Risk Management: New Challenges and Opportunities for Insurance Sectors

Risk management can be described as like the other management procedures of identification, assessment and prioritization of risk. Actually risk management is very much equal to walking on the rope. As defined in ISO 31000 the effect of uncertainty on objectives whether it positive or negative. Risks can come from uncertainty in financial markets, project failures, legal liabilities, credit risk, accidents, natural causes and disasters as well as deliberate attacks from an adversary. Risk Analysis Risk analysis is the process of systematically identifying and assessing the potential threats and uncertainties that occur when trying to achieve a certain goal (such as completing a project), and then finding a reasonable strategy for most efficiently controlling these risks. Risk analysis also helps to define preventive measures to reduce the probability of these factors from occurring and identify countermeasures to successfully deal with these constraints when they develop to avert possible negative effects on the competitiveness. Insurance The most common tool used in risk management is insurance. Besides the standard health, life, and possibly disability insurance, we have to look at the types of liability and property insurance that may we need. Specialized insurance for particular risks in business can also be necessary. For instance, in an industry a chemical component is used in production process, they need special toxic risk insurance. A sense of security may be the next basic goal after food, clothing, and Shelter. An individual with economic security is fairly certain that he can satisfy his needs (food, shelter, medical care, and so on) in the present and in the future. Economic risk (which we will refer to simply as risk) is the possibility of losing economic security. Most economic risk derives from variation from the expected outcome Need for awareness on insurance products Life insurance and general insurance have more products to facilitate the customer needs. According to most of the surveys individual lack the awareness, literacy and skills to adequately assess their needs for financial and social protection and to choose appropriate insurance services. Raising awareness and educating on individuals are challenging priorities for research studies. Because of trends towards increased responsibility of the individuals for the management of risks and coverage, as well as consequences wrong or inappropriate decisions. The education process in the insurance sector involves different types of stake holders’ insurance authorities, insurance entities and intermediaries, other insurance providers, distributors, NGOs and customers themselves. Importance of insurance Importance of insurance is definitely increasing and expanding. Households should be encouraged and provided with the possibilities to enhance their awareness, responsibility to the coverage of their overall risk exposure as well as their understanding the knowledge of insurance products. Yet little research has been undertaken on this subject. With in a frame work of general financial education insurance subject is being handled. Better understanding of financial products can be given to potential consumers. Evaluation of risk in new areas of personnel insurance Increase in perceived and real risk. Emerging catastrophic bond markets shows the rise in risk levels. The range of conventional and new large scale risks seems to have expanded and their frequency has increased. They included risk related to industrial (Bhopal), natural (earthquakes, floods), terrorist attacks, new technologies risks (cyber crimes), Health risk against new diseases. Enhanced needs and demand for risk coverage: Broad increase in savings interest of population started investing in assets like houses, buying materials like gold, investment in financial markets have to be protected. The relative complicity and heterogeneity of insurance products develops confusion among the non expert consumers, as they need insurance. Existing products and new age products have to be updated to the present scenario. Responsibility of the insurance companies to get the feed back from the consumers. Know the difficulties in getting their service. Short term mindset of consumer does not encourage them to get long term coverage. Various studies will help the sectors to study the consumer’s knowledge about the insurance products. Tools like the number of complaints received from the customers, questionnaires to collect the position of the consumer can be used. Innovation of Insurance opportunities in capital markets The capital market risk usually defines the risk involved in the investments. The stark potential of experiencing losses following a fluctuation in security prices is the reason behind the capital market risk. During the global financial turmoil of 2007 and 2008, the stocks were worst affected, even well performing stocks are also beaten up. This is a characteristic feature of capital market. How ever in the time of market fluctuation and turbulence volatile seasons investors losing their hard earned money. Loss occurred to the investors makes the disbelief in capital market and views the market as a gambling spot. Resulting further investment in capital markets by them is stopped. Stock market has to search for another investor. The interest of protecting the investment of the investor is maintained by SEBI and Government of India through its policies, guidelines and certain regulations. Monitoring the markets fraudulent, watc hing the short selling, bulk Purchase, inside trading, etc†¦.and helps logically to protect the investors by legitimately. Apart from SEBI and government interest some professional system has to emerge for protecting investments. Many researches have to be done to provide an insurance system or scheme to capital market securities. Financial innovation has allowed many types of risk to become more tradable including like credit, interest rate, foreign- exchange risk and equity. Risk transfer and a new system for protecting investments of investors in capital market securities have to be analyzed. Emerging capital markets needs investments in a continuous mode. Then only corporate of India can adventure into expansions, mergers and acquisitions to proceed their plan for development. Recent turmoil experienced that no IPO issue got success and others likely to issue IPO is delayed. Financial risk transfer and transparency have been dominant themes since the World War II. Insurance risk comes in many varieties and also segmented into broad categories e.g. life, mortgages, car loan, assets against theft, fire, flood, earth quake, corps. Financial innovation has allowed many type of risk to become tradable including credit, interest rate, foreign exchange risk. The potential market is vast, with total premiums of all the world’s insurers equaling to US$ 4.1 trillion. Most insurance are asset based securities. Treating the investments of securities in capital market as a product and providing insurance as like other risk class is the idea behind the research. Increasing trend in insurance linked securities attracted the research concept. CAT bonds were issued against catastrophic risks such as windstorms, (hurricanes, typhoons) and earth quakes. These serve as collateralized protection for extreme event risk at a multi year fixed price. Industry loss warranties, CAT bonds, cat swaps are triggered by specific indexes. The purpose of the research is to extent insurance linked securities concept and providing an insurance coverage at a premium for expected loss. All progress is born of inquiry. Doubts is often better than overconfidence, for it leads to inquiry leads to invention†-Hudson maxim Any research on this topic will give a better beginning of new innovation to one of the financial market instrument of capital market. Financial institutions, government funds and large retail participants from house hold savings floods the funds to capital market. Further more the inventions to the betterment of the system will bring the trust in the mind of investor. The capital market provides both overnight and long term funds and uses financial instruments with long maturity periods. The following financial instruments are traded in this market are Foreign exchange instruments, Equity instruments, Insurance instruments, Credit market instruments, Derivative instruments. This research deals for the investments in equity stocks. Insurance and Reinsurance Insurance companies are in the business of assuming risks from individuals or companies. They manage those risks by diversifying over a large number of policies, Perils and geographic regions. A particularly difficult problem is the management of risk from high severity, low probability events (catastrophe risk, or â€Å"CAT† risk), such as that posed by major earthquakes or hurricanes. The risk from low severity, high probability events (for example, auto collision or medical insurance) can be diversified by writing a large number of similar policies. Suppose that the insurer charges a premium equal to the expected average annual loss and has a very large number of policies. By the law of large numbers, it can expect to pay out approximately this amount in claims in each year. Under the CAT bond scenario, investors purchase the bond and exchange a principal payment now for future coupon (interest) and principal payments. These payments are contingent on loss experience or the occurrence of a specified catastrophic event. If the bond is not triggered, the investor receives full coupon and principal payments over the life of the bond. If the bond is triggered, the investor may lose the right to future coupon payments, principal payments or both, depending on the type of bond Methodology 1. Formulating the research problem and extension of literature survey. Selecting the securities for investigation from NSE India from Nifty stocks in which investment is going to be insured. Collecting data for period ten years from web sites of NSE and several associated agencies for the frequency of peeks and deeps of price movements. Comparing the data with existing technical analysis theories for trigger price calculating. For the same period of time fundamental analysis has to be done for the same stock. Knowing stability and financial performance of the stock then correlating the both analysis and finding the stocks for making model. . 2. Development of working hypothesis& Building model. After extensive literature survey a model has to be build. Testing for hypotheses for the formula arrived. Development of working by hypotheses is to be state in clear terms. Working hypothesis is intensive assumption made in order to draw out and test its logical or empirical consequences. Conclusion The contribution that the research should make an exposure to the insurance companies to concentrate and find possibilities to take the investment made in capital market as product. By two ways this research will benefit the society one is protecting the investment of the investor by which building the trust and make the continuous investment in capital market through that the market may get regular in flow of funds. Another is new business emerged to the insurance companies. Reference http://finance.mapsofworld.com/primary-market/problems-indian.html

Review on My Name Is Khan

To write a review about a film which contains not only the magical combo of Shahrukh Khan-Kajol-Karan Johar but also something different from melodramatic love story or usual remake of hardcore commercial film is pleasurable. My Name Is Khan has a excellent point to a class of audience who likes to watch Shahrukh Khan in a different characteristic. But the film does not show the excellence enough to get a perfect worship from all audiences and critics.In the movie Rizwan embarks on a touching journey and gets the true recognition of his love,love for Mandira_we reveal a simple but touchy characteristic of an ordinary man’s love,we go through an extra ordinary journey. The movie has some points for which it can be appreciated. Firstly, though such story is not brand new but it has a fresh and own style of presence. Though it can not pass through the mark, made by movie like Forrest Gump but the point is it is not bullshit in any sence. MNIK also gives you a massage and create a different and sometime authentic feelings while you are watching.Secondly,the script makes you feel for the character. It is not Shahrukh Khan,it is Rizwan Khan for whom you will think. It is not chiffon sarees or bubbly dialogue for which you will adore Kajol,it is Mandira. It is a woman who really reflect the motherly affection, a loving and caring wife. Thirdly, the tempo of the movie. It has many subplot but they are quite interesting. It’s an exceptionally relevant to a concept-the unity of nations is of paramount importance, We are all coming together to fight for a common cause – called humanity.Everyone knows that terrorism has no religion and it will never have a religion. As a film, it tries to show social responsibility and the character tries to fulfill that from their position. Though the specificity of activities is not beyond question. Fourthly, the movie can clear it’s idea. It’s not all about a disabled man’s fight against disabil ity. It’s a disabled man’s fight against the disability that exists in the world—terrorism, hatred, fighting. My Name is Khan is also about Islam and the way the world looks at Islam but it not takes any sides.It only tries to say that there are only good people and bad people. There are no good Hindus, bad Hindus, good Christians, bad Christians. Either you are a good person or a bad person. Religion is not the criterion, humanity is. Fifthly, all the actors and actresses has done well. Specially Shahrukh-Kajal combo has got another dimension in bollywood after this movie. Kajal has done very well. Her maturity is used very consciously. We get Shahrukh in a new and pleasant avatar after Chak De! India and Swades. Zarina Wahab is very good as Rizwan’s mom.Thanks Shahrukh for making the character more closer to the audience. Yes we can say he can act. Sixthly, the director has used the complexity and complication provoked by rational and regional aspect th ough it is not totally agreeable in some sense. Moreover sometimes there are many reasons behind any happenings like- 9/11, which can not be described so easily. Moreover, Indian Film Indusrtry don’t have the trend to take a risk by making film relevant to such touchy issues though films like New York ,Kabul Express,Main hoon Na had made.But they were not totally focused. I am not telling that MNIK is all focused but it has got some solid point to relate with a serious issue. Use of metaphorical shot is also notable. Specially Rizwan holding poster-Repair Almost Anything headlined is a brilliant one. This stands for a meaningful thought. The narrative style of story telling and blending past time and present time is good but continuity error like showing objects which don’t match with the time showed in the movie is not expected.The narrative style may influenced by The Shawshank Redemption and Godfellas. The ending is quite good but it may be more gothic and more auth entic. The journey of Khan may be showed more smartly in accordance with happenings as sometime it has feel us melodramatic. Cinematography is worthy off a hand of applause, specially using the background and wide angle shot. Editing is fine. Thanks Ravi K. Chandran (director of photography) and Deepa Bhatia (editing) Shankar-Ehsan-Loy has done a great job both in soundtrack and background score.Thanks to the lyricist(Niranjan Iyengar and Javed Akhtar) The songs such as â€Å"Noor-e-Khuda† blend western bar blues and techno sounds with Indian classical styles such as Sufi and Hindustani. The soundtrack is thus representative of the â€Å"indie fusion genre†. Unlike Karan Johar's other films, this film has no lip-sync songs. All the songs are in background. â€Å"Tere Naina† is a good one. In short The content of My Name Is Khan is diametrically opposite to whatever Karan Johar done in the past. My Name Is Khan is â€Å"not all about terrorism, or 9/11.Itâ€℠¢s about a relationship between two people, between an individual and the State, and between an individual and the country. In short, there the three important components: love story, Islam and a mild form of autism. You can watch it. Sometime it is impressive, dramatic, a little bit slow, inspiring, may be controversial but enjoyable too. The pick up line is – There are only two kinds of people in this world. Good people who do good deeds. And bad people who do bad. That's the only difference in human beings. There's no other difference.

The Effect of Computer in Our Daily Lives

Why Do They Fail? Statistics show that most people who begin high school finish. Some drop out, of course, but approximately three-quarters earn a diploma. At the post-secondary level, however, fewer than two-thirds of the students complete their program of study. Why do so many college and university students drop out? Knowing the factors that prevent students from completing their post-secondary programs may prove crucial to you regardless of whether you are presently a college student or thinking of becoming one.Most educators agree that the principal causes of failure are lack of basic skills, lack of study skills, and lack of motivation. A firm grasp of basic skills—what are termed the three Rs: reading, writing, and arithmetic—is a must for college or university work. Not only are texts and research material more difficult to understand than they were in high school, but also the quantity of required reading is greater.The ability to express oneself clearly in sta ndard written English is essential; garbled essays, ungrammatical reports, or poorly spelled and punctuated papers will be routinely failed by instructors, regardless of the ideas the writer may think he is expressing. Similarly, mathematical skills are essential to a student’s success in many post-secondary programs. Business, science, technology, and some applied arts programs require sound computational skills. Post-secondary students who lack these basic skills often find little remedial help available and little instructor tolerance for poor work; hence, they fall behind and drop out.

Early Twentieth Century, continued Essay Example | Topics and Well Written Essays - 750 words

Early Twentieth Century, continued - Essay Example The manner in which Mine Okubo was treated is perhaps the worst I would expect to come across in a country that I proudly identify with. Placed in her position, I would interpret such form of treatment as betrayal from a country that I expected to protect my rights and freedoms as an American citizen. After undergoing the evacuation and confinement experience, I would relinquish the American citizenship and seek citizenship in my ancestral land rather than continuing living in a country that would turn against its own people on grounds of race in times of trouble. Today, the experiences of Mine Okubo can probably be traced in people belonging to minority or marginalized groups such as the American Indians, African Americans, the Mexican immigrants and people with the Arabic identity (Cadge-Moore 157). Despite being American citizens, Native Americans continue to face discrimination in all aspects of life including education, employment, political participation and health care. Discrimination partially explains why these groups continue to be marginalized and leveraged in poverty in a global economic power base. Terrorism threats currently experienced in America have exposed people with the Arabic identity and other immigrants to similar treatment including confinement in camps and incarceration as terrorism suspects. The war on terror has seen the U.S. Government establish stringent measures at its main entry points to avert illegal immigration. This has indeed contributed to harassment of American citizens in the detention camps as they await verification, a phenomenon experienced by Okubo and other immigrants (Cadge-Moore 146). Therefore, it is clear that some American citizens continue to suffer at the hands of their very own country. Mine Okubo’s art in â€Å"Citizen 13660† serves to depict some of the historical injustices faced by minority groups such as the Japanese Americans and Indian

Ethics (9 topics total Essay Example | Topics and Well Written Essays - 4500 words

Ethics (9 topics total - Essay Example Involuntary euthanasia refers to putting a person to death without obtaining or seeking the patient’s consent; ethically, this action is equivalent to a murder. Abortion is the process of terminating pregnancy by removing the growing fetus from the womb of a mother, which is also equivalent to ending human life. Many cultures around the world treat abortion as unethical, immoral and illegal even if it is done to avoid the growth of babies with genetic deformities. Yet, most parents opt for abortion of fetuses with abnormalities. Aborting the fetus becomes necessary in case of severe damage due to injury or any other cause; in case of abnormal growth of the embryo, which could be harmful for the mother, abortion becomes inevitable. However, abortion has received its notion as unethical action because of intentional abortion decisions taken by parents, mothers and other family members due to various other reasons such as pregnancy out of wedlock, unwanted pregnancy, early or lat e pregnancy and even due to pregnancy caused by failed contraception. For these reasons, the fetus may or may not be healthy and normal. From ethics perspective, euthanasia and abortion have attracted much debate from religious and spiritual sides, human rights activists, sociologists, and even medical professionals. In recent debate over euthanasia and abortion, sparked by Ironside who suggested euthanasia for disabled and grieving children and abortion for preventing the birth of an unwanted child or inherently disabled child (Williams, 1). Although Ironside’s advocacy for euthanasia and abortion seem the right choice in such situations, yet people do not dare to take such stand due to the ethical and moral obligations attached with human life and due to pressure from the religious, spiritual and other groups. Abortion is considered legal in most Western and some eastern countries in case of an abnormal fetus; but euthanasia is opted by very few nations. In most of the East ern nations, euthanasia is treated as strictly illegal irrespective of the patient’s condition. The argument is that ending life cannot be a solution to all sufferings; hence, euthanasia and/or abortion do not fit into the choices of humanity but only as inhuman act against fellow human beings. However, from health of the mother and wellbeing of families’ perspective, these choices seem to be, but not confirmed, ultimate answers. Works cited Feinberg, John S and Paul D Feinberg. Ethics for a Brave New World. 2nd ed. Illinois, Crossway, 2010. Williams, Zoe. Abortion and euthanasia: was Virginia Ironside right? The Guardian. 5 October 2010. Web. 28 March 2012. http://www.guardian.co.uk/world/2010/oct/04/virginia-ironside-tv-euthanasia-abortion 2. Sexual morality Sexuality is considered as something vulgar when demonstrated or spoken about in public despite it being a natural biological process associated with growth. Ethics associated with sexuality in reality are direct ed towards sexual behavior, its constraints, and matters of approval. Sexual behavior is common in every human being, but individuals are expected to express sexual desires only with their approved partners; any

Midterm election in the House of Representatives Essay

Midterm election in the House of Representatives - Essay Example There are two theories that explain the out come of mid term elections. The first one is the theory of rise and fall of a regime and the second is the performance of the regime and the situation at the time of the election. Both the theories provide different analyses but you can also use a combination of the two for analyzing the outcome; this method is supposed to give better reasoning. Analyzing the data for mid term polls in the last hundred years, the ruling party seems to have always lost, except in 1934. After 1940 the loss used to be 30 seats or more than 30 seats. In the midterm elections of 1946 the loss was as high as 46 seats. According to the rise and fall of a regime theory, the strong performance by the presidential party in previous elections may cause a downfall in the midterm election. But this is more statistically correct than logically applicable. Generally the statistical details about the loss of the President's party in elections denote that the extent of the strong performance in the last election will decide the downfall in the present election.1 But the statistical details were the results obtained by applying statistical analysis to available data. Though all the mid term elections are similar to each other, each election will have its own significance. The significant factor changes from term to term. That significant factor will have an important place in analyzing the outcome of the midterm elections along with the standard issues. This year the war on Iraq and the policy of the government regarding it is supposed to be a deciding factor in the elections. According to the rise and fall theory the strong performance by the presidential party in previous elections may cause a downfall in the midterm election. The strong performance of the president's party depends upon the information provided by presidential candidate about his future activities in power. The strong performance indicates the trust of the people in his policies and words. It is clear that two years period is not sufficient to deliver in all the fields. It can be difficult for the party in power to defend the delay. At the same time it is easy for the opposition party to criticize and exploit the situation in the form of votes polled. The performance of George W. Bush in the last election can be termed as strong, because his party withstood an anti - incumbency wave and won a majority. Winning a second time shows greater expectations from the people and the party itself. It takes time to fulfill the promises made during the election campaigns and to materialize the wishes of the people. In the course of these things when the government has to face the midterm polls, generally the electorate compares the performance with the promises before electoral victory. The dissatisfaction due to the non - fulfillment of the promises results in mid term poll losses. A number of reasons for the dissent of the people towards the party in power can be cited. The uproar about the nominal boss of US intelligence Negro Ponte's activities of pleasure, spying and making Iraqis write pro US articles by funding them, can be one of the number of activities which is capable of fixing the regime in trouble.1 The above-mentioned activities may not show direct affect on the people. When the electorate

Development Of Cities Assignment Example | Topics and Well Written Essays - 1750 words

Development Of Cities - Assignment Example Through this development, the region became an early center of civilization. Rivers among other geographical features played a very important role in consolidating people together so that they could engage in economic activities. According to Robert Braidwood, â€Å"most historians and anthropologists point to agricultural revolution†¦ as the central development in this transformation to civilization.† In another instance, the Nile was also a landmark geographical feature that facilitated early civilization in Egypt. The Hymn to the Nile provides first-hand information of how the Egyptians perceived the Nile and the relationship that their relationship with their deity. These aspects made people come together hence the development of the early centers of civilization.  Apart from geographical factors, other influential factors made it possible for early civilization to be achieved. The political leadership played a pivotal role in the consolidating people together for a common objective. This can be viewed through the modern management systems, organizations that have good management are able to outdo those that are mismanaged. For example in Egypt, the Pharaoh was a very influential leader in this early center of civilization. As documented in the Hymn to the Pharaoh, the people demonstrated allegiance and commitment to their leadership. They heaped praise and demonstrated their contentment to the pharaoh through the hymn. The artwork has revealed several of the ancient civilizations. For example, ‘The Royal Standard of Ur’ helps in realizing that aspects of peace and war dominated in the course of early civilization. The availability of peace is an indicator that people will have the freedom to live whatever they wanted and do whatever pleased them.  

Final exam Essay Example | Topics and Well Written Essays - 750 words - 3

Final exam - Essay Example This paper describes the strengths and weakness in writing the said essay. The primary strengths of the essay are the good connection between my main points and my thesis, apt transition sentences, and understandable description of the photo’s meaning and implications to its time and to present times, while the weaknesses are the lack of explanation of several aspects of photo analysis and greater integration of secondary resources to the image analysis. One of the strengths of the essay is that I believe that I made a good connection between my main points and thesis. Every paragraph has a primary point that supports the thesis. For example, my first point is: â€Å"Witty uses four photos of the Tank Man†¦where these images try to underline that this man symbolizes the struggles of all ordinary people against government repression and corruption...† (3). This point supports the thesis, where I asserted that Witty represents the cultural memory of these protests. M y next point supports the thesis too because it shows the implications of the image to modern society. I wrote in the third paragraph: â€Å"Witty’s article, the Tiananmen Square protests continue to make history because it portrays an ordinary man’s greatest act of courage and integrity against symbols of oppression† (4). ... For instance, in the fourth paragraph, I wrote: â€Å"After discussing Witty’s article, the paper explores Calhoun’s text†¦Ã¢â‚¬  (5). Through these transitions, I prepared readers on what they will expect next, by connecting every paragraph to the thesis and the past paragraph. Moreover, within each paragraph, I made use of the right conjunctions to ensure the smooth flow of my ideas. To illustrate, I used the words â€Å"moreover† and â€Å"also† to connect these claims that support each main point. These transitions sentences helped me organize my ideas and ensured consistency in presenting and arguing my thesis. The final strength of the essay is its clear description of the photo’s meaning and implications to its time and to present times. The essay shows how the photo stands for the original memory. For example, I wrote in the second paragraph: â€Å"The cultural memory focuses on four tanks that are ready to crush all those who oppose and criticize the state and one man who will not be crushed at all† (4). This description of the photo serves to analyze what the Tank Man’s actions meant to his time. Furthermore, I explained the implications of the image to current society. In the sixth paragraph, I wrote: â€Å"†¦Calhoun understands that the events of Tiananmen Square Protests endures because the silent dead continue to tell their stories through the lives of people in present times who feel oppressed in China† (6). This statement shows the relationship between past memory and current memory because of enduring struggles for empowerment. Hence, the essay connects the image to its cultural representation for past and present generations. The next to be discussed is the weaknesses of the essay, where I did

Construction Law Essay Example | Topics and Well Written Essays - 2250 words

Construction Law - Essay Example placed on par with other kinds of projects because delays in construction and claims arising out of such delays have always been an integral part of construction law. According to Yates and Epstein, there is an enormous amount of time, energy and cost that is devoted to delay claims which do not strictly begin around the time of completion of the job, rather these delays commence right at the inception stage of the project itself.2 The Protocol states that the process of analysis of delay can only begin to be addressed when there is an understanding about what work was carried out and when such work was carried out, as a result, the Protocol recommends that contractors maintain a written record of what work is to be carried out on the project and when it is to be done over the specified time period. However, as McCredie points out, this causes difficulties, not only in terms of the extensive record keeping which the contractor will now have to maintain, but also from the point of vie w of correlating those records with schedules and locations3. In the case of Great eastern Hotel Company Ltd4, charges of negligence by contractor and resultant losses thereof as claimed by Great eastern Hotel were not upheld by the court and no relief was allowed for losses sustained. In this case, the difficulties in establishing causation of delay leading to losses were also demonstrated. There is no definite court precedent to establish causation of loss due to delays and in this case, it was pointed out that the Courts have not laid down any formal tests to establish causation, rather they have relied upon commonsense and an interpretation of the individual facts in a particular case in order to determine whether the breach of the contract was a sufficiently substantial cause of the claimant’s loss.5 Therefore the party that violates the contract is liable only if the breach was in effect the â€Å"effective cause† of his loss.6 An action for losses caused by a breach of

A paper for oceanography based off of the book called The Eskimo and Essay

A paper for oceanography based off of the book called The Eskimo and the Oil Man by Bob Reis - Essay Example The study of the oceans has enabled the understanding of the global climates and the trending climatic concerns such as the global warming and the possible impacts on the ecosystem dynamics and the life supporting atmospheric portion i.e. the biosphere at large. The atmosphere and the biosphere are interrelated through the natural processes of evaporation, precipitation and the natural heat exchange processes. At a general broad prospect, oceanography is divided into the following branches: 1. Biological oceanography This refers to the study of the ecology of the marine ecosystems with regards to their surrounding ocean environment. Marine biologists study the life in the oceans (marine ecology) and as well as the total organic production in the seas and oceans. The marine life consists of the floating or weakly swimming organisms known as planktons and rapidly swimming organisms referred to as nektons. Marine oceanographers map the floors of oceans, analyze the problems of the shore lines, and study the deposits and other sediments of the ocean floor and rock layers of the earth’s crust. Biological oceanography therefore looks into the influence of the ocean’s physical, chemical and the geological characteristics on the marine ecology or ecosystems. 2. Chemical oceanography (Marine Chemistry) This is the study of the Chemistry underlying the ocean environment and the processes of its interactions with the atmosphere. Chemical oceanography is looks into the chemistry of seawater, the major salts it contains, and other trace elements found in the oceans. 3. Marine Geology ( Geological oceanography) This refers to the study of the geology of the ocean floor with regards to the paleoceanography and the plate tectonics. 4. Physical Oceanography (Marine Physics) This is the study of the physical processes of the oceans such as the mixing, waves, tides, ocean currents, water transparency density and temperature; as well as under water acoustics and sound transmission. In his book, The Eskimo and the Oil Man: The Battle at the Top of the World for America’s Future, Bob Reiss is particularly concerned with the Oil exploration strategy by the Shell Company on the North Arctic coast of Alaska, focusing on the potential threats to the Ocean, impact on the marine ecosystems and the Americans living within the neighborhood. This intertwines all the mentioned branches of oceanography with views on the related impacts to the ocean and its environs. Reiss describes offshore oil exploration, which generally involves operations beyond three miles from the shoreline. This exploration has been especially facilitated by the continuous recession of ice at the coast of Alaska due to the changes in weather and climate patterns, a region that has been for many years covered by ice. Amongst other challenges of offshore exploration is the control of the dynamic changes in the temperatures and pressures when drilling across the rock formations in their strata deep beneath the ocean that may result in to dangerous oil-well blowouts that emit a buoyant plume of oil, produced water and natural gas. The ice recession at Arctic is a concern of the oceanography which tries to look into the prospective repercussions of offshore oil drilling activities on to the local and global climate. It also tries to explain the possible impacts on the surrounding environment as the ice continue to disappear. This phenomenon has been occasioned by global

Errors to Avoid In a Business Letter Essay Example | Topics and Well Written Essays - 750 words

Errors to Avoid In a Business Letter - Essay Example The first error to avoid in a business letter is the use of the irrelevant material in the document. People tend to incorporate a series of irrelevant words in an attempt to please the reader. The use of an irrelevant material is a serious error that makes the written document long, boring and of poor quality. The writer may use long descriptions in order to portray their knowledge in the field. As a result, the reader may fail to comprehend the core purpose of the letter. The use of technical jargon and complex words in a business document frustrates the reader and thus contributes to miscommunication. In business writing, a skilled writer is expected to produce documents with excellent word choice. A writer may say, â€Å"The employees are very concerned with how the layoffs will affect their lives.† This sentence is improper because it uses similar words to express the employees’ reaction to layoffs. In the stated example, the writer is expected to say â€Å"Employees fear that the layoff will affect their morale.† The ideal way to avoid using irrelevant material involves selectively choosing appropriate words that best communicate the intended message. Ambiguous phrases such as ‘It is advisable’ should not be included in business letters. Writers should focus on clear, concise statements that communicate the intended message. Grammatical errors are intolerable in business writing. These errors may be in the form of improper use of verb forms, transitions, and articles. Writers may also incorporate unclear pronoun references, or they may incorrectly use subject/object pronouns. Grammatical errors may be perceived negatively by the reader. The reader may perceive the writer as careless or may fail to acknowledge the seriousness of the written information. Transition errors for example â€Å"The press release was long although the public needed the information.†

Elderly Abuse Essay Example for Free

Elderly Abuse Essay Lifespan stage and counseling-related problems. As part of being a human being, we are born and we grow old as time passes and then we die as life comes to an end. Part of human development is the stage of late adulthood. From the book â€Å"Human Behavior in the Social Environment,† by Jose B. Ashford and Craig Winston LeCroy, the years from age sixty until death are considered late adulthood. At this stage of life, there are many challenges that the elderly people face. Aging comes with the loss of being independent, age discrimination and diminished physical ability. During the aging process, there are also biological, emotional, intellectual, social and spiritual changes. Beside two other big challenges such as poverty and ageism, one of the biggest problems that elderly people face is elderly abuse when they are at the point in their lives where they are dependent of someone to provide supports for them. According to the American Psychological Association, an estimated 4 million older Americans are victims of physical, psychological or other forms of abuse and neglect. Many people who hear â€Å"elder abuse and neglect† think about older people who live in nursing homes or older relatives who live all alone and don’t have visitors. Being part of the counseling program, it is important for counselors to know that majority of incidents of elder abuse do not happen in nursing homes or other residential settings, but rather takes place at their own home with their own spouses, children, siblings or relatives. Forms of elderly abuse to be aware of are physical abuse, verbal/psychological/emotional abuse, sexual abuse, financial exploitation and neglect. Elder abuse is often a very complex problem that is caused by many reasons such as cultural issues, stress, society and other factors. Elder abuse affects both older men and women from all socioeconomic groups, cultures, race s and ethnicities. Bio-psycho-social developmental themes Bio-psycho-social developmental themes affecting late adulthood is crucial in  understanding elderly abuse. During this developmental stage, there are lots of changes in the biological systems among this age group. Problems related to elderly physical health include gradual loss of bone mass, joints are more restricted, variety of foot problems, and arthritis which is known to affect many elderly people. Power and speed of muscle decrease as well as strength and endurance. There is a decline in hearing and vision impairment. Skin gets thin and dryer which make the skin more easily bruised and injured. Maintaining independence and health is very important in the success of someone who is in this stage of development. With the biology of aging, the elderly become physically frail which cause others to care for them sometimes resulting in mistreatment and abuse. Forms of elderly abuse that affect the individuals biologically are physical abuse and sexual abuse. Physical abuse ranges from getting slapped, shoved, beatings, kicking, pinching, burning, and getting restrained with ropes or chains. Giving inappropriate medications is also part of physical abuse. Sexual abuse among this age group ranges from inappropriate touching, forcing sexual contact, rape, sodomy and coerced nudity. It is the least reported type of elderly abuse. Sexual abuse also includes taking pictures and forcing an individual to look at pornography. These two forms of elder abuse usually cause physical problems such as signs of body bruises, bruises around genital areas, unexplained sexually transmitted diseases, untreated wounds, sprains, broken glasses and bloody underclothing. There are changes in the psychological system of this developmental stage that contributed to elderly abuse and mistreatment. Alzheimer’s disease is the most common form of dementia for aging individuals. Alzheimer is literally having memory loss which is common among individuals that are in their sixty and above. Cognitive impairment increases with age and dementia is usually one of the biggest problems that often refer to irreversible cognitive impairment that affects an individual’s memory, personality, and functioning. According to the Alzheimer’s Association, cognitive impairment can sometimes be discovered early in individuals. When individuals are not able to recall names, forgetting words, misplacing things, having memory loss, getting lost in own street or neighbor, not knowing or forgetting chore needs to be done, they may possibly be showing Alzheimer’s disease or other forms of dementia. Behavioral and emotional changes occur in people with Alzheimer’s disease. As the disease gets worsen, those with the disease will experience symptoms that include delusions, agitation, aggression and uncooperative with care. Alzheimer is a commonly known dementia disease in which there is no cure and it gets worse as it progresses. The risk of abuse increases in people with health issues such as dementia (Kohn and Verkoek-Oftedahl 2011). Verbal, emotional and psychological abuses are the common abuses that elderly individuals suffered from. Signs of emotional and psychological abuse are being upset, withdrawn, and unusual dementia-like behavior such as rocking and sucking. Name calling, intimidation, threatening, isolating the individual from families and friends are forms of verbal, emotional and psychological abuse. In late adulthood, the social dimension or support system becomes smaller. Majority of older adults have some family, while others do not. Family is the first line of support for older adults when they need care and assistance. Some older adults or elderly individuals often live with their children including grandchildren, while others live with their spouses. It is important to know that elderly abuse is often caused by family members and the least likely to be reported. For those that do not have family and are dependent for care, they are often live in adult residential homes or care facilities where they only people they interact with are the staffs within those settings. Elderly abuse is sometimes caused by individuals working at the care homes. Some individuals of this population experience loneliness and isolation. When an individual is isolated for no apparent reason, it is sometimes can be part of elderly abuse. Counseling Practice: Assess and Strategy Elderly abuse is often the result of certain societal attitudes that contribute to the violence and discrimination against older people. From the American Psychological Association, such factors that contribute to elderly abuse include the devaluation of and lack of respect for older adults and the society’s belief that what goes on in the home is a private â€Å"family matter.† When societal views regarding older people as insignificant, it results in failure to recognize the importance of assuring support, dignity and nonabusive life circumstances for every older individual. When people outside of the family observe or suspect abuse, they may fail to intervene because they believe that it is a family problem and is none of their  problems or they might be afraid that they are dealing with a private matter. Also, the feeling of shame and embarrassment might often make it difficult for older persons or even family members to report and reveal the abuse because they do n’t want others to know that such events are occurring in their families. Counselors need to take into consideration of certain cultural values, beliefs and traditions that influence the family dynamics and intergenerational relationships. These differences can make the situations difficult to distinguish from abuse or neglect. One big problem is older individuals from ethnic minorities or immigrants that do not speak English and have language barriers, financial or emotional dependence that prevent them from seeking or willingness to report abuse. It is important that anyone who works with older people in potentially abusive situations need to be sensitive to cultural differences and intervene accordingly as well as not to ignore signs of abuse. To prevent elderly abuse, counseling for behavioral or personal problems in the family can be helpful. Treating family members with substance abuse can prevent violence against aging adults in the households. In some cases, it may be a best interest to have the older individuals move to a different safer setting or having the older individuals live in nursing home if adult children are not equipped emotionally and physically to support and handle the responsibility of caring for an elderly person. When suspected of elderly abuse, counselors or any other related mental health professionals are mandated to report elderly abuse to adult protective services as required by laws. It is also important not let fear prevent you from reporting any suspicions of abuse taking place. It is important to know that someone’s life can be saved from further harms including death. People in their late adulthood deserve to be treated with respect and dignity. They are our parents, grandparents and love ones who deserve good care and love as they have reached the full stage of their lives. Cited Page Ashford, J. B., LeCroy, C. W., Lortie, K. L. (2010). Human behavior in the social environment: a multidimensional perspective (4th ed.). Australia: Brooks/Cole, Cengage Learning. Elder Abuse and Neglect: In Search of Solutions. (n.d.). http://www.apa.org. Retrieved November 16, 2013, from http://www.apa.org/pi/aging/resources/guides/elder-abuse.aspx Kohn, R., Verhoek-Oftedahl, W. (2011). Caregiving and Elder Abuse. Medicine Health Rhode Island, 94(2), 47–49. OpenStax College. (2013, July 29). Challenges Facing the Elderly. Retrieved from the Connexions Web site: http://cnx.org/content/m42880/1.4/ Resources Two Current Book References Glicken, M. D. (2009). Evidence-based counseling and psychotherapy for an aging population. Amsterdam: Academic. This book is a practical guide for advanced students, social workers, clinicians or anyone in the mental field that work with elderly clients. It covers the most effective evidence-based practices for assessment and treatment of elderly clients. Each chapter of the book directly addresses different range of conditions and disorders that are the most common for the elderly population such as social isolation, elder abuse and neglect, depression, anxiety disorders, terminal illnesses, dementias and so forth. It also prepares readers for conditions that they will encounter in the real world even working with or interacting with the elderly population. Wilson, G. (2000). Understanding old age critical and global perspectives. London: Sage. This book is about understanding old age or the elderly population. It gives readers a wide range of issues and policies on ageing. It provides many theoretical perspectives on ageing in different societies, the trends involving aging adults and what roles should be taken by older people including those who interact with this population. The book explores migration, different health issues, pensions, the structure of family and institutional care as well as it also touches based on elderly abuse. This book is essential for students, nurses, social work, counselors and those who want further understanding of the older population in our society. Journal Article Thompson, H., Priest, R. (2005). Elder Abuse and Neglect: Considerations  for Mental Health Practitioners. Adultspan Journal, 4(2), 116-128. According to the authors, elder abused is largely an unrecognized problem in the United States and is often untreated. Elder abuse and neglect is so prevalence, that not all incidents are reported. By 2030, the elderly population of late adulthood will double and it is important for mental health practitioners to be aware of intervention, different strategies, consequences, laws and the risk factors that contributed to elder abuse when working with clients. The article addresses the different types of elderly abuse and states real life problems that mental health practitioners including counselors will encounter when working with the population. Educational Internet Website National Center on Elder Abuse (NCEA) www.ncea.aoa.gov The National Center on Elder Abuse or NCEA is directed by the U.S. Administration on Aging. According to the mission of The National Center on Elder Abuse, it is a resource for policy makers, social service and health care practitioners, the justice system, researchers, advocates, and families. The site has prevention strategies and different intervention partners that are good for different work fields such as for those working with older people in the social services, APS, Ombudsman and etc†¦ It provides many different practices that are utilized in different states throughout the United States. Local Referral Source Department of Health and Human Services, Ombudsman Program 7001 A East Parkway Sacramento, CA 95823 Telephone: (916) 875-2000 The Office of Ombudsman provide information, answer questions and resources to address issues. The Office of Ombudsman protects and defends a citizen’s rights.

Maintaining a Childs Healthy Lifestyle

Maintaining a Childs Healthy Lifestyle 1) A healthy lifestyle is paramount for other children and adults to help prevent, or minimize chronic illness and diseases. A healthy lifestyle does not only include diet and exercise but also a healthy mental wellbeing, especially in children. It involves the connection of body and mind; self esteem, self-belief, confidence and building up a natural strength to help them cope during tough times. ‘Every child matters’ a government programmed, came into affect in 2001 to ensure children have access to health are services, to prevent violence against children in their home and in their community. It is also in place to alleviate child poverty. This program helps children with building confidence and creating support networks so they understand they are not alone. Leading a healthy life style can prevent diseases such as obesity, high blood pressure, diabetes, chronic heart disease, strokes, chronic obstructive pulmonary disease, and cancer; I will now explore these diseases and ways to prevent them. It is know fact that the rates of obesity are higher in children who do low levels of exercise than to those who do high, frequent levels of exercise. Exercise is very important for young children in order to keep their bodies from accumulating unnecessary fat, which can lead to chronic illness later on in life such as diabetes. Children who regularly exercise will benefit in better health, not just at present but for future years as their bodies and mind will be conscious of the healthy lifestyle choice they make. Lack of exercise, being over weight and, for adults, exercise alcohol consumption is big risk factors for high blood pressure. It affects approximately one third of the UK. High blood pressure can be treated with medication; however, most of these can produce side affects such as skin irritation, dizziness and feeling drowsy. Some people are able to reduce or even stop treatment if they are able to keep their blood pressure under control whilst on the medication. If patien ts were educated earlier on how to prevent this chronic illness with lifestyle changes then medication would not be needed. Type 2 diabetes is another illness that can be controlled by the individual and their lifestyle choices. Along with taking medication, a persons diet and regular exercise are things that need to be addressed. There are over 3.1 million people in England that suffer from diabetes (type 1 +2). It is important to get diagnosed as early as possible to prevent symptoms worsening. Simple things like keeping blood pressure down and weight are two key ways of preventing type 2 diabetes, however type 1 cannot be controlled. Coronary heart disease is the biggest killer in the UK, it occurs when fatty deposits block the blood supply to the heart. Smoking, having high blood pressure or having diabetes could all cause CHD. Although it cannot be cured there are treatments and lifestyle changes that can reduce further problems such as; lowering cholesterol and maintaining a healthy weight. Strokes can also occur when the blood supply is restricted from the brain. Strokes happen quickly and often cause disabling complications such as paralysis and permanent numbness. To reduce the risks of suffering a stroke it is advised that we do simple and regular exercise and maintain a healthy weight. In doing this we lower our chances of having a stroke. Smoking is a major factor towards strokes due to the arteries clogging with tar, which causes blood clots. Another illness that occurs due to smoking is Chronic Obstructive Pulmonary disease; this is a lung condition in which the airways become narrow and damaged. If a smoker stopped smoking after being diagnosed then the progression could be slowed down but not reversed. Keeping a healthy weight and controlling blood pressure along with keeping active and doing specialized breathing techniques are simple but affective steps to reducing the symptoms. Cancer research UK stated that ‘half of newly diagnosed cancers could be prevented by leading a healthier lifestyle, reducing alcohol intake, eating better, regular exercise, not smoking and safe sun practice.’ By following this simple piece of advice, the majority of these chronic illnesses could be greatly reduced. Smoking is also a major factor in the development of cancer, 86% of lung cancer deaths in the UK are being attributed to smoking. Research from The International Agency for Research on Cancer has shown that smoking can cause cancer in the liver, mouth, pancreas, stomach, bladder, kidney, cervix, bowel and ovaries. Obesity is a risk factor for several types of cancer; breast, uterus and kidney. Research shows many chronic diseases are increasing with poor lifestyle choices made by individuals. Education when we are young on how to make good lifestyle choices could greatly reduce the risks of people inflicting these debilitating illnesses upon themselves. 2) Eating a healthy and balanced diet is a strong foundation for a happy child. Making sure that people has the basic knowledge and understanding for a nutritionally balanced diet will help protect them against chronic illness and even behavioral difficulties. Many people are familiar with ‘5 a day’, which encourages us to eat five different fruit and vegetables a day. However there are other groups that need to be included to make up a nutritionally balanced plate. These groups are`; Fruit and vegetables Fats i.e. butter and oils Sugars Protein Carbohydrates Carbohydrates are a great source of nutrition such as vitamins and iron. Wholegrain varieties are high in fiber, which assists with regular bowel movement, and it helps manage weight. Pulses and lentils also contain fiber along with being low in fat and high in protein. Protein is necessary for growth and to help repair body cells. Another protein is dairy, which contains calcium; essential for healthy, strong bones. The fat in milk provides calories for young children and has important vitamins (B2+B12). Cows milk is not advised for children less than 12 months due to them not being able to digest the protein. Breast-feeding until the infant is at least 6 months is recommended by ‘The Department of Health’ or formula powder to insure the infant is getting the correct nutrition. The National Diet and Nutrition Survey suggest that adults and children are consuming more sugar than recommended. The sugars in chocolate and fizzy drinks are bad sugars, which can cause tooth decay (a very current problem in our country). There are naturally occurring sugars that, in moderation, can be beneficial to our bodies, these sugars are found in milk and fruit. The most important and vital food in our diet is fruit and vegetables, as they are a major source in vitamins and minerals. They are beneficial in a variety of ways; lowering risks of many illnesses and diseases such as strokes and also reducing the risk of kidney stones. Another important food is meat. Lean mince and fish are healthier options, as they are good sources of vitamin B, zinc and iron. Fish also contains fatty acids, which our body uses to keep cholesterol low. Oils and nuts also provide fats that keep low cholesterol; many vegetarians eat lots of nuts, pulses and quorn to maintain similar levels of these essential vitamins. Insuring a mixture of all these important food groups will not only keep a balanced and healthy diet but also will insure the body has the necessary tools to best fight off illness and maintain high energy levels. Children benefit greatly from eating healthily as it improves confidence with self-image; steady and healthy energy levels and can help refute behavioral problems. Being aware of healthy eating improves child’s chances of eating a nutritional food as they progress from childhood to adulthood. 3) to help maintain a healthy life style it is beneficiary to exercise. Exercise burns calories and helps build up strength, without exercising your body and muscles would turn into fat and the organs would become unhealthy. Young children can do many different activities to help prolong a healthy and happier life. Joining football clubs, swimming groups or youth groups. Research from ‘The Lancet Paper ‘ showed that as little as 15 minutes active play per day is all an infant needs to prolong a healthy life. Babies should be encouraged to move around independently by floor play or crawling as often as possible. Having this freedom allows them to strengthen trunk muscles, improve on concentration and move kinesthetically. Crawling also trains their eyes to look both near and far, this is essential for developing binocular vision. Swimming is another activity that builds on trunk muscles and also social skills. Sessions with mother and infant are great ways to initiate bonding and interaction with other mums and babies. Swimming uses trunk strength that improves infants’ balance and muscles development. Physical exercise can also improve breathing techniques; it strengthens the heart and lungs. Outings to indoor play centers and leisure centers are other ways of allowing kids to exercise; they run around with friends and other children. Free play also promotes a Childs imagination and creativity; many adventures to jungles and fairy tale worlds can take place in one Play Park. By following a child’s own ideas and other children’s imagination increases a child self esteem and self-awareness, this contributes to a happy, healthy child. Children can also take part in daily activities at home such as helping with gardening, tidying up and even helping with vacuuming, this it all classed as daily exercise but they can be created into fun activities to do with parents, especially when their parents don’t have much free time, school are getting behind this idea to encourage bonding between children and busy working parents. The government has a duty to protect and promote play opportunities for children and young people. The right to play for al children up to the age of 18 is enshrined in article 31 of the UN Convention on The Right of the Child ratified by the UK Government in 1991. With this law in place many swing parks, play grounds, football fields and more recently skate parks. These areas are for children of all ages to exercise/play and develop social skills. Clubs that teach sports are all essential in building confidence, help to focus their attention and problem solve, these all contribute to strength in mind and emotional development. Research at Monash University 9part of the National Sleep Foundation) proved, in 2009, that children who take part in daily exercise sleep better at night. ‘In addition to falling asleep faster, very active children slept longer throughout the night’. This quote concludes that active children benefit through all aspects of growing up and staying healthy and when they active this at a young age it teaches them good habits which they will use through their whole life. 4) Well being is; the state of being comfortable, healthy and happy in oneself; a person being comfortable with their existence. A childs well being can have a significant impact on their progress throughout their life. Social and health services aim to use a holistic approach when assisting children and their families. They look at all parts of the child’s life; home, school, psychological, physical and even spiritual being to find a way to best help the individual. Workshops are run for parents such as the ‘positive parenting program’ which looks at dealing with family bereavement and spotting signs of emotional stress, conflict in the home and strategies to help build confidence in their children and harmony in the house so everyone feels comfortable to express themselves in a save environment. Parenting can be exhausting and sometimes isolating so by using these free workshops it can greatly enhance the wellbeing of the parents, and ultimately, their children helping achieve a healthy wellbeing for the future. A report published by The National Institute for Clinical Effectiveness, in 2008, wrote ‘childrens social and emotional wellbeing is influenced by a range of factors, from their individual make up, family background to their local community within with they live’, with this in mind we can now find many charities like ‘BIG’, a lottery funded charity, that gives thousands of pounds every year to help continue many different project that work to strive positive mental health, physical health and strong social networks in our communities. There are programs that travel around schools and talk to troubled children about family separation, depression and many other issues. All these groups and workshops ensure that if and when a family needs help in maintaining the wellbeing of their family unit, they have financially achievable opportunities to meet in a secure, non-judgmental and confidential environment. A place they can discuss the issues and work with practioners on improving skills to enhance the wellbeing of their children and family unit. Reference www.healthline.com www.healthyforums.com www.oxforddictionary.com www.bigltteryfund.org.uk www.ehow.com www.psychologytoday.com www.medcentral.org www.babycentre.com www.science.howstuffworks.com www.sleepfoundation.org www.everychildmatters.org www.encyclo.co.uk The foundations of child development Working with children in the early years

Causes for World War One

Causes for World War One Connor Sweeney Q1) The incitement of World War One was the result of different factors set in motion by various political situations with many believing Germany pursued war for aggressive reasons. Additionally, historians illustrate that Germany pursued war as a solution to domestic issues such as the rise of socialism. Many historians believe that Germany pursued war through aggressive means such as policies and diplomatic decisions. Between 1890-1914, Germany adopted a new aggressive foreign policy that focused on territorial expansion called Weltpolitik. The German Foreign Minister, Bernhard von Bà ¼low once said Only a successful foreign policy can help to reconcile, pacify, rally, unite. Germany, as a result of this new policy, required a new larger naval fleet in order to push their expansionist ambitions which in turn threatened Britains status as the worlds colonial power. Consequently, Germanys Navy Laws of 1898 and 1900 upset Britain and sparked the Naval Race, a race to build the largest and most advanced naval fleet which in turn deteriorated Anglo-German relations. As a result, Britain entered into alliances with France in 1904 and Russia in 1907 respectively, creating what was known as the Triple Entente, meaning war with one nation could escalate into a European conflict. Additionall y, Germany pursued foreign interest in Morocco, in what was to be known as the Moroccan Crisis, where he publicly announced Germanys backing of Moroccos independence. This was during the time France was hoping to colonise Morocco with British backing through the Anglo-French Entente and thus Germany hoped to disrupt this relationship, feeling that it posed a threat to Germanys world influence. Towards the end of the 19th century, Germany was undergoing rapid mass industrialisation with coal and steel production increasing. As a result German society was beginning to politically shift as mass urbanisation began with many flocking to cities to work, where there were greater inequalities between the growing working class in the cities and the rural aristocrats in the countryside.   Discontent spread as workers working long hours for poor pay and conditions led changes for greater democracy and rights. This led to a rise in Socialism within German society that challenged the conservative and traditional Kaiser Wilhelm and the German government. This rise in socialist views was exhibited by the rise of the Social Democratic Party (SPD) who, representing the growing working class, pursued social and political change. By 1912 the SPD had 110 seats in the Reichstag as opposed to 35 seats in 1890. The German government and the Kaiser saw the SPD as a dangerous threat and would no t let them the opportunity to govern despite their majority in the Reichstag. As the SPD grew, the right-wing parties in the Reichstag on whom the Kaisers government relied were losing support.   Thus the Kaiser introduced Sammlungspolitik, a domestic motion to support Weltpolitik. This was to ensure political and domestic unity in rallying together Germanys social elites (landowners, new industrialists, and the army) and encouraging patriotism and loyalty to the Kaiser and the government whilst encouraging opposition to socialism. Q2) As Europe entered the period of June August 1914 it became a diplomatic hotbed known as the July Crisis. The July Crisis coins the political and diplomatic situations following the assassination of Archduke Franz Ferdinand, the heir to the Austro-Hungarian Empire, a close ally of Germany. The assassin, Gavrilo Princip, was a member of a Serbian terrorist organisation fighting for Slav Independence from Austria-Hungary. Thus Austria saw this as a direct attack from the Serbian government and as a result sent them an uncompromising ultimatum or war. Germany saw this as an opportunity to push their expansionists aims and gave Austria their full backing. This Blank Cheque, as it was known, became a key step into outbreak of the war as with Germanys full backing, Austria could push on into war with Serbia.   Germany with their issue of the Blank Cheque believed Austria was ready to ignite an immediate and rapid war against Serbia despite their wariness of Russias Dual-alliance with Serbia, potentially escalating the war into a European conflict with the Franco-Russian Alliance causing France to support Russia. However, Theobald von Bethmann-Hollweg, the German Chancellor, thought should a European war occur, that it was better to happen in 1914 than years later when Russia would be at a greater military capacity.   Although Serbia agreed to meet some of the demands of Austrias ultimatum, it did not fulfil all the terms and Austria with the blank cheque of Germany behind them, declared war on Serbia on the 28th July.   During these last few days in July, the European political situation heightened to breaking point with Tsar Nicholas signing motions for plans to both partial and general mobilise the Russian troops despite firm warnings from Germany. On the 29th July 1914 there was telegram exchanges between the Tsar and the Kaiser regarding the newly erupted war in the Balkans. Kaiser writing Of course military measures on the part of Russia would be looke d upon by Austria as a calamity we both wish to avoid[i], showing Germanys unrelenting stance. This was followed up by the Tsars reply I hope from all my heart that these measures wont in any way interfere with your part as mediator which I greatly value.[ii]. From these telegrams both the Tsar and the Kaiser conveyed an unwavering stand that illustrates an inevitability between both nations involvement in the Balkan war. As July drew to a close, events accelerated towards war with Austria-Hungary ordering general mobilisation on the 30th July 1914 with Russia doing the same. News spread to Berlin and by the 1st August Germany had declared war on Russia and started general mobilisation, activating the Franco-Russian Alliance which meant that Germany on the 3rd August declared war on France.   Part of Germanys military strategy against France was the Schlieffen Plan that involved marching through Belgium, a neutral country. In order to help protect Belgian neutrality, Britain had n o choice but to declare war on Germany on the 4th August and so Europe was plunged into war. Q3) There are many varying interpretations on who was responsible and culpable for the origins of WW1 with two of the main differing theories being from historians Fritz Fischer and Christopher Clark. Fischer takes the stance that sole responsibility for the war lies with Germany while Clark on the other hand, looks at the origin of the war as a collective responsibility where all nations must take a share of the blame. Fritz, on one hand, believes that Germanys pursuit of war was just a progression of their vast, expansionist aims. He claims that Germany, in the interest of becoming a global great power, was ready to launch WW1 and that once the war had started, its aims were precise and pre-determined especially in areas of territorial gains in Central and Southern Europe. Furthermore, Fischer believed that it was domestic factors that drove Germanys foreign policy as opposed to the orthodox view that it was external factors. At this time Socialism threatened the old, traditional empirical German society while industrialisation/urbanisation had caused growing inequalities between social classes which Fischer believed the Kaiser and the government wanted to resolve this through the pursuit of war. Fritz thought Germany was actively pursuing war to solve their domestic problems at home and fulfil their expansionist aims in one swoop. In this, he believes the blame lies solely at the step of Germany. On the other hand, Clarks thesis believes that a collective responsibility must be placed on all nations There is no smoking gun in this story; or, rather there is one in the hands of every major character[iii]. Clark states that the outbreak of the war was an accumulative result of political situations and diplomatic manoeuvres that metaphorically stumbled into a war. There is significant evidence to support this thesis such as Russias and Germanys unwavering relentlessness to get involved in the Austro-Serbian conflict as exhibited by the Willy-Nicky telegrams. Personally, the Fischer thesis provides the more convincing theory as it is supported by more significant evidence. In my opinion, Germanys adoption of Weltpolitik, an expansionist policy, forced other nations into alliances such as Britain who formed alliances with France following the Naval Race that was subsequently caused by this policy. Additionally, this aggressive foreign policy led to diplomatic manoeuvres such as the blank cheque to Austria Hungary, a promise of full support, that with its absence may have avoided the Austro- Serbian conflict that started the war. It seemed that Germany manoeuvred themselves into a position where war was inevitable in order to progress their expansionist aims and although many nations must take their share of the blame, it is in my opinion that Germany must take sole responsibility for the outbreak of World War 1. [i] The Willy-Nicky Telegrams, July-August 1914, Kaiser to Tsar (29th July 1914), History A: German Foreign Policy 1890-1914, Pg. 40. [ii] The Willy-Nicky Telegrams, July-August 1914, Tsar to Kaiser (30th July 1914) History A: German Foreign Policy 1890-1914, Pg. 40. [iii] Christopher Clark, The Sleepwalkers: How Europe Went to War in 1914(London: Harper Collins,2012). http://www.history.com/this-day-in-history/kaiser-wilhelm-of-germany-and-czar-nicholas-of-russia-exchange-telegrams http://encyclopedia.1914-1918-online.net/article/germanys_blank_cheque_to_austria-hungary

Symbolism in The Great Gatsby Essay -- Classic American Literature

The Great Gatsby is one of the most renowned books known to mankind. A story about a man’s quest to fit into a society built for the rich whilst wooing a childhood crush may seem extremely simple and straightforward, however, the mystery is not behind the plot, but rather, it is in the writing itself. The words F. Scott Fitzgerald used were chosen with such delicacy, one cannot even hope to assume that anything was a mere coincidence. The book is laced with intricate strands of symbolism bound together by a single plot. One of F. Scott Fitzgerald’s more major themes is the use of locations. The importance of location as symbols are further expressed through the green light at the end of the dock as well as the fresh, green breast of the new world. The green light at the end of the dock has symbolized a hope that Gatsby had. The green light was a light at the end of Daisy’s dock. In the beginning of the book, Gatsby was shown staring at the light with a longing expression. It shows that the green light is a symbol of Gatsby’s hope that Daisy is still available. The green li...

The Cell Essay -- essays research papers

The Cell Theory The cell theory states that all living matter is made up of cells and some living organisms consist of a single cell. Other cells serve a special purpose within advanced organisms like nerve cells. One theory of a cell states that the first form of life on this earth consisted of a lot of different types of small protocells. Protocells are cell like organism. These organisms were able to reproduce in a very limited environment because they are so simple. After many years some of the protocells came together and shared their DNA with each other. These protocells eventually became the cells we are studying now. Type of Cells   Ã‚  Ã‚  Ã‚  Ã‚  There are two types of cells one is the Prokaryote, a Prokaryote is a cell with no nucleus or organelles with membranes, the other, a Eukaryotes are cells that contain a nucleus and organelles and are surrounded by a membrane. Cell Structure Thin membranes surround cells; this is called the cell membranes, they separate the inside from the out. The cell membrane is just like the other organelles in a cell because it has its own specialized jobs. One of its jobs is to control what enters and exits the cell and to protect the cell. Cell membranes are made up of fats with big protein molecules inside them. Molecules move across cell membranes by two processes diffusion or active transport. Diffusion is the movement from a high level of molecules to a low level of molecules. Molecules can diffuse across membranes through the ph... The Cell Essay -- essays research papers The Cell Theory The cell theory states that all living matter is made up of cells and some living organisms consist of a single cell. Other cells serve a special purpose within advanced organisms like nerve cells. One theory of a cell states that the first form of life on this earth consisted of a lot of different types of small protocells. Protocells are cell like organism. These organisms were able to reproduce in a very limited environment because they are so simple. After many years some of the protocells came together and shared their DNA with each other. These protocells eventually became the cells we are studying now. Type of Cells   Ã‚  Ã‚  Ã‚  Ã‚  There are two types of cells one is the Prokaryote, a Prokaryote is a cell with no nucleus or organelles with membranes, the other, a Eukaryotes are cells that contain a nucleus and organelles and are surrounded by a membrane. Cell Structure Thin membranes surround cells; this is called the cell membranes, they separate the inside from the out. The cell membrane is just like the other organelles in a cell because it has its own specialized jobs. One of its jobs is to control what enters and exits the cell and to protect the cell. Cell membranes are made up of fats with big protein molecules inside them. Molecules move across cell membranes by two processes diffusion or active transport. Diffusion is the movement from a high level of molecules to a low level of molecules. Molecules can diffuse across membranes through the ph...

Occurrence Of Dental Caries Health And Social Care Essay

The recent diminution in the happening of dental cavities has brought a alteration in distribution of the cavities job in many populations. At present bulk are particularly kids and striplings, have no or merely a few cavitated lesions, while for a few the cavities experience still remains comparatively high.1,6 Clinical variables, particularly past cavities experience, have been confirmed as the most important forecasters of future cavities development. The position of the most late erupted or open surface is the most appropriate step of past cavities experience. Sociodemographic variables are most of import to anticipation theoretical accounts for immature kids and older grownups. Microbial degrees are included in the most accurate anticipation models.2 Cavities risk appraisal is an of import portion of preventative dental medicine since cavities is preventable, early designation of relevant factors impacting populations that may increase the hazard of cavities is of import. Appraisal of single aetiologic factors for bing carious lesions is a requirement for future cavities risk.3 Repeated finding of the caries-risk allows an rating of the success or the demand for alteration of preventative steps. Indications of an increased caries-risk in specific population in community preventative programmes will let choice of an single preventative programme in order to understate the development of carious lesions.4Multifactorial appraisal of cavities hazard:Dental cavities is a multifactorial disease in which there is interplay of four chief factors: The host ( saliva and dentitions ) , The microbic vegetation ( plaque & A ; micro-organisms ) The substrate ( diet ) and The time.4 The hazard of dental cavities can be evaluated by analyzing and incorporating several causative factors. In day-to-day pattern the caries-risk is determined in order to measure the single patient ‘s hazard, to place the chief causative factors and to urge specific preventative steps for single needs.4Cariogram aa‚ ¬ † A multifactorial appraisal tool:The Cariogram is a cavities hazard forecaster theoretical account that has been developed to depict and cipher the single cavities risk profile. It was developed in 1996 by Bratthall as educational theoretical account, taking at exemplifying the multifactorial background of dental cavities in a simple way.5 The chief intent of the Cariogram is to show the cavities risk diagrammatically, expressed as the Chance to avoid new cavities in the close hereafter. It besides illustrates to what extent assorted factors affect the Chance. And besides to promote preventative steps before new pits could develop.5The five sectors of the cariogram:The Cariogram, a pie circle-diagram, is divided into five sectors, in the undermentioned colors: green, dark blue, ruddy, light blue and xanthous bespeaking the different groups of factors related to dental cavities. An account of each sector is as follows. The green sector shows an appraisal of the Actual opportunity to avoid new pits. The green sector is what is left when the other factors have taken their portion. The dark blue sector Diet is based on a combination of diet contents and diet frequence. The ruddy sector Bacteria is based on a combination of sum of plaque and mutans streptococci. The light blue sector Susceptibility is based on a combination of fluoride plan, saliva secernment and spit buffer capacity. The yellow sector Circumstances is based on a combination of past cavities experience and related diseases. 7 5Factors assessed by cariogram:The Cariogram plan with a constitutional algorithm, evaluates the cavities risk profile of an person. Nine factors of relevancy to cavities are entered into the plan and given a mark harmonizing to predetermined graduated tables for each factor.Cavities experience:Clinical scrutiny of figure of rotten, filled and losing dentitions should be recorded. The cavities prevalence is an of import factor as it illustrates how the balance between opposition factors and cavities bring oning factors has been in the yesteryear. If the cavities prevalence is high, it means that the patient has been susceptible to the disease during a past period of clip.Related general diseases:Several general diseases, conditions can straight or indirectly act upon the cavities procedure, either through impacting saliva formation and composing, through a caries-inducing dietetic form or through medical specialties. Diseases or conditions in early childhood may hold influenced the formation of the enamel. For illustration: Autoimmune diseases, like Sjogren ‘s syndrome Intake of medical specialties Radiation towards the head-neck part Disabilities should be taken into consideration. Because of hapless eye-sight may impact right unwritten hygiene steps. They have troubles in cleaning their dentitions decently.Diet contents:Diet plays a cardinal function in the development of dental cavities, and there is a correlativity between ingestion of fermentable saccharides and cavities. Fermentable saccharides include dietetic sugars chiefly sucrose, glucose, fructose and cooked starches, which can be broken down quickly by salivary amylase to fermentable sugars. A high lactobacillus count will bespeak high saccharide ingestion.Diet frequence:Frequency of consumption of fermentable saccharides is one of the cardinal factors in the appraisal of cavities hazard. 24 hr callback diet history is recorded for frequence of meal consumption.Plaque sum:Plaque is the direct and of import aetiologic factor for cavities as it harbours micro-organisms. Plaque Index harmonizing to Silness & A ; Loe ( 1964 ) was used to gauge the plaque s um.Scoring standards for Silnesss & A ; Loe plaque index.PI 0= No plaque PI 1= A movie of plaque adhering to the free gingival border and next country of the tooth. The plaque may be seen in situ merely after application of unwraping solution or by utilizing the investigation on the tooth surface. PI 2= Moderate accretion of soft sedimentations within the gingival pocket or on the tooth and gingival border which can be seen with the bare oculus. PI 3= Abundance of soft affair within the gingival pocket and/or on the tooth and gingival border.Mutans streptococcuss:Streptococcus mutans considered to play active function in the development of cavities, particularly in the early phases of the lesion formation. Mutans streptococcus are acidogenic and acidophilic bacteriums that they can bring forth acids which can fade out the tooth substance and that they can last and even in a low pH environment. They can besides bring forth extracellular glucans, which helps them to adhere to the tooth surfaces.Fluoride programme:Fluoride is a really strong factor bring oning opposition to cavities and of importance for remineralisation of early cavities lesions. The relevant information on fluorides has to be obtained by patient interviews.Amount spit secreted:Appraisal of the saliva flow rate is done. The sum and the quality of the spit is recorded. Medication, radiation therapy to caput and cervix that affect the salivary secretory organs, salivary rocks, anorexia nervosa, autoimmune diseases and diabetes mellitus are illustrations of grounds for the low secernment rate. In mensurating saliva flow rate, either unstimulated or stimulated saliva secernment is chosen.Saliva buffer capacity:The spit has several of import protective maps, both for dentition and for unwritten mucosal surfaces. Its clearance of nutrient dust, sugars and acids from the unwritten pit is of import for cavities protection. Saliva buffer system seek to maintain pH near to impersonal. Buffer capacity is of import spits factor that is measured.Clinical opinion:The entire feeling of the cavities state of affairs, including societal factors, gives a positive position, more positive than what the Cariogram seems to bespeak. The tester would wish to do the green sector bigger or smaller to better or diminish the Chance to avoid cavities sector for the patient.5Estimating cavities hazard utilizing cariogram:When all the information associating to the factors was estimated, including consequences of the spit trials, the relevant information was entered into the Cariogram computing machine plan to cipher the cavities hazard. Cariogram assesses the hazard of future cavities activity and expresses the consequence as the opportunity of avoiding cavities. The opportunity varies on a graduated table from 0 to 100 % . A 0 % opportunity of avoiding cavities means that lesions will decidedly happen over clip ( high cavi ties hazard ) . And 100 % opportunity of avoiding cavities means that there is no hazard of future cavities activity ( low cavities hazard ) . 8Decision:Cariogram theoretical account can be able to place the caries-related factors that could be the grounds for the hereafter cavities hazard anticipation, and hence assist the tooth doctor to be after appropriate preventative measures.9 This caries-risk appraisal should be repeated on a regular basis as an assistance in the preventative and non-operative direction of the cavities disease.6 Cavities hazard can be estimated in particular attention kids, disabled, bedfast patients and appropriate cavities preventative actions can be initiated.

Management Information Systems in Process-Oriented Healthcare Organisations

Linkoping Studies in Science and Technology Thesis No. 1015 Management Information Systems in Process-oriented Healthcare Organisations by Anna Andersson Submitted to the School of Engineering at Linkoping University in partial fulfilment of the requirements for the degree of Licentiate of Philosophy Department of Computer and Information Science Linkopings universitet SE-581 83 Linkoping, Sweden Linkoping 2003 Management Information Systems in Process-oriented Healthcare Organisations by Anna Andersson Maj 2003 ISBN 91-7373-654-6 Linkopings Studies in Science and Technology Thesis No. 015 ISSN 0280-7971 LiU-Tek-Lic-2003:14 ABSTRACT The aim of this thesis work was to develop a management information system model for process-oriented healthcare organisations. The study explores two questions: â€Å"What kinds of requirements do healthcare managers place on information systems? † and â€Å"How can the work and information systems of healthcare managers and care providers be inc orporated into process-oriented healthcare organisations? † The background to the study was the process orientation of Swedish healthcare organisations. The study was conducted at the paediatric clinic of a county hospital in southern Sweden. Organisational process was defined as â€Å"a sequence of work procedures that jointly constitute complete healthcare services†, while a functional unit was the organisational venue responsible for a certain set of work activities. A qualitative research method, based on a developmental circle, was used. The data was collected from archives, interviews, observations, diaries and focus groups. The material was subsequently analysed in order to categorise, model and develop small-scale theories about information systems. The study suggested that computer-based management information systems in processoriented healthcare organisations should: (1) support medical work; (2) integrate clinical and administrative tools; (3) facilitate the ability of the organisation to measure inputs and outcomes. The research effort concluded that various healthcare managers need the same type of primary data, though presented in different ways. Professional evelopers and researchers have paid little attention to the manner in which integrated administrative, financial and clinical systems should be configured in order to ensure optimal support for process-oriented healthcare organisations. Thus, it is important to identify the multiple roles that information plays in such an organisation. Department of Computer and Information Science Linkopings universitet SE-581 83 Linkoping, Sweden Co n te n ts 1. Introduction †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 1 1. . 1. 2. Organisational and work process models in medical informatics †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 2 Aims of the study†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 3 2. Research methods†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 4 2. 1. The setting of the case study†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 4 2. 2. The data collection†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 2. 2. 1. Archival data †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 2. 2. 2. Interviewing †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 6 2. 2. 3. Diary method †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 6 2. 2. 4. Observation†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 2. 2. 5. Focus groups †¦Ã¢ € ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 7 2. . 6. Feedback loops †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 8 2. 3. Analyses†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 8 2. 4. Modelling†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 9 3. Results†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 9 3. 1. 3. 2. 3. 3. The requirements of healthcare managers for an HIS†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. Interpretation of organisational and work processes in relation to HIS†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 10 A management information system model for process-oriented healthcare†¦. 12 4. Discussion †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 14 5. Conclusions †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã ¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 15 6. Future work †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 15 7. References †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. 7 Management Information Systems in Process-oriented Healthcare Organisations 1. Introduction Swedish healthcare organisations are required by law to maintain a holistic view of their processes (Prop. 1999/2000:149). Thus, such organisations need to have an overview of the entire scope of health service delivery. As a result, system thinking is vital (Senge, 1990). An organisation must be able to collect data from its operational processes and furnish health service management with data concerning the way in which th ey have utilised their resources (Kaplan & Norton, 1996). As a response to this imperative, many healthcare providers have begun to introduce process-oriented structures recently. There are a number of theories about how to design such structures. One theory is based on Business Process Reengineering (BPR), the purpose of which is to identify and redesign organisational processes (Davenport, 1993). Another approach is to analyse a healthcare organisation as a Complex Adaptive System (CAS), an interdisciplinary method that focuses on the self-organisation of systems and patterns, as well as the way in which outcomes emerge. The purpose of a CAS analysis is to resolve issues associated with adaptable systems (Zimmerman, Lindberg & Plsek, 2001). Regardless of whether a BPR or CAS approach is employed, process-oriented organisational structures face difficulties stemming from the fact that healthcare organisations operate on multiple levels, including county councils, hospital management, clinical management, and care providers, each with its own information requirements (Andersson, Vimarlund & Timpka, 2002). Each level struggles to survive under difficult economic constraints, limited growth and the constant threat of regulation (Luce & Elixhauser, 1990). Healthcare organisations need an integrated structure in order to quickly disseminate information among managers and care providers (Van de Velde, 2000). The first challenge is to structure information systems such that they support the workflow in a healthcare environment (Strauss et al. , 1985). Thus, it is not surprising that healthcare managers are increasingly seeking help from health information systems (HIS). Their objective is to minimise the overall costs of healthcare delivery, to improve the quality of their services (Greenes & Lorenzi 1998; Clayton & van Mullingen, 1996) and to correlate costs with resources consumed (Stead & Lorenzi, 1999). One option for gathering data in an 1 Management Information Systems in Process-oriented Healthcare Organisations HIS is to use censors and other devices that continuously furnish the healthcare organisation with data about its finances, quality, competence and level of satisfaction. However, before an HIS can be designed, both managers and developers need to be familiar with work routines, information requirements, and other key parameters at the clinical level, given that medical information is linked to the environment in which it is generated (Berg & Goorman, 1999). Thus, the organisation must outline its information requirements and work procedures. The HIS that ultimately emerges will be embedded in the organisation’s processes and must satisfy the care provider’s information needs (Berg, 1999). To sum up, in order to design an HIS in process-oriented healthcare organisations, attention must be paid to issues such as patient focus, cost effectiveness, service quality, adaptability to the constraints of the organisation, and integrated use of information at both the hospital and clinic level (Ovretveit, 1992; Flarey, 1995). Moreover, a holistic overview based on system thinking is vital, including the gathering of data from multiple sources in order to correlate costs with the utilisation of resources. The challenge is to define models that can support the design of an HIS. 1. 1. 1. Organisational and work process models in medical informatics The main purpose of reengineering was to focus on the processes rather than the functions or an organisation (Hammer, 1990). Further organisational enhancement could be achieved with quality methods such as Total Quality Management (TQM), which included process-oriented models. Another approach is to modify the business culture such that it becomes a learning organisation (Senge, 1990). In the financial area, Balanced Scorecard has been used to translate mission and strategy statements into operational objectives and measurement variables (Kaplan & Norton, 1996). When it comes to medical informatics, attempts have been made to design various kinds of organisational models, such as socio-technical modelling (Berg et al. ,1998). The rationale for introducing these models is to gain a greater understanding of the ways in which an HIS will affect the allocation and content of work tasks. Changes in work activities require modification of information management (Berg, 2001). The validity of a technology rests not only on the fulfilment of functional specifications, but also on the interaction of the technical system with its 2 Management Information Systems in Process-oriented Healthcare Organisations organisational environment (Brender, 1998). The resulting conclusion that has been drawn today is that social, organisational, cultural and contextual issues should be taken into consideration at an early stage of the development process (Kaplan, 2001). Moreover, approaches such as cultural-historical activity theory have been used to perform contextual analyses of clinical cognition and activity. Culturalhistorical activity theory argues that studying the present healthcare setting is insufficient – a researcher must also become acquainted with the history of the setting, given that clinical cognition is embedded in broader institutional structures and longstanding evolution (Engestrom, 1995). One method was to highlight patient data on the presumption that the objective of any healthcare organisation is to improve the health of individuals (Engestrom, 1999). Other researchers argue for a framework that allows for a constant interplay of different models, theories and perspectives (Maij et al. , 2002). The advantages of integrated frameworks are that methods and models can be optimised during the development process, while methods with specific weaknesses can be reinforced by others (Timpka, 1995). Finally, there are approaches for exploring the ways in which healthcare providers tend to reason in clinical contexts – such as situated action, an emerging perspective for studying human cognition and behaviour in order to design intelligent systems (Patel, Kaufman & Arocha, 1995). Such models address the clinical tasks that are to be performed within specific guidelines and define criteria for selecting appropriate options when there is a set of potentials (Wang et al. , 2002). 1. 2. Aims of the study The aim of this thesis is to develop a management information system model for process-oriented healthcare organisations, based on two questions: â€Å"What kinds of requirements do healthcare managers place on information systems? † and â€Å"How can the work and information systems of healthcare managers and care providers be incorporated into process-oriented healthcare organisations? The work is based on a circular process, during which models are developed by collecting and categorising data, as well as by designing small-scale theories about information systems. Organisational process is defined as â€Å"a sequence of work procedures that jointly constitute complete healthcare services†. A work 3 Management Information Systems in Process-orie nted Healthcare Organisations activity is defined as a set of work procedures that are closely related by virtue of their purpose and means of performance. A functional unit is the organisational venue responsible for a certain set of work activities. Healthcare Information Systems (HIS), Management Information Systems (MIS) and Information and Communication Technology (ICT) all define computer-based information systems. 2. Research methods A qualitative research strategy, based on an idiographic case study, was employed. Qualitative research, which has evolved within several disciplines, consists of a set of interpretive practices. It does not accord priority to any single methodology for data collection and analysis, nor does it have a theory or paradigm that is distinctly its own (Denzin & Lincoln, 1998). Qualitative research is best suited for understanding the processes inherent to a situation, along with the beliefs and perceptions of the people involved. Nevertheless, qualitative researchers can make their findings more widely applicable (Firestone, 1993). Furthermore, a case study is both a process of inquiry and the product of that inquiry (Stake, 2000). The researcher needs a wide array of information about the case in order to provide an in-depth assessment (Creswell, 1998). A primary distinction is between single-case and multiple–case designs of such studies (Yin, 1994). A case study whose primary mode of research is hermeneutic is idiographic in a natural setting – its main type of data is qualitative and its fundamental level of analysis is holistic (Fishman 1999). Interpretive studies are well served by a considerable degree of openness to field data, along with willingness to re-examine initial assumptions and theories. The result is an iterative process of data collection and analysis during which initial theories are expanded upon, revised or abandoned altogether (Walsham, 1995). 2. 1. The setting of the case study The setting of the study was a paediatric clinic at a county hospital in Sweden. In 1996, the county council adopted a wide-ranging quality program based on TQM and a Plan-Do-Check-Act (PDCA) cycle. In 2000, the county council started using Balanced Scorecard to measure the healthcare organisation’s outcomes. At the time of the study, the county’s development and change program for 4 Management Information Systems in Process-oriented Healthcare Organisations organisational quality was based on a CAS strategy. Furthermore, a processoriented healthcare information system was being designed. With some 30 clinics and 3,200 employees, the hospital had identified its main organisational objectives as the delivery of emergency and specialist healthcare, as well as county-wide rehabilitation and habilitation services. The purpose of habilitation is to enable someone with a congenital impairment, whereas rehabilitation focuses on recovering lost ability. Above and beyond the responsibilities of healthcare managers in accordance with the functional structure, all clinics at the hospital (including paediatrics) had developed work processes for specific groups of patients. These Patient Need Group Processes (PNGPs) centred on the healthcare needs of individual patients. The main objective of the PNGPs was to cultivate and maintain a high level of knowledge about medical care at the paediatric clinic. The scope of the processes varied considerably. However, a PNGP unit always comprised at least a doctor, nurse and secretary. If necessary, several clinics, hospitals and county councils could collaborate on the same process. In order to improve nursing care, development teams, staffed by practitioners interested in development work, were set up. Specific development areas included palliative care and the use of technical equipment. The teams produced documents concerning their specific areas that could prove of value for their co-workers. New work routines were developed for nursing care and for activities that are indirectly related to the patient care process, such as meal delivery, ordering medication and play therapy. The teams had contact people at each ward who were prepared to step in whenever nursing care problems arose. The team members normally attended meetings during their free time – or overlapping time when two shifts were on duty simultaneously. The paediatric clinic also cooperated with maternity wards and a total of 13 Child Health Centres (CHCs) throughout the county. The clinic was part of a network of specialist clinics in southern Sweden that focused on the exchange of knowledge and experience. At the time of the study, the paediatric clinic employed 12 senior physicians, 21 physicians, 91 nurses, 77 paediatric nurses (specialist nurse’s aides) and 13 secretaries. The management team consisted of six senior physicians, seven nurses and one secretary from the clinic. During the period of the study, the paediatric clinic supplied approximately 16,000 bed-days to inpatients, performed 5,000 scheduled surgical interventions and handled 5 Management Information Systems in Process-oriented Healthcare Organisations 6,000 emergency room visits by children. The paediatric clinic comprised one surgical unit and three wards, each with a physician responsible for medical matters and a nurse as manager. The ward for neonatal patients had eight beds for intensive care and ten for prenatal care. The ward for contagious patients had 16 isolation rooms for newborn babies and contagious children. The institutional care ward for children older than a year had 18 beds. The clinic used 15 PNGPs. 2. 2. The data collection The collection of data was conducted throughout documents, archives, interviews, observations, diaries, focus groups and feedback loops. 2. 2. 1. Archival data Archival data was used to place the research into context before, during and after the studies at the clinical site (Drury, 2002). An obvious danger posed by fixed data is that it can easily become outdated unbeknownst to the researcher. In these studies, archival data was related to: 1) annual reports by the clinic; 2) the county council’s quality pronouncements; 3) the government’s bill for the healthcare organisation; 4) the physical and mental health survey of hospital employees; 5) reports concerning the county council’s development plans for an HIS. 2. 2. 2. Interviewing A common interviewing technique is to meet face to face (Fontana & Frey, 1998). The interview may be structured, semi-structured or unstructured. The scope of an interview can range from five minutes to the lifetime of the subject (Fontana & Frey, 2000). This study involved semi-structured interviews with four doctors and four nurses. A series of open-ended questions addressed daily work routines and communication patterns. 2. 2. 3. Diary method The holistic perspective of this approach identifies connections among the individual, societal and organisational levels. One of the techniques that have evolved is the diary method, which proceeds from subjective assessments of time utilisation. The various steps require a practitioner to enter time, activity, Management Information Systems in Process-oriented Healthcare Organisations location, the names of co-workers with whom they interact and other comments during a specified period (Ellegard, Nordell & Westermark, 1999). In this study, a ward nurse kept a diary during one workweek. She entered the nature of her work tasks, the times that she performed them and the names of the co -workers with whom she interacted. 2. 2. 4. Observation Observation involves gathering impressions of the surrounding world. Qualitative observational research is fundamentally naturalistic (Adler & Adler, 1998). There is â€Å"descriptive observation†, in which the researcher assumes that he or she knows nothing about what is going on and takes nothing for granted. He or she employs â€Å"focused observation†, ignoring that which is defined as irrelevant. Finally there is â€Å"selective observation†, the most systematic approach, during which the researcher concentrates on the attributes of various activities (Angrosino & Mays de Perez, 2000). This type of observation requires a notebook, a storage location for the data that is collected during the process (Ely, 1993). The researcher observes and interacts with care providers at the paediatric wards before and after their rounds. Alongside the observations, the clinical staffs were interviewed again about what they were doing, why they were doing it, what they hoped to gain from an HIS and what benefits they expected. Field notes were entered into a log during the observation study. 2. 2. 5. Focus groups A focus group’s planning process should begin as soon as it is set up. The process includes the following steps: establish research objectives, appoint a moderator, develop moderator guidelines and draw up procedures. The moderator plays an important role during the group session. He or she conducts the interviews. It is important that the moderator not be the same person that put together the moderator guidelines and questions. In this study, a focus group session was held with seven nurses and three paediatric nurses, all of whom were women selected by a ward nurse. The participants had various duties at the paediatric clinic, where they had been employed for anywhere from 9? to 32 years. Five nurses were ward managers and two also managed development teams. They all had experience at each ward, as well as the paediatric surgery. The researcher had furnished the group moderator with 7 Management Information Systems in Process-oriented Healthcare Organisations guidelines and questions (Greenbaum, 1993). The questions were based on the clinic’s profile of itself: administrative activities, care provision and development work. Questions also dealt with work activities and the exchange of information with other units. Some questions focused in on a patient’s relations with the care providers, as well as the time and place for the performance of care activities. The entire focus group session was videotaped and transcribed. . 2. 6. Feedback loops Feedback loops throughout the research project permitted the generation of reports for evaluating data collection. A total of four reports were sent to the practitioners as a result of the case study. In addition, four seminars were held with the practitioners, the purpose of which was to discuss the research findings. The practitioners discussed and critiqu ed the results. 2. 3. Analyses There was no theory at the beginning as to how the material should be analysed. The first step was to break down healthcare management into the hospital, clinical and care process levels. Statements from the various management levels were interpreted on the basis of information requirement, i. e. main objectives, system functions, expected benefits and risks to be avoided. The second step was the analysis of three main work activities, each with three work procedures, at the clinic level. The third step involved the design of a management information system model. All empirical data was categorised. Various themes were identified and classified. After the categories had been cross-compared and clustered, abstract new categories were defined (Strauss & Corbin, 1990). The final analysis started with a category-by-category comparison, which enabled the identification of core categories that were sent to the paediatric clinic as a preliminary report for comment and critique (Glaser, 1978). Finally, the categories were modified in response to the comments. The focus was to come up with a context-based, process-oriented description and explanation of the phenomena (Orlikowski, 1993). The categories were incorporated into two small-scale theories. The first theory interpreted the information requirements of three management levels. The second theory interpreted the work processes employed by institutional care. 8 Management Information Systems in Process-oriented Healthcare Organisations 2. 4. Modelling In order to conduct the final analysis, the two small-scale theories were applied to the modelling of a management information system. Various possible approaches included data modelling (Connolly, Begg & Strachan, 1996), function modelling and object-oriented modelling (Booch, Rumbaugh & Jacobson, 1999). To handle such approaches, various modelling languages have been developed, including the object-oriented Unified Modelling Language (UML) (Fowler & Kendall 1999). The symbols and notations of the various languages can be difficult for the uninitiated to grasp (Sommerville & Sawyer, 2000). Furthermore, the notation and logic for modelling a system must work in tandem with the people involved in the development process. Thus, it is useful to visualise the information flow by means of a modelling approach, using notation and logic that have been established by consensus. As a result, the management information system models were designed in dialog with the practitioners in the case study. The notation was taken from Eriksson & Penker’s (2000) business processes but modified on the basis of the discussions. 3. Results The results are presented in accordance with the three sub-analyses. The first sub-analysis focused on the requirements of healthcare managers for an HIS. The second sub-analysis focused on interpreting organisational and work processes in relation to the HIS. The third sub-analysis focused on designing a management information system model for process-oriented healthcare. 3. 1. The requirements1 of healthcare managers for an HIS Hospital management expressed its intention to use an HIS to empower patients while maintaining control of resource utilisation. Thus, the planned HIS was expected to encourage a greater overall awareness of cost effectiveness with respect to the services provided by various units of the hospital. The biggest risk noted was that of a mismatch between the system and the existing organisational culture, in which it was easy to identify and reward employees who handled 1 Requirements and demands are used as synonym in this chapter and in article 1. 9 Management Information Systems in Process-oriented Healthcare Organisations mergencies. As a result, some of the staff appeared to resist a new way of transmitting information throughout the various levels of the organisation. The goals of the functional units (i. e. clinic management) focused on patients and the introduction of leadership based on co-determination. While management accepted patient empowerment and cost effectiveness as the their main objectives, they thought it was important that employees be allowed to make their own organisational decisions. Management wanted to see a new approach to measuring the activities of their organisational unit. In order to achieve these goals, they sought a way to define the data that is essential to making a reliable estimate. In managing the healthcare process, the objectives of an HIS centred on developing and maintaining specific clinical competence by enhancing support for decision-making and co-operation on the part of care providers. While all the process managers agreed that sharing information and knowledge was important to improving the decision-making process, they were unaware of resource competition issues. However, the withholding of information was not always intentional. Due to limited resources and full schedules, process managers were often unable to share their knowledge with other employees. 3. 2. Interpretation of organisational and work processes in relation to HIS Work activities included: (1) co-ordination of information exchange management; (2) care, including documentation of the care provided and the practice that had evolved at the clinic; (3) supply, including patient assistance and psychosocial support. The work procedures of the various activities were often related to and dependent on each other. Co-ordination activities were oriented toward management of the wards and the clinic. The activities focused on co-ordinating various types of information in order to support the care effort. External co-ordination is related to the exchange of information between the paediatric clinic and other care units. This coordination continued after the patients had been discharged from the clinic. Thus, the coordination of external resources and inter-organisational collaboration was important to the management of the clinic. Patient co-ordination started before a patient was admitted to institutional care. There were two 10 Management Information Systems in Process-oriented Healthcare Organisations easons for such approaches. First, the amount of time that patients stayed at the wards proved expensive for the healthcare organisation. Thus, such approaches saved money. Second, these approaches enhanced the relationship between care providers and caretakers, assuming that patients and their families were kept well informed. Internal co-ordination was related to management and planning activities at the clinic and the wards. Such activities were linked to external and patient co-ordination, given that providers needed to cooperate with other units and patients in order to manage ward care. Care activities were underpinned by what had been agreed upon during the coordination of work activities and the information that was to be used by various co-ordination procedures. Care provision involved medical and nursing care performed by physicians, nurses and paediatric nurses. Care activities were broken down among the various professions. But care was regarded as teamwork from the point of view of the patients. Thus, the work tasks of the various professions cumulatively became what are referred to as the outcome of care provision. Practice development took in both medical and nursing care issues. The knowledge and information cultivated was incorporated into the ordinary work routines of the paediatric clinic. Care documentation activities were linked to care work and development efforts. Documentation provides protection for both care providers and patients. Care documentation served as a means of communication among care providers. Supply activities were indirectly related to care activities. Among employees who performed supply activities were nurses, paediatric nurses, kitchen staff, cleaning staff, play therapists and teachers. Material provision furnished care activities with pharmaceuticals, equipment and materials. Based on the resources that material provision furnished to care activities on a daily basis, estimates were prepared concerning the resources the activities would require over time. Bandages, diapers, syringes, etc. were also a part of material provision. Material provision also included equipment and supplies for play and school activities, such as games, videotapes and textbooks, as well as kitchen and cleaning supplies. Psychosocial support activities called for an information system that could offer emotional support, such as administrative tasks associated with permitting patients to have their own personal phones. Thus, psychosocial support depended on the ability of patient co-ordination efforts to proceed smoothly, assuming that both patients and their families could be kept well 11 Management Information Systems in Process-oriented Healthcare Organisations informed. The main purpose of Patient assistance, which included both material provision and psychosocial activities, was to assist care activities. Such activities were related to supporting the physical and mental well-being of patients while undergoing medical and nursing care. 3. 3. A management information system model for process-oriented healthcare The county council formally required that hospital management monitor and report on service production with regard to quality and cost. As a result, hospital management needed data about resource utilisation and healthcare quality from the hospital organisation, along with information systems that could support methods such as Total Quality Management (TQM) and Balanced Scorecard. To monitor costs and quality, hospital management needed data from the functional units after determining what needed to be collected. The focus of process management was developing and maintaining a high level of quality in the medical and nursing care processes. The process unit was responsible for documentation and quality control operations. Process management needed directives from the functional management unit about both data collection templates and quality for medical and nursing care. Process management generated information about medical and nursing quality data for functional unit management. Best practice guidelines and decision support protocols for clinical practitioners were involved in the clinical process. The HIS application required by process management was a service quality control system that could extract data from and support decision making for medical and nursing care. Functional unit management comprised managers at both the clinic and ward levels. Clinic management organised the monitoring of the clinic’s resources, while ward managers co-coordinated the exchange of information at the wards. Functional unit management requested information about resource allocation specifications and templates for expenditure reports, as well as for patient satisfaction and staff work satisfaction data, from hospital management. Functional unit management needed data concerning the perceptions of patients and staff with regard to the services provided by the unit. Management was also looking for a way to relate its expenditures to resources utilised. In other words, its primary needs were in the areas of data collection, storage and access tools. 12 Management Information Systems in Process-oriented Healthcare Organisations Thus, functional unit management required data from clinical activities, but not at an individual or contextual level. The systems it was seeking were to supply data for use at a composite level, including the volume of financial and human resources that specified care activities necessitated. To monitor service delivery, management units in process-oriented healthcare organisations need data in three distinct areas: (1) medical and nursing care, (2) patient flows and (3) the utilisation of human and material resources. Although the management units may have access to a common data warehouse, requirements for data analysis and presentation vary considerably. Similarly, data collected from the healthcare organisation during daily work routines can be shared, but the primary data must be converted into a format that is usable by healthcare managers. The data that is collected should ideally be located where it can be made available to ordinary healthcare activities. For instance, networked devices can be used to monitor pharmaceutical use. Intelligent devices can also be connected to equipment in order to track their use, and material storage and use (diapers, sheets, etc. ) can be traced by bar-code systems. Furthermore, patients and healthcare staff can be registered with smart cards as they come and go. However, computerised patient records (CPRs) are the most logical central resource for data collection in the clinical setting. The data that is documented in the records can be used to monitor the clinical activities that have been performed. CPRs can also furnish data about work activities at the healthcare organisation. Such data is of little value as long as it is limited to individual patients. What is useful is to analyse cumulative data, such as the number of radiology examinations that have been conducted on leukaemia patients. The purpose of the data warehouse is to store what has been collected from various sources. The application and its interface are the parts of the HIS with which healthcare managers interact and with which users most readily identify. Thus, the application must help healthcare managers use information and must supply the right information to the right healthcare managers. Moreover, the application must support the specific analysis methods, tools and data formats required by current organisational analysis procedures, such as Balanced Scorecard and quality assurance methods. 13 Management Information Systems in Process-oriented Healthcare Organisations 4. Discussion The aim of this thesis was to develop a management information system model for process-oriented healthcare organisations. The research effort employed qualitative methods such as archival data analyses, interviews, observations, diary analyses and focus group analyses. Constant feedback loops among the participants in an idiographic case study helped establish a balanced interpretation. Meanwhile, categorising and modelling formed the pattern of interpretation for the management information system model. The main findings of the study are that an HIS in a process-oriented organisation must support the medical work, integrate clinical and administrative tools, and furnish information that allows for the measurement of organisational inputs and outcomes. As a result, it is important to identify the multiple roles that information plays in a process-oriented healthcare organisation. Most of the organisational development methods that healthcare currently takes advantage of, such as reengineering and quality management, include process definitions. However, the interaction between various groups of processes has seldom been analysed. Several recent organisational methods, such as Balanced Scorecard (Kaplan & Norton, 1996), address the problem of relating costs to resources. The areas in which information systems are expected to enhance care delivery range from access to medical knowledge bases, patient and clinician communication, and the minimisation of medical errors. Nevertheless, little attention has been paid to how integrated administrative, financial and clinical systems should be configured in order to support process-oriented healthcare organisations in an optimal manner. Internal co-ordination is informed by and dependent on documentation of care activities, particularly by monitoring the way in which human resources are harnessed to take care of patients. Furthermore, such co-ordination relies on information about the utilisation of material resources, i. e. durable equipment and disposables. Thus, internal coordination must obtain information from care activities in order to synchronise the work of the clinic, as well as to track costs associated with care and supply activities. The various processes monitor costs and allocate resources, relating them to the kinds of care activities that have been provided. 4 Management Information Systems in Process-oriented Healthcare Organisations The third sub-analysis discovered that the various management levels in process-oriented healthcare organisations need the same type of primary data, though in differing formats. An HIS for healthcare management in a processoriented healthcare setting can adhere to its structure and practice activities. Moreover, CPRs and other tools can be used to directly collect management data where and when the activities take place. But the data is useful only if healthcare management has the opportunity to examine it with its own analysis tools. For instance, while computerised ordering systems are regarded as important, the fit between organisational and information system models is not identified as a success factor. Clearly, there is a need for systems that optimise clinical workflow, as well as those that support the maintenance of equipment and supplies. However, systems provide optimal organisational value only if they support an integrated organisational model and business plan. 5. Conclusions This thesis points out that healthcare managers at different levels in an organisation all need the same primary data. The differences among the various management levels all concern the ways in which they compile the data that they need for their work. One problem when developing management information systems for healthcare organisations has been a lack of interest in integrating administrative, financial and clinical systems. In process-oriented healthcare organisations, integration is essential to obtaining the full benefits of such a structure. System thinking must also pervade the development of healthcare management information systems. As a result, the multiple roles played by information in process-oriented healthcare organisations must be identified. 6. Future work Identifying the multiple roles played by information in a process-oriented healthcare setting requires additional research about the process of designing an HIS. In the complex environment that healthcare organisations represent, various practitioners are required to pinpoint data sources and information 15 Management Information Systems in Process-oriented Healthcare Organisations requirements, as well as to advocate for the process of change in the organisational and information structure. Healthcare managers have differing preferences when it comes to information requirements, organisational processes and work activities. Thus, the development process relies on tools that can incorporate those divergent needs into system thinking. As a result, primary data is refined into information differently at the various levels of a processoriented healthcare organisation. More research is required concerning information system models and their notation. Though various groups (system analysts, designers, programmers and healthcare managers) can employ models and modelling activities during a development process, their objectives differ. Healthcare managers need to visualise their work environment and organisational processes, system analysts are interested in developing information systems in collaboration with designers, and programmers are looking for coding specifications. They may share a vision in terms of designing a healthcare information system, but their perspectives vary. Thus, the modelling effort should be based on at least two dimensions: (1) furnishing models with notations and objectives oriented towards specific groups; (2) ensuring that the models visualise the same system but address varying interpretations. Arguments based on the cognitive and practice perspective have identified prototyping as a fruitful approach to the development process (Houde &Hill, 1997). Prototyping is often used when the design calls for a high degree of involvement on the part of practitioners and end-users (Bodker & Gronb? k, 1991). Modelling, on the other hand, is linked to an organisational perspective and is frequently employed by system analysis methods. Thus, there is an opportunity to combine these two perspectives during the development process. Modelling is useful as part of a design theory with a high degree of practitioner involvement alongside of system analysts, designers and programmers. The process can subsequently be analysed based on the representations in the models that emerge from the requirements of the various groups. Additional research should examine what the groups need when it comes to the substance of the models, how the models are to be visualised and the ways in which they can interact with the differing requirements of the groups in order to ensure a fruitful development process. 16 Management Information Systems in Process-oriented Healthcare Organisations 7. References Adler P. A. , Adler P. , (1998), Observational Techniques, in Denzin N. K. , Lincoln Y. S. , (eds), Collecting and Interpreting Qualitative Material, Thousand Oaks, Sage Publication. 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