Friday, November 29, 2019

Planning and Goal Setting Essay Example

Planning and Goal Setting Essay S. Small Business Administration MP-6 PLANNING AND GOAL SETTING FOR SMALL BUSINESS Management and Planning Series ____________________________________________________________ __________________ While we consider the contents of this publication to be of general merit, its sponsorship by the U. S. Small Business Administration does not necessarily constitute an endorsement of the views and opinions of the authors or the products and services of the companies with which they are affiliated. All of SBAs programs and services are extended to the public on a nondiscriminatory basis. ___________________________________________________________ __________________ TABLE OF CONTENTS INTRODUCTION 1 MANAGEMENT BY OBJECTIVES 1 PREPARING FOR THE MBO PROGRAM Understanding the Requirements of an MBO Program 1 Defining Your Business 2 Setting Goals 2 Devising a Work Plan 2 Reporting Progress 3 Evaluating Performance 4 INSTALLING THE MBO PROGRAM 6 THREATS TO AN MBO PROGRAM 6 SUMMARY 6 APPENDIX: INFORM ATION RESOURCES 7 ____________________________________________________________ __________________ INTRODUCTION Many authorities on business management identify the five major functions of management as ! ! ! ! Planning. Organizing. Directing. Controlling. Coordinating. The planning and controlling functions of management often receive less attention from the small business owner-manager than they should. One way to more effectively fulfill these two functions is through effective goal setting. The success of a business will depend on its long-range goals for sales, profits, competitive position, development of personnel and industrial relations. To accomplish these goals, the company will need to identify intermediate goals that it can work toward each year. ____________________________________________________________ _________________ MANAGEMENT BY OBJECTIVES Traditionally, people have worked according to descriptions that list the activities or functions of the job. The management by objectives (MBO) approach, on the other hand, stresses results. Lets look at two examples. ! Suppose a credit managers job description states that he or she will supervise the credit operations of the company. This description simply lists the functions of the credit manager. Under the MBO approach, the owner-manager and the credit manager would identify five or six goals covering important aspects of the managers work. For example, one goal might be to increase credit sales enough to support the 15 percent increase in sales expected by the sales department. The traditional job description for a personnel specialist may include conducting a recruiting program for the company. Under the MBO approach, the personnel specialist would identify five or six appropriate goals, one of which could be, Recruit ten new employees in specified categories by July 1. ! With MBO, jobs are viewed in terms of achievements rather than simply functions. Activity alone is not enough; each activity must bring the worker closer to achieving his or her goals. ___________________________________________________________ __________________ PREPARING FOR THE MBO PROGRAM Understanding the Requirements of an MBO Program Management by objectives has been used by all kinds of organizations, but not every business has had the same degree of success. From examining MBO programs that have worked, it is clear that all met the following minimum requirements: ! ! ! Goals were expressed in specific and measurable terms. Each employee proposed 5 to 10 goals to cover those aspects of his or her job crucial to successful performance. We will write a custom essay sample on Planning and Goal Setting specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on Planning and Goal Setting specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on Planning and Goal Setting specifically for you FOR ONLY $16.38 $13.9/page Hire Writer A final written statement of each goal was prepared, including a statement of the goal, method of evaluating the goal, work steps needed to complete the goal and an estimated time needed to complete the steps. Progress was evaluated at regular intervals (at least quarterly) and compared with the original goals. Problems that hindered progress were identified and corrected. Goals were related to each level of management, both those above and those below. ! ! ! Defining Your Business The first step in developing an effective MBO program is to define your business. Ask yourself the following questions: ! ! ! What business am I in? Is my definition right for todays market? Do I need to change my business to meet emerging customer needs? A clear vision of your business is crucial for planning your marketing, product development, buildings and equipment, and financial and staff needs. For example, a drop in sales caused a small business manufacturer of metal trash cans to reexamine its product. To regain lost sales, the owner decided to redefine the product as metal containers and to develop a new marketing plan. Setting Goals Long-range business goals will be the cornerstone of your companys MBO program. To achieve these goals, you must have a method to communicate them to your managers and employees. One way is to bring managers and employees into the process by asking them to help formulate the companys short- and long-range goals. If they have a role in establishing the goals, they will be more committed to achieving them. All goals should relate to and support the long-range objectives for the company. In this way, you can ensure that the goals of all levels of management are consistent. If goals are incompatible, you may find that employees feel like the middle manager of a research and development company who exclaimed in a seminar, How can I set my goals when I dont know where top management wants to go? Types of Goals What areas of your managers work are suitable for goal setting? Ask managers to identify the most important aspects of their work. In each area, they should set both short- and long-term goals. Carefully developed goals, if attained, should give the manager better control of the job. Each manager should define one or two goals in each of the following categories: ! ! ! Regular work goals. Problem-solving goals. Innovative goals. Development goals. By asking your managers to set at least one goal in each of these four areas, you may open their eyes to new possibilities they had not seen before. The goal-setting process can be a very useful educational step. Regular Work Goals These include the major part of the managers responsibilities. For example, the head of production should focus on the quantity, quality and efficiency of production and the head of marketing should concentrate on developing and conducting the market research and sales programs. In defining their regular work goals, employees should include ways of ! ! ! Operating more efficiently. Improving the quality of the product or service. Expanding the total amount produced or marketed. Problem-Solving Goals These provide managers an opportunity to define their major problems and to set a goal to solve each one. There is no danger of ever running out of problems; new problems or new versions of old problems are always present. Innovative Goals Because of the push for new products and new methods in todays marketplace, innovation now gets much attention in seminars and publications for top managers. Managers and workers should seek new and better production methods, explore better ways to serve customers and propose new products for the company. Managers will need to use innovative approaches to make the company competitive in a fast-changing national and international economic environment. Development Goals In setting development goals, you and your managers recognize the importance of acquiring new skills. Managers should plan for the continued growth of each employee, both in technical areas and in work relations with fellow employees. Devising a Work Plan You and your managers should use a miniature work plan to develop goals that are complete and useful (see Exhibit 1). In developing the plan, the following five areas should be addressed: ! ! ! ! ! Goal Be specific and concise. Measurement What benchmarks will you use to measure whether you have achieved your goals? These usually can be expressed in quantitative terms. Major problems anticipated. Work steps List three or four of the most essential steps. Give completion dates for each. Supervisors goals Employees should identify which of their managers goals relate to their own goals. On the work plan, managers can show each of the major work steps (subgoals) necessary to reach a goal. If the work steps are completed by the indicated date, the goal is reached. Use the form in Exhibit 1 to discuss goals with your managers. By looking at the form, you can see not only the goal but also the plan for reaching that goal. This will allow you to (1) ask questions about the work steps and any potential problems; (2) decide the best way to evaluate progress on the goals and (3) help each of your managers understand how his or her goals relate to those of the company. All problems listed on the work plan should include a solution. For example, suppose the head of a supply department sets a goal to deliver all packages within one day after they are received. Because employees may have difficulty meeting the new deadlines, the work plan should include necessary steps to teach them the new procedures before the program goes into effect. _______________________________________________________ Exhibit 1 Plan to Achieve Objectives SUPERVISOR: ____________________________________ OBJECTIVE #1: Increase gross sales margin of my area by 12 percent by 9-1-92 and maintain at that level for remainder of 1992. ______________________________________________________ Major Action Steps January December J F M A M J J A S O N D 1. Decrease cost of serving small accounts. X a. Identify all customers not purchasing $5000 per month. X b. Determine sales potential of each target customer. X c. If potential is less than $5000,, transfer to jobber. X d. Inform customer and schedule jobber visit with customer. X e. If potential is $5000, develop cooperative sales promotion program. X f. Implement program. X g. Evaluate report results. X 2. Increase minimum calls per salesperson to 10 per day. X a. Analyze work methods of high call salespersons. X b. Identify salespersons with fewer than 10 calls placed. X c. Analyze territory and order of calls. X d. Determine best routing of calls. X e. Determine most effective realigning of all territories. X f. Implement plans. X g. Evaluate report results. X _______________________________________________________ Reporting Progress An MBO program must include a provision for regular progress reports. For this reason, the MBO concept is sometimes called MBO/R, where the R refers to results. You and your managers will only accomplish your goals or objectives if the MBO program calls for a regular review of progress. For example, one large organization issued nearly 100 pages of well-developed goals prepared by many of its managers. The document was very impressive, but it lacked a reporting system of any kind. You can imagine the skeptical reaction of those who set goals for the first year when they were asked the following year to draw up new goals. A monthly or quarterly review of progress toward goals will help you determine where progress is below expectations. For example, suppose that one of your goals is to reduce overtime work by 50 percent in one year, but you only reduce it by 15 percent in the first quarter. Based on this information, you can exert a special effort in the succeeding quarters to regain the lost ground. When progress is below expectations, you should identify the problems holding back progress and assign someone to resolve them. Failure to reach goals can result from ! ! ! The wrong objectives being established at the outset. Organizational restrictions being overlooked. Personal failure or a combination of factors. In order to solve problems and meet a goal, managers may have to adjust their time line or change the goal itself. All changes should be written as new goals and included in the MBO files. Evaluating Performance In contrast to traditional methods, which evaluate performance based on personal qualities such as leadership ability, the MBO method evaluates performance based on objective results. Such evaluation is a complex task that must be undertaken with care by someone who fully understands MBO. (See Exhibit 2 for a comparison of traditional and MBO evaluation methods. _______________________________________________________ Exhibit 2 Comparison of Traditional and MBO Evaluation Methods _____________________________________ Characteristic Traditional method MBO method _______________________________________________________ Frequency Emphasis Usually annually (if at all). Traits. Usually quarterly. Results versus objectives. Subordinates frame of mind Mental block. (doesnt know how tr aits will be evaluated). Poor receptivity (much has been based on employees traits). Rewards usually not directly tied in. Positive (feedback has told employee how well he or she is doing). Positive (much has been based on employees job performance). Rewards usually tied directly to results. Suggestions for improvement Tie in to rewards Summary Little connection Results oriented. to results. _______________________________________________________ Under the MBO program, you evaluate your managers performance based on whether they have achieved their five to eight goals. You also must determine how well they have performed the secondary duties that do not fall under goals. (See Exhibits 3 and 4 for examples of traditional and MBO performance evaluation forms, respectively. _______________________________________________________ Exhibit 3 Example of Traditional Performance Evaluation Form Factor Excellent Above Average Below Poor average average Degree of costconsciousness X Grasp of function X Initiative X Decision-making ability X Application X Judgment X Health X Appearance X Loyalty X Relationship with people X Ability to develop subordinates X Work habits X Contributi on to companys progress X Potential for advancement X ___________________________ Employee:_________________ Rated by: __________________ Date:_____________ Reviewed by: _______________________ _____________________ Acknowledgment: I acknowledge this performance appraisal has been discussed with me. This acknowledgment does not constitute agreement with the findings. Signed:____________________ Date: __________ ____________________________________________________________ _____ Exhibit 4 Results-Oriented Evaluation Form Results achieved Quarters Total year 1st 2nd 3rd O T Achieved in 97 percent of cases. Objectives 1. Improve by 10% number of qualified applicants referred for job openings. 2. Increase by 12% number of qualified welders during 19xx. Measure 1. At least T three qualified candidates referred for each job opening. 2. Number of O persons completing basic welding course #5. T T 17 completed course. Note: T = On target. No action necessary. O = Off target. Action necessary. ____________________________________________________________ _____ INSTALLING THE MBO PROGRAM When installing an MBO program, start by asking your managers to define their jobs, including their major responsibilities. Then, for each responsibility, you and your managers must decide the most effective way to measure performance in terms of results. The outcome of this exercise may surprise you. You and your managers may not agree on the major responsibilities of a certain position. Also, you may find that no one is performing some functions that you consider important. If the MBO system is to succeed, you must show interest from the beginning and set the example for your subordinate managers. The education of your managers may be a formidable task. Until this time, they have thought in terms of specific functions managing a sales department, directing a credit office, etc. rather than in terms of goals that contribute to the organization. One way to introduce the MBO system to your managers is in a seminar conducted by you or a consultant. However, if you choose a consultant, be sure that you are present for the entire seminar. In this way, you will communicate to your managers that the MBO system is a management priority. During the seminar, ask each participant to prepare an actual goal. Also, in small group sessions, have your managers review each others work plans and offer suggestions to improve them. The experience of setting and reviewing goals makes MBO a learning experience for all employees. Encourage your managers to express their doubts, reservations or opposition to MBO. They should get their feelings out in the open as soon as possible. You, the consultant or other participants can help to ease their concerns. In the beginning of your MBO program, your managers will have to learn to measure their own performance accurately, anticipate real problems that will thwart their progress and take steps to solve delays and other problems. During this learning period, your managers should set fewer goals than would usually be expected, perhaps three or four. After they develop and achieve these goals, they can extend the number and area covered by each goal. MBO may look simple on the surface, but it requires experience and skill to make it work effectively. If managers set annual goals, it may take three to four years before good results from this new system appear. ____________________________________________________________ __________________ THREATS TO AN MBO PROGRAM Not all MBO programs are successful. Some of the reasons why programs fail to reach their potential are ! ! ! Top management does not become involved. Corporate objectives are inadequate. MBO is installed as a crash program. ! It is difficult to learn the system because the nature of MBO is not taught. ____________________________________________________________ __________________ SUMMARY It is hard to get people to think in terms of results rather than the functions of their job; however, it can be done. The sequence of steps you use may not work for someone else. It is often an individual matter. No matter what steps you use, the final results are what count. If you feel that you are ready to introduce MBO to your company, why not set it as a goal for yourself? Turn back and follow through with the work plan. List your goals, method of measurement, anticipated problems and the work steps necessary to get your company managing by objectives. ____________________________________________________________ __________________ APPENDIX: INFORMATION RESOURCES U. S. Small Business Administration (SBA) The SBA offers an extensive selection of information on most business management topics, from how to start a business to exporting your products. This information is listed in The Small Business Directory. For a free copy contact your nearest SBA office. SBA has offices throughout the country. Consult the U. S. Government section in your telephone directory for the office nearest you. SBA offers a number of programs and services, including training and educational programs, counseling services, financial programs and contract assistance. Ask about ! Service Corps of Retired Executives (SCORE), a national organization sponsored by SBA of over 13,000 volunteer business executives who provide free counseling, workshops and seminars to prospective and existing small business people. Small Business Development Centers (SBDCs), sponsored by the SBA in partnership with state and local governments, the educational community and the private sector. They provide assistance, counseling and training to prospective and existing business people. Small Business Institutes (SBIs), organized through SBA on more than 500 college campuses nationwide. The institutes provide counseling by students and faculty to small business clients. ! ! For more information about SBA business development programs and services call the SBA Small Business Answer Desk at 1-800-U-ASK-SBA (827-5722). Other U. S. Government Resources Many publications on business management and other related topics are available from the Government Printing Office (GPO). GPO bookstores are located in 24 major cities and are listed in the Yellow Pages under the bookstore heading. You can request a Subject Bibliography by writing to Government Printing Office, Superintendent of Documents, Washington, DC 20402-9328. Many federal agencies offer publications of interest to small businesses. There is a nominal fee for some, but most are free. Below is a selected list of government agencies that provide publications and other services targeted to small businesses. To get their publications, contact the regional offices listed in the telephone directory or write to the addresses below: Consumer Information Center (CIO) P. O. Box 100 Pueblo, CO 81002 The CIO offers a consumer information catalog of federal publications. Consumer Product Safety Commission (CPSC) Publications Request Washington, DC 20207 The CPSC offers guidelines for product safety requirements. U. S. Department of Agriculture (USDA) 12th Street and Independence Avenue, SW Washington, DC 20250 The USDA offers publications on selling to the USDA. Publications and programs on entrepreneurship are also available through county extension offices nationwide. U. S. Department of Commerce (DOC) Office of Business Liaison 14th Street and Constitution Avenue, NW Room 5898C Washington, DC 20230 DOCs Business Assistance Center provides listings of business opportunities available in the federal government. This service also will refer businesses to different programs and services in the DOC and other federal agencies. U. S. Department of Health and Human Services (HHS) Public Health Service Alcohol, Drug Abuse and Mental Health Administration 5600 Fishers Lane Rockville, MD 20857 Drug Free Workplace Helpline: 1-800-843-4971. Provides information on Employee Assistance Programs. National Institute for Drug Abuse Hotline: 1-800-662-4357. Provides information on preventing substance abuse in the workplace. The National Clearinghouse for Alcohol and Drug Information: 1-800-729-6686 toll-free. Provides pamphlets and resource materials on substance abuse. U. S. Department of Labor (DOL) Employment Standards Administration 200 Constitution Avenue, NW Washington, DC 20210 The DOL offers publications on compliance with labor laws. U. S. Department of Treasury Internal Revenue Service (IRS) P. O. Box 25866 Richmond, VA 23260 1-800-424-3676 The IRS offers information on tax requirements for small businesses. U. S. Environmental Protection Agency (EPA) Small Business Ombudsman 401 M Street, SW (A-149C) Washington, DC 20460 1-800-368-5888 except DC and VA 703-557-1938 in DC and VA The EPA offers more than 100 publications designed to help small businesses understand how they can comply with EPA regulations. U. S. Food and Drug Administration (FDA) FDA Center for Food Safety and Applied Nutrition 200 Charles Street, SW Washington, DC 20402 The FDA offers information on packaging and labeling requirements for food and food-related products. For More Information A librarian can help you locate the specific information you need in reference books. Most libraries have a variety of directories, indexes and encyclopedias that cover many business topics. They also have other resources, such as ! Trade association information Ask the librarian to show you a directory of trade associations. Associations provide a valuable network of resources to their members through publications and services such as newsletters, conferences and seminars. Books Many guidebooks, textbooks and manuals on small business are published annually. To find the names of books not in your local library check Books In Print, a directory of books currently available from publishers. Magazine and newspaper articles Business and professional magazines provide information that is more current than that found in books and textbooks. There are a number of indexes to help you find specific articles in periodicals. ! ! In addition to books and magazines, many libraries offer free workshops, lend skill-building tapes and have catalogues and brochures describing continuing education opportunities.

Monday, November 25, 2019

Commercialism Americas Hidden Artform essays

Commercialism Americas Hidden Artform essays art n. the quality, production, expression, or realm, according to aesthetic principals, of what is beautiful, appealing, or of more than ordinary significance. The Random House Dictionary Josh, you just have to see the new GAP Khakis commercial! proclaimed my excited brother. I even went as far as watching the same channel until I finally saw the commercial. I sat in front of the television for over a half an hour, and turned my head at the sound of catchy swing music to see young men and women dancing to music on a stark white backdrop. Their energy and enthusiasm to dance was like nothing I had seen in reality. In all the twisting and tangling of arms, legs, and female hair, I froze in my seat as everyone on the dance floor froze in mid air. My heart stopped as I followed the camera around the frozen dancers. The new perception heightened the dancing energy. The GAP Khakis sign invaded the screen for a few seconds and the screen went blank. Was this the work of an evil genius trying to get my attention so that I could be brainwashed into buying a product? Could it perhaps be simply one artist communicating a new sense of beauty to the whole world, regardless of the product I was deeply affected by the strange time and space rendered in front of me in thirty seconds. Commercial film affects me more than fine art in a museum does. It has also proven to be much better at portraying subtleties to a mass audience in a clear and definite way. People are ashamed of this comparative strength. Many of my self-fabricated intellectual friends claim to enjoy gallery fine art more than they enjoy movies and television. When we are at the gallery, I watch my friends ooh and aah at the work as they interpret its meaning amongst themselves. After dragging them cynically into the movie theater, they exit two hours later wiping their eyes off not wanting to say anything to anyone. ...

Thursday, November 21, 2019

Survey analysis Research Paper Example | Topics and Well Written Essays - 1000 words

Survey analysis - Research Paper Example In this survey The AC Nielsen Online Consumer Company aimed to determine the confidence levels in consumers and conducted a worldwide survey in 42 markets. The results from the survey indicated that in markets with a sample size of 500, the error margin was plus or minus 4.4% and in markets with a sample size of 1000 consumers, an error margin of plus or minus 3.1% was likely to occur. In this confidence survey, over 23,500 people were interviewed in 42 markets word wide in : Argentina, Australia, Austria, Belgium, Brazil, Canada, Chile, China, Czech Republic, Denmark, Finland, France, Germany, Greece, Hong Kong, Hungary, India, Indonesia, Ireland, Italy, Japan, South Korea, Malaysia, Mexico, Netherlands, New Zealand, Norway, Philippines, Poland, Portugal, Russia, Singapore, South Africa, Spain, Sweden, Switzerland, Taiwan, Thailand, Turkey, UAE, United Kingdom, and the United States. The market sample in each market was approximately 500 but in China, France, Germany, the United Kingdom, and the United States it was 1000. About 57% of the respondents admitted to cut down on out of home entertainment and 53% claimed to spend less on buying new clothes to sustain their budgets. About 48% said that they would delay upgrading their technology in order to stay within their budgets. In the five regions surveyed worldwide, the priorities given by the consumers varied among the consumers. Out of home entertainment was the first thing that 61% of consumers in Latin America would cut down on, 58% in Asia pacific and 54% in Europe. In North America, 70% of Canadians and 66% of Americans would be the takeout meals as compared to out of home entertainment. In addition, saving on gas and electricity was a priority among the North Americans. A survey on the political situation in the United States of America regarding the popularity of American presidents namely The presidential job approval was conducted and

Wednesday, November 20, 2019

Biomedical Ethics Essay Example | Topics and Well Written Essays - 1250 words - 1

Biomedical Ethics - Essay Example Where Mary Anne Warren maintains that legal rights should not be extended to fetuses as doing so would violate women’s rights such as the right to self-determination for one, I concur that it would prove difficult to protect individual persons who share one body. This was evident in the Supreme Court’s decision in the Case of Ms. G (Thomas & Waluchow, 2002). The ruling further supports Warren’s position on the issue. I will conclude the paper stating that a fetus is also a person and thus deserves our moral respect but any right it may have comes only second to a higher right, that of the woman who bears it. This may sound harsh but it will be best to remember, as history has shown us with slavery, apartheid & abortion, that what is legal isn’t always going to be moral. For the subject of this paper, I will be treating a fetus’ moral right separately from its legal right. In discussing why birth, not conception, is morally significant, Mary Ann Warren presented several opposing assumptions. Believers of the intrinsic-properties assumption find that birth does not change any intrinsic properties of a fetus. Both fetuses & newborn infants almost have the same intrinsic properties. According to one believer, only the capacity of sentience, or being responsive, and the degree of such is a valid basis for moral standing. Warren argues other species would have a higher moral standing than infants if proven that these species are highly sentient. She further says that if the sentient criterion is true then all sentient beings should be treated as moral equals. Therefore, killing other sentient beings such as a mouse or a fly should be considered as immoral as killing an infant. Another philosopher claims that unless a being is capable of wanting to exist, it can’t have a right to life. Since neither an infant nor a fetus is self-aware then killing them wouldn’t be inherently

Monday, November 18, 2019

Lean Thinking Research Paper Example | Topics and Well Written Essays - 750 words

Lean Thinking - Research Paper Example Its adoption of this strategy seems to be the reason why this business organization has survived in a competitive business environment. Supply chain management is a strategy that is used to streamline all business operations to ensure that they occur at the least cost possible and in the most efficient manner. In a competitive market environment, the cost of a product dictates the attractiveness of a business and consequently the inflow of customers (Taylor and Brunt, 2001). The development of products right from the time when raw materials are acquired to the time the final product reaches the customer has a cumulative impact on the cost of the products delivered in market. Harrison and Hoek (2011) point out that understanding consumer behaviour is important for a business that intends to survive in a competitive market. This is the reason why the Starbucks Corporation has decided to develop its lean thinking strategy to model an effective supply chain. One lean strategy of the Star bucks was to reduce the employee motion by bringing products closer to the customers. The company has a team of lean thinking implementers who have engaged in developing strategies that will define an effective supply chain. Ms Jordan, a developer in the lean team noted â€Å"†¦. how much my partners were moving for things that were never at the same place †¦Ã¢â‚¬  and notes the much that was wasted while preparing a single cup of coffee (Jordan, 2009). In response, she advised the employees to place goods on top so that they can avoid the time wasted while bending. Also, she suggested that some essential ingredients be placed closer to the customer to ensure that every customer has access to the product without having the need for employees to supply them every time. Saving time was part of developing an effective supply chain that reduces wastage of time, an important resource in an organization. The strategy employed by Starbuck Corporation can be regarded as minimiza tion of waste of unnecessary motions. Harrison and Hoek (2011, P. 195) point out that if employees have to move, bend or stretch unnecessarily, this is a waste of time that would have been utilized in the productivity. The activities of the company benefited this organization in two dimensions. First, the organization was able to increase the amount of sales which directly contributes to the financial performance of the organization. Secondly, customers attach value to organizations that provide timely services without due wastage of time. In fast food companies where time is a factor, responding to customer orders in time assures an organization of loyalty from the customers. This is the idea that Scott Heydon when he engaged a strategy to minimize motion wastage in the organization. Jargon (Para. 15) points out that there was an increase in customer loyalty in Starbucks after the motion in this organization was minimized. In 2008, the customer loyalty changed from 56% to 76% betwe en April and June and the number of transactions increased by 9% during this time. Harrison and Hoek (2011, p. 60) provides that satisfying the customer value is a key business aspect that garners loyal customers and pulls new buyers. This kind of business trends is important for an

Saturday, November 16, 2019

Empirical Literature on Asthma Care

Empirical Literature on Asthma Care This brief critically considers the empirical literature on asthma care. Emphasis is on UK studies although research from the USA (and other countries) is also considered. It is argued that both environmental and genetic factors are implicated in asthma onset, based on epidemiological evidence. Deficits in care provision persist: these gaps in care may be attributable to a wide range of modifiable factors, including unsatisfactory health professional (GP, nurses) input, limited use of care plans, and patient unawareness. Overall, however, conclusive inferences about asthma care provision are hampered by: A preponderance of retrospective/correlational studies, and a paucity of randomised control trials, which demonstrate causality; A paucity of research on particular gaps in asthma care; Failure to account for third-variable moderator effects. The Office for National Statistics (2004) publishes comprehensive statistics on asthma-related mortality, morbidity, treatment, and care, collapsed by demographic categories. Data is collected from the General Practice Research Database (GPRD). Issues addressed include mortality, prevalence, time trends, patients consulting general practice, incidence of acute asthma, and hospital inpatient admissions. Research suggests that health care providers often fail to agree on the precise criteria for diagnosing asthma, whether mild or severe (e.g. Buford, 2005). Severe asthma is often defined based on pulmonary function measurements, such as forced expiratory volume in 1 second, and hospitalisation. However, neither of these indicators reliably predicts asthma severity (Eisner et al, 2005). Eisner et al (2005) evaluated the efficacy of a method for identifying a cohort of adults with severe asthma based on recent admissions to an intensive care unit (ICU) for asthma. Four hundred adults with severe asthma enrolled at seventeen Northern Carolina hospitals were surveyed. A control group of patients hospitalised without ICU unit admission was also recruited. The study examined whether admission to an ICU unit is in itself a reliable indicator of asthma severity. Asthma patients with a recent ICU admission generated higher asthma scores (based on the frequency of current asthma symptoms, use of steroids and other medications, and history of hospitalisations/intubations), and poorer quality of life, were more likely to have been hospitalised, visited an asthma specialist in the previous twelve months, been in an asthma-related emergency department, and received inhaled corticosteroids in the past year. Data analysis controlled key background variables (e.g. demographic factors), increasing confidence in the reliability of the findings. However, this study was based on quasi-experimental design and hence may be confounded by sampling bias. Trends in annual rates of primary care consultations, mortality, and hospital visits/admissions were monitored for children under 5 years and 5-14 year olds. For children aged For 5-14 year olds, weekly general practice visits rose in the early 1990s (circa 70/100,000 in 1990), showed a fluctuating pattern through the mid 1990s, but has declined steadily since 1997 (about 50/100,000 by 2000). The number of patients treated annually for asthma has risen slowly but steadily, although this increase seemed to level out by the mid/late1990s. Both mortality rates have dropped steadily since the early 1990s, from about 14 million in 1990 to circa 2 million by 2000. Annual hospital admissions has also fallen steadily, from just under 30/10,000 in 1990 to about 15/10,000 by 2000. These patterns suggest an increase in self-management (e.g. action plans) that obviates the need to visit a general practice, and that asthma care overall is having the desired effect on mortality. The prevalence of wheezing and asthma in children has generally increased during the last 40 years. Although there is a paucity of reliable national statistics, data is available from specific parts of the UK, notably Leicester, Sheffield, and Aberdeen (see Figure 1). The prevalence of wheezing increased from 12% (1990) to 26% (1998) in Leicester, and from 17% (1991) to 19% (1999) in Sheffield. The prevalence of asthma showed a similar pattern in both cities, rising from 11% (1990) to 18% (1998) in Leicester, and from 18% (1991) to 30% (1999) in Sheffield. Wheezing incidence rates for Aberdeen increased from 10% (1964), to 20% (1989), 25% (1994), and 28% (1991). Data from national birth cohorts suggests a sharp increase in the average weekly GP consultations for hay fever/allergic rhinitis from 1991 to 1992. The rates rose from circa 13/100,000 (0-4 year olds) and 40/100,000 (5-14 years olds) in 1991 to about 25/100,000 (0-4 year olds) and 76/100,000 (5-14 year olds) as 1992 approached. Trends subsequently dropped off slightly but then started to show an increase again around 1998. By the year 2000 the figures were roughly 20/100,000 (0-4 year olds), and 56/100,000 (5-14 year olds). Data from a nationally representative sample of schools across the country suggests that the prevalence of asthma was fairly even across different regions. However, Data for England suggests a higher prevalence outside big cities. The greatest proportions of wheezing was found in the South West, while the highest proportion of asthma cases was found in East Anglia and Oxford (see Figure 2). In a recent Annual Report, Asthma UK (2003/2004) noted that one child in 10 has asthma and a child is admitted to hospital every 18 minutes due to an asthma attack. Over 600 copies of Asthma in the Under Fives are downloaded from the UK Asthma website monthly and on average every classroom in the UK has at least 3 children with asthma. The impact of acute asthma can be debilitating. Around 5.2 million people in Britain are presently being treated for asthma, and asthma prevention/care costs the NHS on average almost  £900 (i.e.  £889) million per year. GPs across the country treat over 14,000 new episodes of asthma each week, and UK Asthma met almost 25,000 requests for health promotion documents and other materials. About 40% of workers who have asthma find that working actually exacerbates their asthma, and 1 in 5 asthmatic people feel excluded from areas of the workplace in which people smoke. Over 12.7 million working days in the UK are lost as a result of asthma, and it is estimated that the annual cost of asthma to the economy is  £2.3 billion. Asthma UK also states that 82% of people who are asthmatic find that passive smoking triggers their asthma, and 19% of people with asthma indicate that their medical condition makes it difficult for them to play with children in their family. One in 3 children has had their routine daily activities disrupted due to asthma and 39% of asthmatic people are badly affected by traffic fumes (which stop them exercising). About 500,000 people have asthma that is very difficult to control. In 2003/2004 over 90 researchers worked on Asthma UK-funded projects and, Asthma UK spent  £2.5 million on asthma-related research. The group funded/is funding 63 research projects. These statistics paint a rather bleak picture of asthma prevalence, incidence, and the effects on people’s lives. Numerous epidemiological studies have been published that address the etiology of asthma in population groups (International Archives of Allergy Immunology, 2000; Kitch et al, 2000; Schweigert et al, 2000; Tan, 2001; Court et al, 2002; Smyth, 2002; Weissman, 2002; Tan et al, 2003; Wenzel, 2003; Gibson Powell, 2004; Barnes, 2005; Pinto Almeida, 2005). Barnes (2005) considered evidence on the role of genetic factors in resistance to atopic asthma, Studies which focus on the role of genetic factors in resistance to tropical/parasitic diseases (e.g. malaria) overlap with genetic associations found for asthma. It was concluded that genetic factors might be implicated in the development of allergic illnesses. Pregnancy is thought to increase the probability of asthma attacks in about 4% of all pregnant women. Beckmann (2006) assessed eighteen pregnant women with asthma. The study was based on a longitudinal design. Participants were recruited from local prenatal clinics and private enterprises, and enrolled during the first trimester. Patients kept a daily log recording peak expiratory flow data until delivery. Three peak-flow assessments were recorded after which the best value was entered into the log. Asthma was diagnosed by a health professional. Participants were also required to record asthma symptoms, exacerbations, medications, and cigarette use. To increase participation, subjects were reminded by telephone to complete their log. Data analysis showed that peak expiratory flow (PEF) was variable as a function of particular trimesters. Peak air flow was highest during the second trimester, with a statistically reliable difference between the second and third trimester. Unfortunately, the small sample size limits the generalisability of the findings. However, the study was based on a longitudinal design, allowing tentative causal inferences. Schweigert et al (2000) reviewed the literature on the role of industrial enzymes in occupational asthma and allergy. Enzymes used by detergent manufacturing companies (e.g. amylases, cellulases) are toxicologically benign, with mild irritation effects on the body. However, these enzymes do affected asthma and allergy. Thus, the industry is required to adhere to exposure guidelines for these enzymes. Kitch et al (2000) considered literature on the histopathology of late onset of asthma (i.e. onset in adulthood), and whether allergic exposure and sensitivity have the same impact on asthma development in adulthood as they do in children. Epidemiological studies suggest that the prevalence of asthma in older adults aged 65years or more is between 4% and 8%. The illness appears to be more common in women, especially those with a long history of smoking, and with respiratory symptoms (e.g. cough, wheeze, shortness of breath). Asthma in adulthood often developed before the age of 40, with maximum incidence occurring around early childhood. Beyond the age of 20 years the incidence of asthma tends to remain stable through young, middle-aged, and older adulthood. Death rates in adults are generally lower than figures for children; â€Å"Mortality rates attributable to asthma among those aged between 55 and 59 years of age and 60 and 64 years of age were 2.8 and 4.2 respectively, per 100,000 people, the highest rates among all age groups† (p.387). However, as adults get older asthma is less and less likely to be identified as the main cause of death due to the increased incidence of other pathology. Epidemiological research in Japan highlights a link with air pollution (International Archives of Allergy Immunology, 2000). The prevalence of asthma among kindergarten and elementary school children has increased steadily since the early 1960s, rising from 0.5-1.2% between 1960 and 1969, to 1.2-4.5% (1970-1979), 1.7%-6.8% (1980-1989), and 3.9-8.2% (1990 onwards). By contrast, data indicates little or no change in asthma prevalence amongst adults. Figures range from 1.2% in 1950-1959 to 1.2-4.0% (1960-1969), 0.9-5.0% (1970-1979), 0.5-3.1% (1980-1989) the 1960s to 1.6-2.9% (1990 onwards) (see Figure 3). Asthma in Japanese children is more common amongst boys than girls although this gender difference has diminished noticeably since the 1960s. Asthma usually appears in infancy or early in childhood but has been known to begin across all age groups. Inherited (genetic) dispositions to allergies have been implicated in the onset of asthma. There is normally a strong correlation between asthma onset and a family history of asthma. Overall, asthma-related mortality in Japan has decreased since the mid 1990s. Delays in seeking treatment and rapid exacerbation of symptoms have been strongly implicated in asthma mortality. Unfortunately, this article offers little information about the designs of studies reviewed. Inferences regarding the possible causes of asthma morbidity and mortality may be inconclusive if much of the evidence is derived from cohort studies, rather than case control studies that more effectively eliminate alternative causes. The premenstrual period in women has been implicated in asthma exacerbation. Tan (2001) reviews epidemiological literature suggesting that female sex-steroid hormones may be significant in understanding the premenstrual-asthma link, albeit the available evidence is tenuous. The luteal phase of the menstrual cycle is associated with airway inflammation and hyper-responsiveness, and hence may explain asthma exacerbation during the premenstrual phase. However, this increase in asthma severity can still be treated effectively using the normal drugs. Studies suggest that premenstrual asthma affects the rate of hospital admissions – the majority of adults admitted are women, indicating that hormonal factors play an important role. Other evidence suggested that emergency presentations increased before ovulation. It is suggested that oral contraceptive pills or gonadotrophin releasing hormone analogues may be especially effective treatments. However, premenstrual asthma was rarely associated with serious mortality. Unfortunately, most of the studies reviewed were retrospective and questionnaire based, and hence subject to response bias. There was a paucity of randomised control trials, or pseudo experiments that may permit causal inferences. Court et al (2002) considered the distinction between atopic (extrinsic) asthma, common in younger people, and non-atopic (intrinsic) asthma, found mostly in older groups. Additionally, they also considered whether identification of asthma cases in epidemiological research should be based on a doctor’s diagnosis or self-reported asthma symptoms. Nearly 25,000 people in England were surveyed. Data was collected regarding whether participants had experienced wheezing in the past 12 months and/or had been diagnosed as asthmatic by a doctor. People with atopic asthma were more likely to have experienced wheeze and been diagnosed as asthmatic in the past, compared with the non-atopic group. Logistic regression analysis showed that gender, social class, smoking status, living in an urban/rural area, and house dust mice (HDM), were all risk factors for the presence of wheeze both with (age not significant) and without (urban/rural area not significant) a diagnosis of asthma. Wheeze/asthma was more prevalent in women, younger people, lower social classes, previous/current smoking, living in an urban area, and greater HDM IgE levels. Smoking status, social class, and age were all risk factors for wheeze in both atopic and non-atopic cases. Gender was also a risk factor for atopic subjects, and urban living for non-atopics. Other research has considered the epidemiology of severe or ‘refractory’ asthma, which is rather less well understood compared with milder forms of asthma. Wenzel (2003) reviews evidence indicating that severe asthma (defined as asthmatics requiring continuous high-dose inhaled corticosteroids or oral corticosteroids for over half of the preceding year) may account for circa ≠¤ 5% of asthma cases. Data from a large Australian-based study, which has followed a large cohort of asthmatics for over three decades, implicates childhood pulmonary problems with reduced lung function in adulthood. Data suggests that over two-thirds of severe asthmatics were afflicted with asthma in childhood. Other risk factors implicated include genetic mutations (in the IL-4 gene and IL-4 receptor), and environmental factors (e.g. allergen, tobacco exposure, house dust mite, cockroach and alternaria exposures), respiratory infections (e.g. pathogens like chlamydia), obesity, gastroesophageal reflux disease, increased body mass index, lack of adherence to corticosteroid regimes, and poor physiological response to medication. Physiological factors are also implicated, notably structural changes in airway reactivity, inflammation of the peripheral regions of the lungs. Steroids are the main form of treatment. Tan et al (2003) demonstrated the role of respiratory infection in patients with severe (i.e. near fatal) asthma, acute exacerbations, or chronic obstructive pulmonary illness (COPD). Participants had all been diagnosed as asthmatic by a physician and were undergoing treatment. All showed evidence of forced expiratory volume in 1 second (FEV1) increase of 200mL. COPD patients were suffering from chronic cough and dyspnea, with a predicted FEV1% 50%, with no ÃŽ ²-agonist reversibility. Near fatal cases were patients undergoing ventilatory support in the intensive care unit of a hospital (National University Hospital and Alexandria Hospital, Singapore) as a result of a severe exacerbation. Acute asthma subjects were characterised by non-improvement following administration of ÃŽ ²-agonists, and/or severe exacerbation judging from clinical/blood data. Analysis showed that near-fatal cases were the least likely to have the influenza A + influenza B virus, but the most prone to have adenovirus and picornavirus, compared with the other two groups (see Figure 4). This suggests that viral infection may be a risk factor for severe asthma. However, due to sampling size/bias (n= 68), and failure to control for key background variables (e.g. asthma history, smoking history, prior medication use, and outpatient spirometry), the findings can be considered tentative. Smyth (2002) reviewed epidemiological studies on asthma in the UK, and worldwide. The number of new asthma cases seen by GPs has increased noticeably since the mid 1970s. Nevertheless, asthma incidence has tended to decrease since the early 1990s, consistent with data from the Office for National Statistics (2004). By the year 2000 circa 60-70, 40-50, 20-25 new cases (per 100,000 of a given age group) were reported amongst, respectively, preschool children, 5-14 year olds, and people older than 15 years. Significant ethnic differences have been reported, with high asthma prevalence in Afro-Caribbean children. Since 1962, the number of preschool children hospitalised for asthma rose steadily, then peaked in the late 80s and early 90s, and has begun to decline since. The hospitalisation rates in 1989 were 90/10,000 (preschool children), 30/10,000 (5-14 year olds), and 10/10,000 (15 years or older). By comparison the rates for 1999 were 60/10,000, 20/10,000, and 10/10,000 respectively ( see Figure 5). The British Thoracic Society identifies specific benchmarks or ‘best practice’ which health professionals are required to meet when caring for asthma patients (BTS, 2004). These recommendations are mostly based on scientific evidence from RCTs, epidemiological studies (cohort and case-control), meta-analytic reviews, and other good quality research. The recommendations related specifically to the following topics: Diagnosis and assessment in children and adults (e.g. key symptoms, recording criteria which justified diagnosis of asthma); Pharmacological management (e.g. use of drugs [inhaled steroids, ÃŽ ²2 agonist] to control symptoms, prevent exacerbation, eliminating side effects, employing a ‘stepwise’ protocol for treatment); Use of inhaler devices (technique and training for patients, agonist delivery, inhaled steroids, CFC vs. HFA propellant inhalers, suggestions on prescribing devices); Non-pharmacological management (e.g. breast feeding and modified milk formulae for primary prevention, and allergen avoidance for secondary prevention, alternative medicines); Management of acute asthma (initial assessment, clinical features, chest x-rays, oxygen, steroid treatment, referral to intensive care) Asthma in pregnancy (drug therapy, management during labour, drug treatment in breastfeeding mothers); Organisation and delivery of care (e.g. access to primary care delivered by trained clinicians, regular reviews of people with asthma, audit tools for monitoring patient care after diagnosis); Patient education (e.g. action plans, self-management, compliance with treatment regimes). Overall, despite these guidelines, recent research suggests that patients’ treatment needs are not being met. For example, Hyland and Elisabeth (2004) report data on the unmet needs of patients. Focus groups were organised between parents, patients, and clinicians. Patients and parents reported various needs that weren’t been met including frequent exacerbations, and a preference for less complex drug regimens (i.e. with fewer drugs). Many individuals had worries regarding treatment and experienced asthma symptoms 3 or more days per week. As Levy (2004) suggests, there is a need for health professionals to address these concerns, especially in relation to the BTS guidelines. Levy, a GP and Research Fellow in Community Health, identified current deficiencies in the care of asthma victims. These comprised: Higher than expected exacerbations (42/1000 patients per year); Under-diagnosis: more patients presenting for treatment with uncontrollable asthma, who had not been diagnosed previously; Deficiencies in treatment uptake: many patients fail to collect their prescriptions; Many patients with symptoms delay presenting for treatment, until their medical situation becomes critical; Health care professionals are failing to assess patients objectively (PEF, oximetry), both pre- and post-treatment; Failure to adhere to national guidelines for the care of acute asthma (e.g. not enough oral steroids and ÃŽ ²-agonists are prescribed for patients presenting with asthma attacks. Considerable variations across GPs, NHS Trusts, clinics, and other sources of care provision: patient follow-up appointments range from a few days to six months, in direct violation of standards set by the British Thoracic Society (BTS, 2004). Levy suggests various strategies for improving asthma care including diagnosis criteria (e.g. â€Å"any patient with recurring or respiratory symptoms [cough, wheeze, or shortness of breath], or who has been prescribed anti-asthma treatment should be considered to have asthma† (p.44)), use of computerised templates, having systems or triggers in place for recalling patients (e.g. patients requesting more medication, or who have been seen out of hours), introducing more effective protocols for monitoring and informing asthma patients (e.g. using a checklist to ascertain various key information on patients status, such as effects of asthma on patients life, recent exacerbations), providing written self-management plans (e.g. how to detect uncontrolled asthma, using PFM charts), and having an agreed procedure for managing acute asthma attacks (e.g. selecting a low threshold for using oral steroids). Currently there is a lack of research testing the value of these recommendations on asthma health outcomes. However various strategies are continually being implemented in various parts of the country to improve the quality of asthma care. For example, Holt (2004) describes the effects of implementing the RAISE initiative, launched by the National Respiratory Training Centre, in a primary care setting. This scheme is designed to raise awareness of existing variations in standards of care, improve standards of care through education, support, and feedback, increase awareness and understanding of respiratory disease, use asthma as platform to demonstrate the value of shared experiences across different agencies/professionals, and augment the profile of primary care settings as the main source of asthma care and innovation. The RAISE led to various improvements, such as: The use of ‘active’ and ‘inactive’ asthma registers, to distinguish patients who currently have asthma symptoms from those who don’t. Introduction of computerised templates to improve accuracy and reliability of data recording during consultations (e.g. progressing sequentially from assessment of symptoms, to peak flow, inhaler, and advice stages). Use of symptom questionnaires (e.g. handed out with repeat prescriptions) that help patients with well-managed asthma decide whether they can opt for a telephone consultation, rather than taking the trouble to visit the practice for a face-to-face consultation. Haggerty (2005) identifies several factors paramount to effective care and management of asthma in UK patients. These comprise adequate patient education about the nature of asthma (e.g. number of asthma episodes, use of quick relief medicines, long term symptoms, restrictions on daily activities, and emergency visits), use of asthma action plans, and customised treatment plans (to achieve early control), and addressing patients own concerns and perception. Treatment for asthma is usually in the form of regular inhaled corticosteroids (ICS), oral corticosteroids (OCS), and ÃŽ ² agonists. These treatments are usually administered by a health professional when symptoms manifest and/or become severe. However, since asthma can often exacerbate rapidly, before an individual can seek medical help, it is vital that asthma patients receive the necessary care from health professionals, and also self-management skills. GPs and nurses play a critical role. Griffiths et al (2004) conducted a randomised control trial to assess the effect of a specialist nurse intervention on the frequency of unscheduled asthma care in an inner city multiethnic clinic in London. The role of specialist nurses in asthma care has been uncertain. Interventions in which specialist nurses educate patients about asthma, after hospital attendance with acute asthma, were shown to have inconsistent effects on unscheduled care. However, outreach initiatives to educate medical staff had shown no effect. Thus, an intervention was designed that combined patient education with educational outreach for doctors and practice nurses. It was suspected that such an integrated approach would benefit ethnic minority groups, especially given their higher hospital admission rates and reduced access to care during asthma exacerbation. The key research question was whether specialist nurses could improve health outcomes in ethnic minority groups. Outcome variables were the percentage of patients receiving unscheduled treatment for acute asthma during a 12 month period, and time to first unscheduled attendance with acute asthma. The study was based on 44 practices in two east London boroughs. Participants comprised over 300 patients (aged 6 to 60) who were admitted to or attending the hospital, or the out of hours GP service with acute asthma. Half the sample were classified as South Asians, 34% were Caucasian, while 16% were Caucasian. The intervention was based on a liaison model. Practices were assigned to either a treatment or control condition. Practices randomised to the treatment condition ran a nurse led clinic involving liaison with GPs and practice nurses, incorporating education, raising the profile of guidelines for the management of acute asthma, and providing on-going clinical support. In practice these practices received two one-hour visits from a specialist nurse who discussed guidelines for managing patients with acute asthma. Discussions were based on relevant empirical evidence. A computer template was provided to elicit patient information on various treatment issues, such as inhaler technique and peak expiratory flow, and offer self-management advice. By contrast, control practices received a visit promoting standard asthma care guidelines. Data analysis showed that the intervention lengthened the time to first attendance (median 194 days for intervention practices, and 126 days for control practices), and also reduced the proportion of patients presenting with acute asthma (58% treatment practices versus 68% in control practices (see Figure 6). These effects were not moderated by individual differences in ethnicity, albeit Caucasians seemed to benefit more from the intervention compared with minority ethnic groups. O’Connor (2006) noted that asthma care in the UK remains below the required standards. The majority of the 69,000 hospital admissions and circa 1400 deaths annually are attributable to poor patient adherence to treatment regimens. Nurses, it is argued, play an important role in promoting adherence. Additionally, use of a new inhaled corticosteroids – circlesonide – may also help increase adherence. Circlesonide is much easier to use than more established asthma drugs (e.g. it has a once-daily dosing). Evidence is reviewed suggesting that peak expiratory flow remains stable when patients are given circlesonide compared with a placebo. Tsuyuki et al (2005) assessed the quality of asthma care delivered by community-based GPs in Alberta, Canada. They reviewed clinical charts for over 3000 patients from 45 primary care GPs. Of this number 20% had ever visited an emergency department or hospital, 25% had evidence that a spirometry had been performed, 55% showed no evidence of having received any asthma education, 68% were prescribed an inhaled corticosteroid within the past 6 months, while a very small minority (2%) had received a written action plan. Figure 6 shows percentage of participants receiving medication. Sixty-eight percent were prescribed an inhaled corticosteroid, 11% were given an oral corticosteroid, and 80% received a short acting ÃŽ ²-agonist, while 8% were prescribed a long acting ÃŽ ²-agonist. Participants with an emergency room/hospital event were (marginally) more likely to be prescribed medication (no group differences in use of short acting ÃŽ ²-agonists). Regarding pulmonary testing, 25% had evidence of a pulmonary function test (not peak flow), 46% had peak flow monitored, 34% showed no evidence of pulmonary function tests, while 26% had an x-ray. Again individuals with an emergency room/hospital event were more likely to be tested (see Figure 7). Data about education received by patients was also evaluated. Twenty-two percent received information about environmental triggers, 20% on inhaler use, 10% on how to perform a home PEF test, 2% on written action plans, while 55% received no education at all. Those with an emergency room/hospital event were more likely to receive education. Receiving asthma education, use of spirometry, and prescription of inhaled corticosteroids, were all predicted by number of asthma-related clinic visits (4 or more) and having an emergency room/hospital event. Additionally, asthma education was predicted by cormorbidities, and absence of documentation regarding asthma triggers, while use of spirometry was predicted by being a non-smoker, and symptoms or triggers. Finally, use of inhaled steroids was predicted by symptoms. Overall, this study highlights numerous gaps in the care provided by GPs, partly echoing criticisms of GPs in the UK (Levy, 2004). For example, Levy (2004) cited ‘under

Wednesday, November 13, 2019

Exploitation in Child Beauty Pageants :: Argumentative Persuasive Essays

Exploitation in Child Beauty Pageants It is 6:00 a.m. on Friday morning, and Sharon is about to awaken her eighteen month old baby, Jessica, to prepare her for a long weekend of make-up, hairspray, and gowns. Jessica is one of the thousands of babies forced into the many children's beauty pageants each year. Sharon is among the many over-demanding parents who pressure their young and innocent children into beauty pageants each year and this is wrong. Beauty pageants were started many years ago but became more prominent in the society in 1921, when a hotel owner started a contest to keep tourists in town past Labor Day. The winner of this contest would be called Miss America. Miss America pageants have been a yearly event ever since then, except during the Great Depression. Then, in 1960, pageants were getting so popular that a Little Miss America was started for parents who wanted their children in beauty pageants (Nussbaum). Children's beauty pageants are judged by the following: modeling sportswear and evening wear, how well they dance, and how much talent they have. The children themselves are judged by their looks, how well they perform, and how confident they appear. Approximately 250, 000 children participate in pageants each year. Mothers who have their children in beauty pageants say that their children gain confidence through performing. They also say that they are more prepared for life and will be more socially comfortable. They argue that their children mature at a younger age than "normal" children do. Why would any parent want their children to grow up any faster than they already do? Beauty pageants are not the only way that a child at such a young age can gain confidence. The only confidence that a child at eighteen months needs to gain is eating on her own, standing up on her own and the confidence that her family loves her. If these children have and learn these three things, they will most likely have great self-confidence. On the other hand, take the child who loses the pageant, for example. There are visible effects that the child shows if she loses; she then thinks less of herself and thinks she has let her parents down because she did not place first (Christman). Parents also conclude that children who participate in beauty pageants may receive scholarships (Gleick). Beauty pageant scholarships are not the only scholarships available.

Monday, November 11, 2019

Liquidity Ratio Essay

In this case study, our main purpose is to analyze the company financial statements and investigate the effects of financial analysis announcements on the stock price from 2000 to 2004. Besides that, we concerned about the financial management or strategy in the company and how are they sustaining their company growth and expected earnings in the stock market. We also discuss about the company financial analysis and competition in the industry. 2. 0Case Study Summary Krispy Kreme Doughnut operation was started in 1937 when the founder of Kripsy Kreme, Vernon Rudolph began making doughnuts from a special recipe he bought from a French chef. Then, Krispy Kreme was so well-known and it expanded from a wholesale enterprise to an addition of Krispy Kreme’s retail operations and franchising. Rudolph focused on excellent quality of doughnuts and customer service. The result was always good when it was under the control of Rudolph. After Rudolph’s death, Krispy Kreme was acquired by Beatrice Foods and its priority was to earn profit. Beatrice encouraged additions to the menu and changed the original recipe and logo of Krispy Kreme to cut cost. Unfortunately, the business went down Beatrice decided to sell it. In 1982, the new owner of Krispy Kreme, Joseph McAleer bought Krispy Kreme by using leverage. Joseph maintained back the original logo and recipe of Krispy Kreme. One of the priorities of Joseph and Krispy Kreme focused on hot and fresh doughnut. In 1989, Kripsy Kreme was free from debt and began to expand. In 1996, doughnuts and added branded coffee were their main focus. In year 2000, Kripsy Kreme went public and the initial share price reached $40. 63. After going public, the corporation was planning aggressively to increase the number of stores and enter international markets. The revenues of Krispy Kreme Doughnuts were generated from n-premises sales, off-premises sales, manufacturing and distribution of product mix and machinery and franchise royalties and fees. In May 2004, Krispy Kreme announced three major adverse results for the first time as a public company. Firstly, the company suffered loss due to the trend of low-carbohydrate diet. Secondly, it planned to divest Montan a Mills and would be charged. Thirdly, the company planned to close three of its new Hot Doughnut and Coffee Shops. These announcements made the shares closed down by 30%. In year 2003, SEC announced that Kripsy Kreme was too aggressive in acquiring franchise. The practice of Krispy Kreme acquiring Michigan franchise was so wrong. The company recorded the interest income on past-due loan from Michigan as immediate profit and the purchase cost on Michigan as intangible asset and did not pay off. In the same time, the company was being charged due to the quitting of the Michigan’s top executive. The shares of Krispy Kreme fell for another 15% due to the announcement from SEC. SEC published another report stated that Krispy Kreme was facing the problem of growing too fast and the company was too rely on the profits made from manufacturing and distribution of franchise equipment. Strengths Krispy Kreme is a well-established and long running company. It has a strong and consistent consumer base in United State and abroad. Krispy Kreme is a nationally well known consumer brand because the company offers product that is second to none regarding on the taste, freshness and the finest ingredients. The company has consistent expansion and growth. Currently, the corporation has 395 stores with the presence in 40 states in United State and in 16 foreign countries. Krispy Kreme gains the most popularity in grocery, convenience stores and retail outlets due to easy accessibility to the product. The corporation offers more than 20 different types of doughnuts and other menu items including of coffee and bakery items. They are also selling those collectable memorabilia such as mugs, hats and toys. Besides that, Krispy Kreme introduced the neon sign of â€Å"Hot Doughnuts Now† because it offers variety of freshly made doughnuts with high quality everyday. Krispy Kreme is also the first corporation that cut a hole in its factory’s wall to sell its fresh doughnuts directly to the customers. Krispy Kreme is a vertically intergrated company with three business units which are company store operations, franchise operations and supply chain operation. They produce doughnuts in a cost effective manner because of the using of an accelerated approach. Thus, Krispy Kreme has a high capacity of production because each factory stores could produce 4000 dozen to 10000 dozen of doughnuts in a single day. In addition, Kripsy Kreme also differentiated itself with the others by offering customers an experience to see the production of doughnuts. 3. 1. 2Weaknesses Krispy Kreme has the following weaknesses which is the low inventory turnover ratio. If not attended to quickly the firms supply line will continue to cost more money and reduce future profits. Next, the financial condition of Krispy Kreme is better compared to its competitors but does have some areas that need improvement. Krispy Kreme’s young management is showing that they want to be alert and have employed an almost zero tolerance policy regarding debt. Poor management or financial practices hurt reputation and stock prices of this company. Limited amount of â€Å"healthy† menu selections, limited â€Å"non-breakfast† menu items 3. 1. 3Opportunities International expansion gives better returns to company. Krispy Kreme can grab the chance to expand its business and enter into new markets like Asia countries because Asians love sweet goods and they are open to trying foreign foods. The popularity of Western brands in these markets is quiet high.

Saturday, November 9, 2019

English Literature Coursework Essays

English Literature Coursework Essays English Literature Coursework Essay English Literature Coursework Essay To explore this question I am going to examine how Shakespeare creates and maintains dramatic tension in Act One Scene Five.This is a pivotal scene in which Romeo and Juliet meet for the first time and fall in love.I am going to discuss the servants busy preparations for the party, Romeos passionate soliloquy on first glimpsing Juliet, Tybalts recognition of Romeo and his subsequent anger and Romeo and Juliets horrified reactions at discovering that they are enemies.I am also going to study Shakespeares use of language and imagery, his use of Elizabethan sonnet form and the social and historical context of the play.To start with, I am going to mention that at the end of the preceding scene, Romeo has a premonition. He foresees his own death.Romeo:This would mean that the tension level is already quite high, as a consequence of this scene ending with such a sense of foreboding. This tension is relieved somewhat by the actions of the servants.The servants busy preparations for the banq uet create dramatic tension in that they are frantic and loud. The tension is initially created, and maintained, while the servants shout and call each other. They create an impression of disorder and a sense that everything is speeding up.Servant 1:The servants speeches are written in blank verse, which contrasts greatly with the lyrical words of Romeo and Juliet and also with that of Lord Capulet and Tybalt.The scene then moves on to Lord Capulet welcoming his guests to the party. He is in a good mood and greets his guests warmly. This causes the tension created by the servants to dissipate slightly and the audience can relax a little. Lord Capulets speeches are very flamboyant and full of life. A festive atmosphere is rapidly established.Lord Capulet:His speeches are full of noble language that contrasts greatly with the coarse language used by the servants previously.The next event in this scene is when Romeo first sees Juliet. Her beauty stuns him.Romeo:His language is very ric h and even nobler than that of Lord Capulet. At this point in the scene, we see the tension rising again as Romeo sees Juliet and instantly falls in love with her. However, as his speech goes on, the tension evens out, as the audience settle into Romeos sudden love for Juliet.He then goes on to speak ten lines about Juliets beauty and how incomparable she is to Rosaline. Her beauty stuns him.Romeo:It is through Romeos language that Shakespeare shows that Romeo is of a noble birth, and this distinguishes him from the servants. His language is also very intense, which makes the audience believe that he is sincere in his love of Juliet. Also Shakespeares subtle use of rhyme causes us to see how pure and real his love is, as Romeos soliloquy is written in rhyming couplets.The tension is raised now because of the audiences awareness of Romeo being a Montague, and Juliet being a Capulet. The audience gets to see them fall deeply in love with each other, with them totally unaware of their respective identities. The audience knows that when they do discover each others identities, they will be horrified and that the consequences cannot be good.Immediately Romeo finishes waxing lyrical about Juliet, we hear Tybalt in a furious rage because a Montague is at the Capulet party.Tybalt:His sudden rage and fury at seeing Romeo causes the dramatic tension to soar as the audience anticipate his actions. His violent, forceful language contrasts greatly with Romeos gentle, sweet words. However, Lord Capulet intervenes and Tybalt is halted before he can act on his anger. He argues with his uncle because he wont let him fight Romeo, because it would spoil the party. Their dispute is heated and the tension steadily rises.Tybalt:Lord Capulet:Their language is violent and aggressive which would cause the audience to sit up and take notice of the strong emotions involved.The tension drops when Tybalt obeys his uncle and agrees not to act on his anger that night. He does however leave a lingering tension with the threat.Tybalt:In other words, he shall seek revenge at another time, just to please his uncle. It is with these words that he exits the scene. This leaves the audience at a loss as to what is coming next. This would cause an increase in tension because of eager anticipation for the next installment of the blooming romance.The next section of the scene is where Romeo and Juliet meet and share their first (and second) kiss. Their language is the key point when explaining how Shakespeare creates an isolated bubble around the pair of lovers. They speak lovingly to each other, and lots of references to religion and faith are made. They talk about holy shrines, blushing pilgrims and holy palmers. However the majority of what they say is concerning the body. They speak of two blushing pilgrims meaning lips and their hands touching as holy palmers kiss. These references to religion and faith are used to simulate images in the audiences minds, of purity and since rity.They seem to exist only for each other, and are isolated and set apart from the rest of the party. This separation is defined by their gentle, loving language, which contrasts with the violent, bustling activity of the party.At this point in the scene, their conversation is written in sonnet form. In Elizabethan times the sonnet was the most popular form of poetry. They were usually written as love poems, to the writers beloved. The audience of the time Romeo and Juliet was written would have understood this, and it would have been a clear message to them that Romeo and Juliet were talking about love. This form of poetry also ensures that Romeo and Juliet seem to be moving in a world of their own.Just after they are separated, Romeo discovers that Juliet is a Capulet, his enemy, and the dramatic tension reaches its peak.Romeo:Not long after Romeo discovers their enmity, Juliet finds out for herself. This only prolongs the high level of dramatic tension.Juliet:Their reactions ar e ones of despair and horror. They dont understand how they could each have fallen in love with their only enemies. Their despair is only short-lived because they each know that, despite the barrier created by their enmity, their love is pure and absolute.Juliet:This is Juliets way of saying that if Romeo is married; she would die because it would break her heart. This emphasises just how deeply they have fallen in love with each other.Then at the end of the scene, Juliet is called to her mother, and the build up of dramatic tension is dissolved.Shakespeare also uses his extensive control of the English language to control the dramatic tension. Using violent language during the heated argument between Lord Capulet and his nephew, and sacred, religious words during the first meeting of Romeo and Juliet. He uses rhyme to emphasise the emotions behind a moment. The servants speak in blank verse, which shows them as low class people using common, coarse language. Romeo speaks in rhyming couplets when he first sees Juliet, this would encourage the audience to take notice of what is happening, and creates an impression of Romeo as a nobleman.Such uses of language and rhyme would have had to be used because in Elizabethan times, there would have been no sophisticated props or such like. Shakespeare had to use different styles of language to differentiate between classes and characters.Throughout this crucial scene, the level of dramatic tension fluctuates. Shakespeare ensures this by using strong contrasts- the noise and frivolity of the party, and the gentle, quiet love between Romeo and Juliet.Shakespeare uses various techniques to ensure the dramatic tension is maintained throughout this scene. One of these techniques is to use contrasting language and imagery. Also to use different rhyme schemes to display different feelings.In my opinion William Shakespeare is a very talented writer and has used his mastery of the English language to manage the dramatic tension throughout Act One Scene Five. English Literature Coursework Essays English Literature Coursework Essay English Literature Coursework Essay Life is the farce that everyone has to perform (Arthur Rimbaud). Explore your different responses to this statement with reference to the structure, form and characters of Noises Off. How far do you agree that the disintegration of the farce Nothing On is mainly a means to comment on the human condition? One could interpret Rimbauds statement as analogous to that of the insinuated, deeper reference of Michael Frayns Noises Off, due to human life sharing similar elements as the convention of comedy that is farce. Life is like a drama, full of isinterpretation, unanticipated events and tragedy. This view aligns with Arthur Rimbauds statement; although, one could easily argue that Frayns meta-farce structure was in fact a device used in order to satirise the acting industry, an impeccable example of this satirisation is Lloyds excessive use of the word love , this repetition could conceivably be used to exaggerate and highlight actors and actresses insincerity. Michael Frayn has experienced the anarchy that develops behind closed doors on an acting set, and this disputably elevates the play from a farce to an intricate, multi-layered theatrical experience. Another interpretation could be that that Noises Off needs no deeper reading as a common definition of farce is a ludicrous, hollow show; a mockery. When examining whether Noises Off intends to relate to the human condition, the structure of Frayns work can not be neglected. The meta-farce structure used by Michael Frayn is arguably integral in reflecting human nature and life, conjointly, this is most evident in Act One as Nothing On slowly begins to disintegrate through misinterpretations and disorder. The structure of the play creates depth, therefore when disarray does arise, such as the disappearance of Selsdon in Act l, Garry: Selsdon! We cant find him! , proceedings have to be adjourned which also causes Noises Off to be disrupted. This is very much comparable to life, because as one event occurs, this could lead to a detrimental effect on other affairs and it postpones future matters. On the other hand, it could comfortably be argued that Frayn does not intend to create a locus in which the reader should etch away the surface of the structure and read more thoroughly. This is apparent as ultimately Noises Off is a farce. Had Michael Frayn intended to convey the similarities between farce and the uman condition, then perhaps an essay format would have been more appropriate which means that we can only assume that his intentions were to evoke laughter from his audience. A device that could be argued as being utilised by Frayn to portray the human condition within Nothing On is the revolving stage. The stage allows the audience to get a full perspective of the farce without any interruptions, and it is this device that is likened to Carl Jungs persona mask theory. The characters within the play have to depict a certain role to the audience which masks them from their true being and it s not until the stage has revolved 180 degrees that we as the spectators are granted access to their real nature and the mask is unveiled. Typically, this is similar to human life as people have to put on a show to impress their peers and appear in control, but ultimately when they are alone or in their comfort zone, people allow their mask to slip. This can be depicted from Arthur Rimbauds view by his use of the term performed when describing life. Alternatively, it could be argued that Frayn used the revolving stage in order to convey the actors unprofessionalism and the omplete turmoil that occurs behind closed doors on an acting set in order to create shock and laughter. Perhaps the revolving stage has no deeper meaning that relates to human condition as the proposed masks are Just traits of our character that may be rendered as false by other beings. Characterisation is pivotal in an attempt to illustrate lifes formalities and surprises in Noises Off. In Act One, Selsdon says Sixty years now and the smell of the theatre still haunts me, this is in response to Poppy who nearly offends him by implying he smells. This is acutely comparable to the comedic convention of wordplay as Poppy oesnt actually say Selsdon possesses an undesirable odour, if you stand anywhere near Selsdon, you cant help noticing this very distinctive but is instead is interrupted by him before she can completely offend. This is incredibly funny as it creates awkwardness between Selsdon and Poppy. Obviously Selsdon is one of the more senior members of the cast and should theoretically be wiser from his experiences, although that is not the case. Arguably Frayn is implying that it does not matter how accomplished you may be in certain aspects of life, your lifetime will be ull of consternations and revelations that can not be prepared for. Again, this adds to the validity of Rimbauds assessment as farce incorporates highly improbable plots situations and exaggerated characters which is similar to what human beings can perceive as life. In contrast, it could be contended that Selsdons dialogue has no broader meaning and is in fact Just used to create an awkward situation. It could also be argued that the writer intended to stereotype Selsdon as an actor who is coming to the end of his career, is no longer concerned with his profession and is seemingly oblivious to his surroundings. The use of complications in Nothing On, such as the actors troubles with the opening and shutting of doors, could be considered a key component by Frayn as a means to comment on the human condition. We see throughout almost the entirety of Act One and Act Two, the predicament that the doors cause. whilst Brooke and Garry enter through the doors on the upper stage, Belinda and Fredrick exit through the lower stage doors in perfect time and sequence. This evokes laughter from the audience as it creates confusion throughout the cast who are oblivious to each others presence, and ultimately this excites the audience as it eludes to the rogression of a riotous event, in typical slapstick comedy style. Furthermore, within the noumenal of Noises Off it depicts the doors as a gateway backstage which allows the audience to see the true nature of the actors and additionally utilised by Frayn as a vehicle for satire. While one cant argue against the fact that Frayn intended the play to be a riotous event, the potential for deeper reading when examining the doors can not be ignored. It is possible that Frayn used the doors as a device to symbolise them as a portal to another world and point of view, implying that veryone incurs implications when attempting to follow new paths in life, Just as the actors have difficulties trying to open and shut the doors. The form in which Michael Frayn presents the disintegration of Nothing On through his use of common components of farce such as broader physical humour and the use of props suggests that his prime intention was to elicit amusement from his spectators. The use of slapstick comedy and misplacement of props in Nothing On is especially funny as it creates uncertainty within the cast which ultimately leads to further complications and adds to the riotous event that is to entail. A leading example of this would be Dottys (Mrs. Clackett) ineptitude to take or replace the sardines at the correct instances Mrs Clackett: What I did with the first lot of sardines I shall never know, also we see in Act I Fredricks pants fall down which arouses laughter from the audience as it generates awkwardness and this is a key component of farce. By Act 3 the destruction of Act I of Nothing On is almost complete, and the significance of this is arguably commensurate to the human condition. The disintegration of Nothing On could have stemmed from the actors inability to erform the intelligible task of replacing props, and this comments on human life in the sense that misunderstanding can lead to feelings of anger and Jealousy during which, things escalate out of control. In conclusion, it is apparent that Michael Frayn did indeed intend to evoke laughter from his audience through the use of typical farce components, such as the violence that occurs in Act 2 which almost leads Noises Off into taking a more tragic narration, although whether it was unintentional, the more Michael Frayn attempts to reflect aspects of life itself through Noises Off, the more it succeeds in the intention to create humour.

Wednesday, November 6, 2019

The News Entries Should Each Refer To Something Important That Is

The News Entries Should Each Refer To Something Important That Is The News Entries Should Each Refer To Something Important That Is Currently Happening In The World – Coursework Example News Entries Obama hits 50% approval rating in Poll The news article is about a recently released poll results in relation to the rating of the United States of America president Barrack Obama. The polls were conducted by new Washington Post-ABC News poll in December. The current survey ratings are considered as the highest since a similar poll was conducted in 2013. Thus, the polls indicated that president Obama’s rating had hit 50%. This was considered as a relief to the Americans who are keen in how the president will address the key issues that affects them as a state. The polls were conducted as a result of voters granting Republicans authority over the senate and an increased GOP majority in the U.S. House. According to the polls the ratings of president Obama improved considerably as a result of perceived good economic improvements. In addition, the poll reflected a further sharp divide among the Americans along Democratic and Republican lines. However the article gave more hope of the two sides of the political divide to overcome their political differences and pave way for political stability and tolerance in the United States. It was therefore evident that President Obama’s ratings had greatly improved since November 2014 as a result of the president’s zeal in resolving such issues as immigration and climate change within the context of United States. According to the polls the ratings of president Obama could further improve in future if he successfully addresses various issues that affect the Americans. In addition, the unity and political stability among the Republicans and Democrats is crucial in the American politics (David, 2015). David, Jackson, Obama hits 50% approval rating in poll. USA today, 19th January, 2015. Retrieved on 19/01/2015 from: usatoday.com/story/theoval/2015/01/19/obama-approval-rating- washington-post-abc-news-50-percent/21987691/

Monday, November 4, 2019

Marketing plan Essay Example | Topics and Well Written Essays - 500 words - 4

Marketing plan - Essay Example The application of these media would facilitate the building of a loyal customer base. The products of Pizza Restaurant are Pizza and other food items. However a lot of the customers like to spend their time in the restaurant because they like leisure and entertainment activities. Therefore the critical factor is to design a message that will appeal to the emotions of the customers. The message should communicate the exciting features that are offered by the restaurant. One possible message can be: Pizza Restaurant delivers the best products in town. This simple message will appeal to the emotions of the customers, particularly when delivered through attractive audio-visuals. Such a message broadcast online and through TV can communicate to the mass market and create an emotional appeal for Pizza Restaurant. Answer to Question 2 The most important element is the positioning strategy. Implementing an effective positioning strategy will enable Pizza restaurant to emphasize upon the uni que quality of its products and services (Armstrong and Kotler, 2005). Since the restaurant will be targeting customers most of whom are from rich families, the critical success factor is to create a unique positioning within the minds of the customers (Fred, 2006).

Saturday, November 2, 2019

Factors an Organization Needs To Consider When Developing a Global Assignment - 1

Factors an Organization Needs To Consider When Developing a Global Staffing Strategy - Assignment Example This paper illustrates that the global staffing strategy would incorporate the perspectives of the people as to how they view the entire working mechanism of the world and what the different nations bring to the fore with their respective working realms Hence creating and eventually developing a global staffing strategy is a Herculean task if seen within the proper scheme of things as it cultivates a sense of trust and empathy within the region where the headquarters are located. The expatriates working within the different nations of the world is an enticing opportunity for the staffing avenues that have shaped up with the passage of time. The global staffing strategy with regards to these expatriates gets its basis from the management hierarchies which are present within the organization itself. It is their decision to find out how the organization will have its own staff situated at the different locations worldwide, where it exists to satisfy the varied customers. What is interes ting to note here is the fact that these people who are recruited could either be from the locations where the office domains have been set up or recruited from the headquarters themselves. The need is to select and hire people who understand the dictum of the organization more than anything else, and this can only be done through an understanding which is based on the collective understanding of the global staffing strategy which has been in place now for some amount of time. If the right people get hired at the different locations where the business is run, this would mean that the entire organization would benefit as a result of the same. However, if this is not the case, then the global staffing strategy would implicate to a failure without a doubt, and this would mean that the recruiting issues have not been resolved in an amicable fashion. The role of the human resources management departments within the headquarters and the separate locations all around the world are signific antly more so because they perform tasks which could be easily replicated across the board if proper vision and a sense of purpose exist. If there is a lack of such visionary elements, then this would suggest for a lack of comprehension on the part of the global staffing strategy that has been adopted by the organization.