision making. Chapter 7
introduces the
building blocks for many of the advanced tools used later in the
book. (This
chapter may serve as a review or reference for readers who
already have good
statistical skills.)
Closely related to statistical thinking is the emerging science of
analyt-
ics. With powerful new software tools and big data repositories,
the ability to
understand and predict organizational performance is
significantly enhanced.
Chapter 8 is new to this edition and presents several tools that
have become
available to healthcare analysts and leaders since publication of
the second
edition.
Some projects require a focus on process improvement. Six
Sigma tools
(chapter 9) can be used to reduce variability in the outcome of a
process. Lean
tools (chapter 10) help eliminate waste and increase speed.
Applications to Contemporary Healthcare Operations Issues
This part of the book demonstrates how these concepts can be
applied to
some of today’s fundamental healthcare challenges. Process
improvement
techniques are now widely deployed in many organizations to
significantly
57. improve performance; chapter 11 reviews the tools of process
improvement
and demonstrates their use in improving patient flow.
Scheduling and capacity management continue to be major
concerns for
most healthcare delivery organizations, particularly with the
advent of advanced-
access scheduling, a concept promoted by the Institute for
Healthcare Improve-
ment and discussed in chapter 12. Specifically, the chapter
demonstrates how
Setting goals
and executing
strategy
Performance
improvement
tools,
techniques, and
programs
Fundamental
healthcare
operations
issues
High performance
EXHIBIT 1.5
Framework
for Effective
Operations
Management in
Healthcare
58. H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t14
simulation can be used to optimize scheduling. Chapter 13
explores the optimal
methods for acquiring supplies and maintaining appropriate
inventory levels.
Chapter 14 outlines a systems approach to improving financial
results, with a
special emphasis on cost reduction—one of today’s most
important challenges.
Putting It All Together for Operational Excellence
In the end, any operations improvement will fail unless steps
are taken to
maintain the gains; chapter 15 contains the necessary tools to do
so. The
chapter also provides a detailed algorithm that helps
practitioners select the
appropriate tools, methods, and techniques to effect significant
operational
improvements. It demonstrates how our fictionalized case study
healthcare
system, Vincent Valley Hospital and Health System (VVH),
uses all the tools
presented in the book to achieve operational excellence. In this
way, a future
is envisioned in which many of the tools and methods contained
in the book
are widely deployed in the US healthcare system.
Vincent Valley Hospital and Health System
Woven throughout the chapters are examples featuring VVH, a
fictitious but
59. realistic health system. The companion website contains an
expansive descrip-
tion of VVH; here we provide some essential details.
VVH is located in a midwestern city with a population of 1.5
million.
The health system employs 5,000 staff members, oper-
ates 350 inpatient beds, and has a medical staff of 450
physicians. It operates nine clinics staffed by physicians
who are employees of the system. VVH competes with
two major hospitals and an independent ambulatory surgery
center that was
formed by several surgeons from all three hospitals.
The VVH brand includes an accountable care organization to
reflect
the increased emphasis it has placed on population health in its
community.
The organization also is working to create a Medicare
Advantage plan. It has
significantly restructured its primary care delivery segment and
has contracted
with a variety of retail clinics to supplement the traditional
office-based primary
care physicians with whom it is affiliated. It recently added an
online diagnosis
and treatment service, with 24-hour telehealth now available.
Three major health plans provide most of the private payment to
VVH,
which, along with the state Medicaid system, have recently
begun a pay-for-
performance reimbursement initiative. VVH has a strong
balance sheet and a
profit margin of approximately 2 percent, but its senior leaders
60. feel the orga-
nization is financially challenged.
The board of VVH includes many local industry leaders, who
have asked
the chief executive to focus on using the operational techniques
that have led
them to succeed in their own businesses.
On the web at
ache.org/books/OpsManagement3
C h a p t e r 1 : T h e C h a l l e n g e a n d t h e O p p o r t
u n i t y 15
Conclusion
This book is an overview of operations management approaches
and tools. The
reader is expected to understand all the concepts in the book
(and in current use in
the field) and be able to apply, at the basic level, most of the
tools, techniques, and
programs presented. The reader is not expected to execute at the
more advanced
(e.g., Six Sigma black belt, project management professional)
level. However,
this book prepares readers to work effectively with
knowledgeable professionals
and, most important, enables them to direct the work of those
professionals.
Final Note About the Third Edition
Prior editions of this book included a chapter on simulation.
61. Although simula-
tion is a valuable tool in many industries, it is not used widely
in healthcare, so
the chapter was eliminated, with some of the principles of
simulation moved to
chapter 11. We hope the industry embraces this tool in the
future—and then
we will bring this chapter back.
Discussion Questions
1. Provide three examples of system improvements at the
boundaries of
the healthcare subsystems (patient, microsystem, organization,
and
environment).
2. Identify three systems in a healthcare organization (at any
level) that
have reinforcing feedback.
3. Identify three systems in a healthcare organization (at any
level) that
have balancing feedback.
4. Identify three systems in a healthcare organization (at any
level) in
which feedback delays affect the performance of the system.
References
Agency for Healthcare Research and Quality (AHRQ). 2010.
“National Healthcare Quality
Report, 2009: Key Themes and Highlights from the National
Healthcare Qual-
ity Report.” Last reviewed March.
62. http://archive.ahrq.gov/research/findings/
nhqrdr/nhqr09/Key.html.
Centers for Medicare & Medicaid Services (CMS). 2015.
“National Health Expenditure
Projections 2014-2025 Forecast Summary.” Published July 14.
www.cms.gov/
Research-Statistics-Data-and-Systems/Statistics-Trends-and-
Reports/National
HealthExpendData/Downloads/Proj2015.pdf.
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t16
Institute of Medicine (IOM). 2011. Learning What Works:
Infrastructure Required for
Comparative Effectiveness Research. Workshop Summary.
Accessed August 8, 2016.
www.nap.edu/catalog/12214/learning-what-works-
infrastructure-required-for-
comparative-effectiveness-research-workshop.
———. 2001. Crossing the Quality Chasm: A New Health
System for the 21st Century. Wash-
ington, DC: National Academies Press.
———. 1999. To Err Is Human: Building a Safer Health
System. Washington, DC: National
Academies Press.
Joshi, M. S., E. R. Ransom, D. B. Nash, and S. B. Ransom.
2014. The Healthcare Quality
Book: Vision, Strategy and Tools, 3rd edition. Chicago: Health
Administration Press.
63. Landrigan, C. P., G. J. Parry, C. B. Bones, A. D. Hackbarth, D.
A. Goldmann, and P. J.
Sharek. 2010. “Temporal Trends in Rates of Patient Harm
Resulting from Medical
Care.” New England Journal of Medicine 363 (22): 2124–34.
National Guideline Clearinghouse (NGC). 2016. Home page.
Accessed August 8. https://
guideline.gov/.
Ransom, S. B., M. S. Joshi, and D. B. Nash (eds.). 2005. The
Healthcare Quality Book: Vision,
Strategy, and Tools. Chicago: Health Administration Press.
Rotter, T., L. Kinsman, E. L. James, A. Machotta, H. Gothe, J.
Willis, P. Snow, and J. Kugler.
2010. “Clinical Pathways: Effects on Professional Practice,
Patient Outcomes, Length
of Stay and Hospital Costs.” Cochrane Database of Systematic
Reviews 3: CD006632.
Senge, P. M. 1990. The Fifth Discipline: The Art and Practice
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Healthcare Trends and
Implications 2016–2021. Chicago: SHSMD and Health
Administration Press.
CHAPTER
64. 17
2HISTORY OF PERFORMANCE IMPROVEMENT
Operations Management in Action
During the Crimean War, a conflict that waged from
October 1853 to February 1856 pitting Russia against
Britain, France, and Ottoman Turkey, reports of ter-
rible conditions in military hospitals began to emerge
that alarmed British citizens. In response to the out-
cry, the British government commissioned Florence
Nightingale, now widely recognized as a pioneer in
nursing practice, to oversee the introduction of nurses
to military hospitals and to improve conditions in the
hospitals. When Nightingale arrived in Scutari, Turkey,
she found the military hospital there overcrowded and
filthy. She instituted many changes to improve the
sanitary conditions in the hospital, and many lives
were saved as a result of these reforms.
Nightingale was among the first healthcare
professionals to collect, tabulate, interpret, and graph-
ically display data related to the impact of process
changes on care outcomes—what is known today as
evidence-based medicine. To quantify the overcrowd-
ing problem, she compared the average amount of
space per patient in London hospitals—1,600 square
feet—to the space in Scutari—about 400 square feet.
She developed a standardized document, the Model
Hospital Statistical Form, to enable the collection of
consistent data for analysis and comparison. In Feb-
ruary 1855, the patient mortality rate at the military
hospital in Scutari was 42 percent. As a result of Night-
ingale’s changes, by June of that year the mortality
rate had decreased to 2.2 percent.
65. To present these data in a persuasive manner, she developed a
new type of
graphic display, the polar area diagram. The diagram was a pie
chart with a monthly
slice for mortality numbers and their causes displayed in a
different color. A quick
glance at the diagram “showed that except for the bloodiest
month in the siege of
Sevastopol, battle deaths take up a very small portion of each
slice,” notes Lienhard
O V E RV I E W
This chapter provides the background and historical
context for performance improvement—which is not
a new concept. Several of the tools, techniques, and
philosophies outlined in this text are based in past
efforts. Although the terminology has changed, many
of the core concepts remain the same.
The major topics in this chapter include the
following:
• Background for understanding operations
management
• Systems thinking and knowledge-based
management
66. • Scientific management
• Project management
• Introduction to quality, and quality experts of
note
• Philosophies of performance improvement,
including Six Sigma, Lean, and others
• Introduction to supply chain management
• Introduction to big data and analytics
Although these tools and techniques have been
adapted for contemporary healthcare, their roots
are in the past, and an understanding of this history
(exhibit 2.1) can enable organizations to move success-
fully into the future.
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t18
(2016). It revealed that “The Russians were a minor enemy. The
real enemies were
cholera, typhus, and dysentery. Once the military looked at that
eloquent graph,
the modern army hospital system was inevitable” (Lienhard
67. 2016).
After the war, Nightingale used the data she had collected to
demonstrate
that the mortality rate in Scutari following her reforms was
significantly lower than
in other British military hospitals. Although the British military
hierarchy was resis-
tant to her changes, the data were convincing and resulted in
reforms to military
hospitals and the establishment of the Royal Commission on the
Health of the Army.
Were she alive today, Nightingale would recognize many of the
philosophies,
tools, and techniques outlined in this text as essentially the
same as those she
employed to achieve lasting reform in hospitals throughout the
world.
Sources: Information from Cohen (1984), Lienhard (2016),
Neuhauser (2003), and Nightingale (1858).
Background
The healthcare industry faces many challenges. The costs of
care and level of
services delivered are increasing; even as the population ages,
we are able to pro-
long lives to an ever greater extent as technology advances and
expertise grows.
The expectation of quality care with zero defects, or failures in
care, is being
pursued by government and other stakeholders, driving the need
for healthcare
providers to produce more of a high-quality product or service
68. at a reduced
cost. This need can only be met through improved utilization of
resources.
Specifically, providers must offer their services more
effectively and effi-
ciently than at any time in the past by optimizing their use of
limited financial
assets, employees and staff, machines and facilities, and time.
Enter operations management.
Operations management is the design, implementation, and
improve-
ment of the processes and systems that create and deliver the
organization’s
products and services. Operations managers plan and control
delivery processes
and systems within the organization.
Forward-thinking healthcare leaders and professionals have
realized
that the theories, tools, and techniques of operations
management, if properly
applied, can enable their organizations to become efficient and
effective care
delivery environments. However, for many of the aims
identified by the US
healthcare system to be achieved, essentially all healthcare
providers must adopt
these tools and techniques, many of which have enabled other
service indus-
tries and manufacturing sectors to improve efficiency and
effectiveness. The
operations management information presented in this book
should similarly
69. enable hospitals and other healthcare organizations to design
systems, processes,
products, and services that meet the needs of their stakeholders.
Importantly,
it should also allow continuous improvement in these systems
and services to
keep pace with the quickly changing healthcare landscape.
C h a p t e r 2 : H i s t o r y o f P e r f o r m a n c e I m p r o
v e m e n t 19
C
P
M
m
et
h
o
d
P
E
R
T
m
et
h
o
95. in
P
er
fo
rm
an
ce
Im
p
ro
ve
m
en
t
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t20
To improve systems and processes, however, one must first
know the
system or process and its desired inputs and outputs.
Knowledge-Based Management
This book takes a systems view of service provision and
delivery, as illustrated
in exhibit 2.2, and focuses on knowledge-based management
(KBM)—using
data and information toward basing management decisions on
96. facts rather than
on feelings or intuition—to frame that view. The improvement
in computer
systems and new analytical approaches support the increased
use of KBM,
especially in terms of building a knowledge hierarchy.
The knowledge hierarchy relates to the learning that ultimately
under-
pins KBM. As illustrated in exhibit 2.3, the knowledge
hierarchy consists of
the following five categories (Zeleny 1987):
Knowledge
hierarchy
The foundation of
knowledge-based
management,
composed of five
categories of
learning: data,
information,
knowledge,
understanding,
and wisdom.
Feedback
Transformation
process
Labor
Material
Machines
Management
Capital
98. Knowledge
Learning
Information
Data
EXHIBIT 2.3
Knowledge
Hierarchy
C h a p t e r 2 : H i s t o r y o f P e r f o r m a n c e I m p r o
v e m e n t 21
1. Data. Symbols or raw numbers that simply exist; they have
no structure
or organization. Entities collect data with their computer
systems;
individuals collect data through their experiences. At this stage
of the
hierarchy, one can presume to know nothing because raw data
alone are
not adequate for decision making.
2. Information. Data that are organized or processed to have
meaning.
Information can be useful, but it is not necessarily useful. It can
answer
such questions as who, what, where, and when—in other words,
know
what.
99. 3. Knowledge. Information that is deliberately useful.
Knowledge enables
decision making—know how.
4. Understanding. A mental frame that allows use of what is
known and
enables the development of new knowledge. Understanding
represents
the difference between learning and memorizing—know why.
5. Wisdom. A high-level stage that adds moral and ethical views
to
understanding. Wisdom answers questions to which there is no
known
correct answer and, in some cases, to which there will never be
a known
correct answer—know right.
A simple example may help explain this hierarchy. Say your
height is
67 inches and your weight is 175 pounds (data). You have a
body mass index
(BMI) of 26.7 (information). A healthy BMI is 18.5 to 25.5
(knowledge).
Your BMI is high, and to be healthy you should lower it
(understanding). You
begin a diet and exercise program and lower your BMI
(wisdom).
Finnie (1997, 24) summarizes the relationships in the hierarchy
and
notes our tendency to focus on its less important levels:
We talk about the accumulation of information, but we fail to
distinguish between
100. data, information, knowledge, understanding, and wisdom. An
ounce of information
is worth a pound of data, an ounce of knowledge is worth a
pound of information,
an ounce of understanding is worth a pound of knowledge, an
ounce of wisdom is
worth a pound of understanding. In the past, our focus has been
inversely related to
importance. We have focused mainly on data and information, a
little bit on knowl-
edge, nothing on understanding, and virtually less than nothing
on wisdom.
Knowledge Through the Ages
The roots of the knowledge hierarchy can be traced to
eighteenth-century
philosopher Immanuel Kant, much of whose work attempted to
address the
questions of what and how we can know.
The two major philosophical movements that significantly
influenced
Kant were empiricism and rationalism (McCormick 2006). The
empiricists,
most notably John Locke, argued that human knowledge
originates in one’s
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t22
101. experiences. According to Locke, the mind is a blank slate that
fills with ideas
through its interaction with the world. The rationalists,
including Descartes
and Galileo, argued that the world is knowable through an
analysis of ideas
and logical reasoning. Both the empiricists and the rationalists
viewed the mind
as passive, either by receiving ideas onto a blank slate or
because it possesses
innate ideas that can be logically analyzed.
Kant joined these philosophical ideologies by arguing that
experience leads
to knowing only if the mind provides a structure for those
experiences. Although
the idea that the rational mind plays a role in defining reality is
now common,
in Kant’s time this was a major insight into what and how we
know. Knowledge
does not flow from our experiences alone, nor only from our
ability to reason;
rather, knowledge flows from our ability to apply reasoning to
our experiences.
Relating Kant’s philosophy to the knowledge hierarchy, data are
our
experiences, information is obtained through logical reasoning,
and knowledge
is obtained when we apply structured reasoning to data to
acquire knowledge
(Ressler and Ahrens 2006).
The intent of this text is to enable readers to gain knowledge.
We discuss
tools and techniques that allow the application of logical
102. reasoning to data
toward obtaining knowledge and using it to make decisions.
This knowledge
and understanding should help the reader provide healthcare in
an efficient
and effective manner.
History of Scientific Management
Frederick Taylor (whose work is covered in more detail later in
the chapter)
originated the term scientific management in The Principles of
Scientific Man-
agement (Taylor 1911). Scientific management methods called
for eliminating
the old rule-of-thumb, individual way of performing work and,
through study
and optimization of the work, replacing the varied methods with
the one “best”
way of performing the work to improve productivity and
efficiency. Today, the
term scientific management has been replaced with operations
management,
but the concept is similar: Study the process or system and
determine ways to
optimize it to achieve improved efficiency and effectiveness.
Mass Production
The Industrial Revolution and mass production set the stage for
much of Tay-
lor’s work. Prior to the Industrial Revolution, individual
craftsmen performed
all tasks necessary to produce a good using their own tools and
procedures.
In the eighteenth century, Adam Smith advocated for the
division of labor—
103. increasing work efficiency through specialization. To support a
division of
labor, a large number of workers are brought together, and each
performs a
specific task related to the production of a good. Thus, the
factory system of
Scientific
management
A disciplined
approach to
studying a system
or process and
then using data
to optimize it to
achieve improved
efficiency and
effectiveness.
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v e m e n t 23
mass production was born, and Henry Ford’s assembly line
eventually emerged,
making industrial conditions ripe for Taylor to introduce
scientific management.
Mass production allows for significant economies of scale, as
predicted
by Smith. Before Ford set up his moving assembly line, each car
chassis was
assembled by a single worker and took about 12½ hours to
produce. After the
introduction of the assembly line, this time was reduced to 93
104. minutes (Bellis
2006). The standardization of products and work ushered in by
the assembly
line not only led to a reduction in the time needed to produce
cars but also
significantly reduced the costs of production. The selling price
of the Model
T fell from $1,000 to $360 between 1908 and 1916 (Simkin
2005), allowing
Ford to capture a large portion of the market.
Although Ford is commonly credited with introducing the
moving
assembly line and mass production in modern times, both
processes were
in practice several hundred years earlier. The Venetian Arsenal
of the 1500s
employed 16,000 people and produced nearly one ship every
day (NationMas-
ter.com 2004). Ships were mass produced using
premanufactured, standardized
parts on a floating assembly line (Schmenner 2001).
One of the first examples of mass production in the healthcare
industry
is Shouldice Hospital (Heskett 2003). Much like Ford, who is
commonly cited
as saying people could have the Model T in any color, “so long
as it’s black,”
Shouldice, founded in 1945 in Toronto, performs just one type
of surgery—
routine hernia operations—and it continues to thrive with its
unique approach
(Heskett 2003).
Furthermore, evidence is growing in healthcare that level of
105. experience in
treating specific illnesses and conditions affects the outcome of
that care. Higher
volumes of cases often result in better outcomes (Halm, Lee,
and Chassin 2002).
Specifically, the additional practice associated w ith higher
volume results in bet-
ter outcomes. The idea of “practice makes perfect,” or learning-
curve effects,
has led organizations such as the Leapfrog Group (made up of
organizations
that provide healthcare benefits) to list patient volume among
its criteria for
quality (Halm, Lee, and Chassin 2002). The Agency for
Healthcare Research
and Quality (AHRQ) report Localizing Care to High-Volume
Centers devotes an
entire chapter to this issue and its impact on medical practice
(Auerbach 2001).
Frederick Taylor
Taylor began his work when mass production and the factory
system were in
their infancy. He believed that US industry was “wasting”
human effort and
that, as a result, national efficiency (now called productivity)
was significantly
lower than it could be. The introduction to The Principles of
Scientific Manage-
ment (Taylor 1911) illustrates his intent:
[O]ur larger wastes of human effort, which go on every day
through such of our acts
as are blundering, ill-directed, or inefficient, and which Mr.
[Theodore] Roosevelt
106. H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t24
refers to as a lack of “national efficiency,” are less visible, less
tangible, and are but
vaguely appreciated. . . . This paper has been written:
First. To point out, through a series of simple illustrations, the
great loss which the
whole country is suffering through inefficiency in almost all of
our daily acts.
Second. To try to convince the reader that the remedy for this
inefficiency lies in
systematic management, rather than in searching for some
unusual or extraordinary
man [referring to the so-called great man theory prevalent at the
time].
Third. To prove that the best management is a true science,
resting upon clearly
defined laws, rules, and principles, as a foundation. And further
to show that the
fundamental principles of scientific management are applicable
to all kinds of human
activities, from our simplest individual acts to the work of our
great corporations,
107. which call for the most elaborate cooperation. And, briefly,
through a series of illus-
trations, to convince the reader that whenever these principles
are correctly applied,
results must follow which are truly astounding.
Note that Taylor specifically mentions systems management as
opposed
to the individual; this is a common theme that we revisit
throughout this book.
Rather than focusing on individuals as the cause of problems
and the source
of solutions, emphasis is placed on systems and their
optimization.
Taylor believed that much waste was the result of what he
called “sol-
diering,” which today might be thought of as slacking. Further,
he believed
that the underlying causes of soldiering were as follows (Taylor
1911):
First. The fallacy, which has from time immemorial been almost
universal among
workmen, that a material increase in the output of each man or
each machine in
the trade would result in the end in throwing a large number of
men out of work.
Second. The defective systems of management which are in
common use, and which
108. make it necessary for each workman to soldier, or work slowly,
in order that he may
protect his own best interests.
Third. The inefficient rule-of-thumb methods, which are still
almost universal in all
trades, and in practicing which our workmen waste a large part
of their effort.
To eliminate soldiering, Taylor proposed instituting incentive
schemes.
While at Midvale Steel Company, he used time studies to set
daily production
quotas. Incentives were paid to those workers who reached their
daily goals,
and those who did not reach their goals were paid significantly
less. Productiv-
ity at Midvale doubled. Not surprisingly, Taylor’s ideas
produced considerable
backlash. The resistance to increasingly popular pay-for-
performance programs
in healthcare today is analogous to that experienced by Taylor.
Taylor believed that “one best way” existed to perform any task
and
that careful study and analysis would lead to the discovery of
that way. For
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v e m e n t 25
109. example, while at Bethlehem Steel Corporation, he studied the
shoveling of
coal. Using time studies and a careful analysis of how the work
was performed,
he determined that the optimal amount of coal per shovel load
was 21 pounds.
Taylor then developed shovels that would hold exactly 21
pounds for each
type of coal; workers had previously supplied their own shovels
(NetMBA.com
2005). He also determined the ideal work rate and rest periods
to ensure that
workers could shovel all day without fatigue. As a result of
Taylor’s improved
methods, Bethlehem Steel was able to reduce the number of
workers shoveling
coal from 500 to 140 (Nelson 1980).
Taylor’s four principles of scientific management are to
1. develop and standardize work methods on the basis of
scientific study,
and use these to replace individual rule-of-thumb methods;
2. select, train, and develop workers rather than allowing them
to choose
their own tasks and train themselves;
3. develop a spirit of cooperation between management and
workers
to ensure that the scientifically developed work methods are
both
sustainable and implemented on a continuing basis; and
4. divide work between management and workers so that each
has an
110. equal share, where management plans the work and workers
perform
the work.
Although some would be problematic today—particularly the
notion
that workers are “machinelike” and motivated solely by
money—many of
Taylor’s ideas can be seen in the foundations of newer
initiatives such as Six
Sigma and Lean, two important quality improvement approaches
discussed in
depth later in the book.
Frank and Lillian Gilbreth
The Gilbreths were contemporaries of Frederick Taylor. Frank,
who worked
in the construction industry, noticed that no two bricklayers
performed their
tasks the same way. He believed that bricklaying could be
standardized and the
one best way determined. He studied the work of bricklaying
and analyzed the
workers’ motions, finding much unnecessary stooping, walking,
and reaching.
He eliminated these motions by developing an adjustable
scaffold designed
to hold both bricks and mortar (Taylor 1911). As a result of this
and other
improvements, Frank Gilbreth reduced the number of motions in
bricklaying
from 18 to 5 (International Work Simplification Institute 1968)
and raised out-
put from 1,000 to 2,700 bricks a day (Perkins 1997). He applied
what he had
learned from his bricklaying experiments to other industries and
111. types of work.
In his study of surgical operations, Frank Gilbreth found that
doctors
spent more time searching for instruments than performing the
surgery. He
H e a l t h c a r e O p e r a t i o n s M a n a g e m e n t26
developed a technique still seen in operating rooms today:
When the doctor
needs an instrument, he extends his hand, palm up, and asks for
the instru-
ment, which is then placed in his hand. This technique
eliminates searching
for the instrument and allows the doctor to stay focused on the
surgical area,
thus reducing surgical time (Perkins 1997).
Frank and Lillian Gilbreth may be more familiarly known as the
parents
in the book Cheaper by the Dozen (Gilbreth and Carey 1948)
(which was made
into a movie by the same title in 1950 and remade in 2003). The
Gilbreths
incorporated many of their time-saving ideas in their family as
well. For example,
they bought just one type of sock for all 12 of their children,
thus eliminating
time-consuming sorting.
Scientific Management Today
Scientific management fell out of favor during the Depression,
partly because
112. of the sense that it dehumanized employees, but mainly because
of a general
belief in society that productivity improvements resulted in
downsizing and
increased unemployment. Not until World War II did scientific
management,
renamed operations research, see a resurgence of interest.
In healthcare today, standardized methods and procedures are
used to
reduce costs and increase the quality of outcomes. Specialized
equipment has
been developed to speed procedures and reduce labor costs. In a
sense, we are
still searching for the one best way. However, we must heed the
lessons of the
past. If the tools of operations management are perceived to be
dehumanizing
or to result in downsizing by healthcare organizations, their
implementation
will meet significant resistance.
Project Management
The discipline of project management began with the
development of the Gantt
chart in the early twentieth century. Henry Gantt worked closely
with Frederick
Taylor at Midvale Steel and in Navy ship construction during
World War I.
From this work, he developed bar graphs to illustrate the
duration of project
tasks and display scheduled and actual progress. These Gantt
charts were used
to help manage large projects, including construction of the
Hoover Dam,
113. and proved to be such a powerful tool that they are commonly
used today.
Although Gantt charts were originally adopted to track large
projects, they
are not ideal for very large, complicated projects because they
do not explicitly
show precedence relationships, that is, what tasks need to be
completed before
other tasks can start. In the 1950s, two mathematic project
scheduling techniques
were developed: the program evaluation and review technique
(PERT) and
the critical path method (CPM). Both techniques begin by
developing a project
network showing the precedence relationships among tasks and
task duration.
Program
evaluation and
review technique
(PERT)
A graphic
technique to
link and analyze
all tasks within
a project; the
resulting graph
helps optimize the
project’s schedule.
Critical path
method (CPM)
The critical path
is the longest
course through
114. a graph of linked
tasks in a project.
The critical path
method is used to
reduce the total
time of a project
by decreasing the
duration of tasks
on the critical path.
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v e m e n t 27
PERT was developed by the US Navy to address the desire to
acceler-
ate the Polaris missile program. This “need for speed” was
precipitated by
the Soviet launch of Sputnik, the first space satellite. PERT
uses a probability
distribution (the beta distribution), rather than a point estimate,
for the dura-
tion of each project task. The probability of completing the
entire project in a
given amount of time can then be determined. This technique is
most useful
for estimating project completion time when task times are
uncertain and for
evaluating risks to project completion prior to the start of a
project.
The CPM technique was developed at the same time as PERT by
the
DuPont and Remington Rand corporations to manage plant
maintenance