Crystal Starfish Ornament or Decoration

Gem Starfish Ornament or Decoration Develop gems on a little starfish to make a shimmering precious stone starfish adornment or improvement. Precious stone Starfish Materials You can develop any precious stone arrangement on the starfish, including borax, salt, alum, Epsom salt and sugar. Borax is pleasant in light of the fact that the precious stones become for the time being and add a humble shimmering appearance to the starfish. Likewise, these precious stones endure capacity and pressing between occasions very well. little dried starfishstringjar sufficiently large to hold the starfishstringhot waterborax (e.g., 20 Mule Team Borax The most effective method to Grow Crystals on the Starfish Tie a string or bit of nylon angling line to the starfish. Cause certain the starfish to can hang in the container without contacting the side or base. You can fold the string over a pencil or spread blade to control its length. Expel the starfish from the container.Mix an answer of hot or bubbling water and borax. Continue blending in borax until it quits dissolving. This will be the point at which a limited quantity of strong material stays in the base of the container.Pour this arrangement into the jar.Suspend the starfish in the fluid. Make certain it is lowered, yet not contacting the container. Permit the precious stones to develop for a few hours or overnight.Remove the solidified starfish from the fluid and hang it to permit it to dry. That is it! You can utilize it as a vacation adornment or other decoration.You can store the starfish by wrapping it delicately in tissue paper to shield it from residue and moistness. Tips and Tricks Borax permits the characteristic shade of the starfish to appear. Be that as it may, on the off chance that you need to include shading, you can. Just include a limited quantity of food shading when you blend the borax and water. The food shading doesn't shading the gems, however it will color the starfish.Try developing gems on little shells. Youll have the best accomplishment with permeable shells since they give spots to the gems to append and develop. More Crystal Holiday Decorations Borax Crystal SnowflakeCrystallized Holiday StockingCrystal Paper SnowflakesMore Holiday Ornament Projects

3rd Disease Papers

third Disease Papers third Disease Papers Bio 2 Sickness Papers third Term 11/20/12 Simmons seventh Period 7-01 Prakash Akula Rabies is an amazingly fatal infection transmitted by the spit of tainted creatures. Some regular creatures local to the United States are skunks, raccoons, bats, foxes, coyotes. By and large once somebody is determined to have rabies its close to deadly. Rabies is known to not have clear indications, however when the manifestations show up its close to the finish of its cycle. A few manifestations incorporate cerebral pain, fever, sleep deprivation, parietal loss of motion, unreasonable salivation, tension, fomentation, mental trips, trouble of gulping, hydrophobia. In uncommon cases if a contaminated creature has rabies and licks an open injury you can contract rabies from that creature. Some different pets that can contract rabies are dairy animals, felines, hounds, ponies, goats, hares, and ferrets. Other wild creatures can contract rabies too including beavers, monkeys, and woodchucks. At the point when somebody is chomped by a creature there is know method of knowing whether th at creature has rabies. What a specialist can do is take tissue and blood tests to check whether you have been presented to rabies. There are no evident medicines of rabies, however in the event that you are found to have been nibbled by a creature with rabies then you will be given numerous shots. On the off chance that you do have rabies you will be given five shots over the genuine of fourteen days. A few different ways to be certain you don't get rabies is to immunize your pets, guard your creatures from wild creatures, keep bats out of your home hold, keep your pets kept, don't move toward wild creatures, lastly take the rabies immunization in the event that you are making a trip to be protected from everything. Parkinson’s Disease Parkinson’s Disease Is a confusion where the sensory system is influenced and adjusts your development. It can simply begin with one scarcely observable jerk. In pre phases of parkinson’s ailment you can see possibly slurred discourse and the adjustment of your arms when strolling. A few manifestations incorporate tremors, eased back development, discourse changes, hindered pose, loss of developments, inflexible muscles. There has been look into that says Parkinson’s ailment can be gone down through hereditary qualities. Another causes could be poisons noticeable all around or work source that can achieve Parkinson’s infection. Specialists have likewise discovered little bunches of substances inside synapses that are attached to Parkinson’s malady. Youth once in a while are found with Parkinson’s infection, yet in the event that its found in the family, at that point its normal to be seen later on throughout everyda y life. It’s found that guys are bound to have Parkinson’s infection then ladies. In the event that you do have Parkinson’s ailment, at that point you may likewise experiance bladder issues, rest issue, sexual brokenness, thinking challenges, blockage, and melancholy. There are no tests that can determine you to have this malady, yet a specialist can determine you to have Parkinson’s illness dependent on your side effects and clinical history. There are prescriptions not to fix Parkinson’s illness, however to mitigate the side effects of Parkinson’s infection. Since specialists don't have the foggiest idea where Parkinson’s sickness originates from that point are no avoidances that are unequivocal. There has been some reasearch that caffine can decrease the danger of creating Parkinson's. A few people likewise state that back rubs and needle therapy can help the side effects of this infection. Cystic Fibrosis Cystic Fibrosis is an exceptionally lethal confusion wherein the lungs could be seriously harmed including the stomach related framework. Cystic Fibrosis is conventionally acquired and influences the cells that make stomach related juices, bodily fluid, and sweat. Cystic Fibrosis makes bodily fluid, sweat, and stomach related juices clingy and thick. The manifestations differ contingent upon how much its advanced in your body. Some respiratory side effects incorporate wheezing, lung diseases, stodgy nose, continuous hack that produces sputum, diminished capacity to work out. Stomach related side effects incorporate oily amazing solid discharges, unbearable blockage, poor weight increase and development, and meconium ileus in babies. The reason for

Chinese Cinderella Essay Topics

Chinese Cinderella Essay TopicsChinese Cinderella stories are a universal phenomenon that could be used as the basis for an essay topic. Sometimes this is the most difficult part of the writing process as you will find yourself getting lost in an ocean of information on the rich and famous or suffering through a bevy of American celebrity biographies. However, with a little research and planning you can narrow down your research to a few top choices for the topic that is most likely to be of interest to you.An English Cinderella story has little to do with the everyday lives of the rich and famous and most of the time it is the ordinary people who have to battle against great odds to keep their lives intact. Thus, I've listed some of the most common areas of study for an essay on Chinese Cinderella stories. Once you have your list in hand, you can begin your research from there. For example, let's say you are particularly interested in the life of Disney's Chinese Cinderella, so you might want to go back to the drawing board and look at her Disney film counterparts.Chinese fairy tale movies are far more diverse than ever before. Today's Chinese producers are producing some really good cinema but there still seems to be something missing. The focus has been shifting towards western mythologies. This makes for a refreshing change of pace and one which I believe can certainly appeal to many college students.Chinese essay topics are also popular nowadays but again, there seems to be something missing when compared to the Disney films. While I will admit that this is a huge contrast in perspective, there does seem to be a tendency towards an ahistorical approach which is far removed from the more educational nature of fairy tale literature.With that said, I would like to propose the creation of an essay on Chinese essay topics based around the lives of two recent Chinese celebrities. We all know that Jennifer Chen and Xiaoxiao are two very different people who repre sent a fascinating fusion of culture and artistry. Let's look at how we might use these two stories to illustrate a variety of issues relevant to today's essay topic.For example, what about a joint Chinese actress and model essay that give a look at how China is going about its task of creating a more international image and how one artist and the other model are combining forces to promote it? Consider how this topic might play out when the artist's art is exhibited, and how it might impact the fact that many of her fans from abroad now feel more at home in this region of the world.Another good way to employ these topics is to use them to illustrate the differences between Chinese actors and actresses and their American counterparts. If you can, consider how the American actors are generally getting more press here in the West and they are not given the opportunity to share their talent with the wider world. Rather, they are expected to perform within their cultural conventions whi ch is not necessarily the case for Chinese actors.These are just a few examples of Chinese essay topics that can be used to make the material more interesting. In short, let's take our times and do some digging!

Chapters Take Away - 1283 Words

OVERVIEW OF CHAPTER In this chapter, how management thought has evolved in modern times and the central concerns that have guided ongoing advances in management theory are explored. First, the classical management theories that emerged around the turn of the twentieth century are examined. Next, behavioral management theories developed before and after World War II are examined, and then management science theory, which developed during the second World War. Finally, the theories developed to help explain how the external environment affects the way organizations and managers operate are examined. LEARNING OBJECTIVES 1. Describe how the need to increase organizational efficiency and effectiveness has guided the evolution of†¦show more content†¦Taylor believed that by increasing specialization and the division of labor, the production process would become more efficient. †¢ According to Taylor, the way to create the most efficient division of labor could best be determined by scientific management techniques, rather than intuitive or informal rule-of-thumb knowledge. He developed four principles to increase efficiency in the workplace. Principle 1: Study the way workers perform their tasks, gather all of the informal job knowledge possessed by workers, and experiment with ways of improving task performance to increase efficiency. Time and motion studies were one of Taylor’s main tools. Principle 2: Codify the new methods of performing tasks into written work rules and standard operating procedures. Principle 3: Carefully select workers so that they possess the skills and abilities that match the needs of the task and train them to perform the tasks according to the rules and procedures established in step two. Principle 4: Establish a fair or acceptable level of performance for a task and then develop a pay system that provides a higher reward for performance above the acceptable level. †¢ By 1910 Taylor’s system of scientific management had become nationally known, but some managers implemented the new principles selectively, resulting in problems. DissatisfiedShow MoreRelatedCry, The Beloved Country By Alan Paton1155 Words   |  5 Pageswhen the book was written. Strong examples of this come across in the choral chapters of the novel. These chapters give voice to the people of South Africa. Chapter nine shows the struggles of being black during apartheid, chapter 12 shows the white citizens racism and fear, and chapter 23 shows the goals of social movements. 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The Experience Of Interning At Ey - 962 Words

I had the opportunity of interning at EY from June 3rd to August 3rd, 2015. I interned in the Baltimore office with 26 other interns as a part of the Assurance service line. Over the course of the internship, I had the opportunity to attend regional training for interns in Washington D.C. in addition to a service line training, lasting a total of 5 days combined. We received general information in training about the company, their mission, organizational structure, and employee expectations. The training that covered the service line was very extensive and structured. We learned about the expectations for auditors during an engagement as well as how to work some of the EY programs used during an audit so that we would have a better idea of how to complete assigned tasks while working on the clients we were scheduled to work with. Additionally, they also answered important questions about how to interact with a client and explained the importance of independence. The first client I wa s assigned to was a healthcare provider with about 4 hospitals as subsidiaries. The client was at its year-end and the audit team was at the beginning stages of the audit. Being on this client for approximately 3 weeks, I was able to learn a lot on this engagement. One of the main responsibilities that I had for the first week was rollforward of documentation in addition to summarizing meeting minutes. I learned that rollforward procedures with certain documentation saves the auditors a lot of

The Effect of Electronic Journals on Scholarly...

The Effect of Electronic Journals on Scholarly Communication In recent years, scholarly communication has virtually exploded into the on-line electronic world. This has brought a number of demonstrable benefits to the scholarly communication process as well as highlighting a number of inefficiencies and obstacles to the full deployment of information technology. However, the explosion has also brought a spate of credulous accounts concerning the transformative potential of information technology. These accounts, though well intentioned, do not contribute to a sociological understanding of information technology in general, or its effect on the scholarly communication process more specifically. In order to develop our understanding of†¦show more content†¦In addition, there are a number of initiatives designed to reproduce classic and modern texts by digital imaging or SGML [2] markup. [3] The EJS has experienced similar growth. From sporadic access to the WWW server just over a year ago when the journal was founded, we are now viewed by over 1500 individuals each month from 38 countries around the world. Most documents are served to the United States, Canada, Australia, Germany and Sweden. However access by other countries is steadily increasing. [4] Curiously though, the EJS remains virtually the only journal devoted to sociology on the internet. At the time of this writing, the Yahoo index [5], generally considered the most comprehensive index for the WWW, of Sociology Journals contains two listings. One is for the Electronic Journal of Sociology and the other for a Hungarian journal entitled Replika. In this paper, I will provide an overview of the issues surrounding the emergence of electronic journal publication while attempting to relate them to our experience at the Electronic Journal of Sociology. Some of these issues are straightforward and include the direction in which e-publication is moving, the benefits of electronic publication, and the obstacles to its full deployment. These I will deal with in the first two sections of the paper. However there are currents in the emerging debates which are strongly reminiscent of the popular and semi-academic eulogies to theShow MoreRelatedThe Teen Sleep Loss Epidemic : What Can Be Done? Essay806 Words   |  4 PagesBryant, N. B., Gà ³mez, R. L. (2015). The teen sleep loss epidemic: What can be done? Transla-tional Issues in Psychological Science, 1(1), 116-125. doi:10.1037/tps0000020 This scholarly journal article deliberates the necessity of sleep and the phenomenon that adolescent children are suffering from a lack of sleep. The loss of sleep can negatively af-fect a teenager’s academic performance, driving capabilities, cognitive abilities and more. 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Employment Relations

Question: Write an essay on Employment relations. Answer: Employment relations are vital as it is directly proportionate to the success of the organization. The management within the company thus needs to implement the effective strategy to maintain positive employment relations within the workplace. The employment relations also help the company to change the behavior of the employee within the business which adds as an added advantage towards the company as a whole. The effective implementation of the labor law within the workplace also helps the company to gain quality productivity and thus help to increase the potentiality of the employee within the workplace (Al Rajhi et al. 2012). As per the UK labor law, the relations between the employees, labor, and the employer, as well as the trade unions, help the company to increase the profit sale of the company and thus help in gaining competitive advantage as well. The UK labor law claims towards the right to equality of the employee within the company. The right of the employee provides equality to the labor regarding right to wages within the company. The Labour law thus claims for the right to labor equality and helps in labor equity as well. The labor law of UK also helps the labor regarding the time regulations within the business which helps the company to retain more labor within the business as well. The Employment Rights Act also helps the labor within the company to take a leave for the child care (Holgate et al. 2012). Thus, the various effective implementation of law helps the company to retain labors and also help in employment relation as well. UK Labour Laws: The UK labor laws within the company help the labor to gain equality within the workplace. This helps the company to provide equal opportunity towards the labor and thus help in gaining productivity of the company as well. The Pension Act also helps the labor to get a basic occupational law which helps in providing security to the labor and thus help in retaining more employees within the business as well. The UK labor law also provides Employment rights to the labors which provide the labors with the leave for the child care and thus help in attracting more loyal employees within the company (Hutchinson 2012). The UK labor laws thus help in protecting rights of the employees as well. Saudi Aramco implements effective Labour Law, which helps the business to retain more labor within the business. The company implements the effective strategy to build a strong employment relation and thus help in gaining competitive advantage in the international scenario (Twomey 2012). This helps the company to retain more loyal employees within the company and helps in sustainability as well. The effective strategy also helps the company to motivate more labors within the workplace and thus add value towards the brand name of the company as well. The brand value of the company also helps in developing the satisfaction level of the consumers and thus improves the economic structure of the company as a whole. The satisfaction level of the labors plays a vital role in considering the employment relations within the company which further help the company to avoid any dispute within the workplace as well. This helps the company towards the technological development and advancement whic h further helps in the employment relations within the business as a whole. Factors that impact towards the employment relations: The Saudi Aramco implements various effective employment strategies that get influenced towards the development of the corporate as a whole. Thus, the various internal and external factors influence the employment relations within the workplace (Wanrooy et al. 2012). Internal The internal factors of the company Saudi Aramco gets influenced by conflicts within takes place due to grievance of the employees and the labour within the business. The demographic factors like education, sex and age also affects the employee relations and thus led the organization towards developing the employee relations as well. The skills of the employee also help the company to increase the productivity and thus help in the development of the company as well (Shutes 2012). The internal factors of Saudi Aramco also get influenced through nature of workforce within the business and thus led to improve the employee relations within the workplace as a whole. External- The external factors within the workplace also get influenced by various perspectives which led the company towards the development as well. The external factors thus gets influenced by technology which stand as a barrier towards the organizational development. The business always need to get updated by the advanced technology and thus retain its position in the competitive market (Hecker 2012). The continuous change of the market conditions also affect the profitability of the company and thus the business gets challenge in every step of development as well. The social and political changes also led the business to suffer a set back and thus effect the employment relations within the business as a whole. Different types of employment Status: As per the UK Labour Laws the workplace thus involves the various types of employment status. The employment status thus includes the worker or labour within the workplace, the employee of the business, the director and the office holder of the company as a whole. Thus, the employment status thus helps the company to improve the internal structure and also helps the employee towards achieving development as a whole. The various employment status also help the company Saudi Aramco to improve the infrastructure of the business which further helps the business to gain competitive advantage in the market (Huws and Podro 2012). The workers within the workplace thus also help the business to improve the quality of increased productivity and thus help the employee to gain satisfaction as a whole. The UK labour laws also state that the employment status helps the business to increase the rate of profit margin as well. Importance of individuals employment status: The employment status plays a vital role in considering the profit growth of the business and helps the business to gain sustainability as well. The labour within the workplace helps the business to gain loyal workers. As per the Labour Law of UK the workers also get equal rights within the workplace which further helps the business to increase the rate of productivity (Wilkinson and Wood 2012). The employee within the workplace also helps the business to avoid dispute and thus help to increase the employee retention rate as a whole. The director of the company also helps the business to get updated with the new technology and thus help the business to penetrate easily in the international market as well. The office staff also helps the business to increase the sales rate through effective productivity and thus help the company to gain growth rate in the market as well. The employee status thus helps the business to gain advancement and also helps the organization to compete easily in the market with competitors (Van Wanroo et al. 2012). The various employment statuses also help the company to overcome all challenges in the market and thus lower the employee turnover rate in the market as a whole. This helps the company also to expand its market in the international scenario and thus helps in increasing the profitability in the competitive market. Importance of work life balance: The work life balance is important within the workplace in order to satisfy the need of the employees. This also helps Saudi Aramco to retain more loyal employees within the business with improved productivity. Working hours- The importance of the working hours also helps the employees to stay loyal towards the business and thus help in the organizational development (Hartley and Stephenson 2012). The flexible working hours also help the employee to satisfy their basic needs and thus help them to input their best talent within the workplace as well. The flexible working hours also help the employees within Saudi Aramco to maintain their family and social life which further helps the business to retain its position with increase rate of employee satisfaction as a whole. Holidays- Holidays are also regarded as the important factor in influencing more employees within the workplace. Employee need to enjoy compensatory holidays within workplace which helps the employees to gain more satisfaction towards the business as well. As per the rules of UK Labour laws Saudi Aramco Ltd also need to provide holidays to the labor on Saturday and Sunday which helps to put more efficient effort towards improved productivity de (Graaf-Zijl 2012). Workers within the company also need to enjoy Annual holidays, Casual leaves, Medical leaves, Gazette holidays and Festival holidays which help to motivate more employees towards the organization and thus help in gaining positive employee relations as well. Rest periods- The rest periods for the employee need to be fixed by the company to fain satisfaction of the employee as a whole (McGovern et al. 2012). The workers and the employees within Saudi Aramco also need to enjoy 45 min lunch break and Namaz break including two 15 min tea break as well. All these benefits help the company to enjoy employment relations which add profitability to the company as a whole. Maternity Leave: As per the UK Labour Laws, the maternity leave needs to be provided to the pregnant women serving Saudi Aramco. This helps the company to gain positive impact of the women towards the company and also helps to retain more employees within the workplace as well. Women need to get at least two weeks before the expected date of delivery and also need to be provided with four weeks normal delivery or abortion leave with full pay which is based on the average weekly or regular wages within the workplace (Lieber 2012). Paternity Leave: The parental leave helps the company Saudi Aramco to retain more loyal employees and workers who help the individual to enjoy longer parental leave with extra financial assistance. The parental leaves also help the corporate to motivate the employees more towards increasing the productivity within the organization and thus help the company to gain profit rate in the market (Gallie et al. 2012). Adoption Leave: The adaption leave helps the employees to overcome the challenges in their family life and thus help to lead a happy and normal life. This also helps the parents and the children to enjoy a quality time which further helps Saudi Aramco to motivate more employees towards the organization. UK labor Laws also states that the adoption leave helps the employee to increase the quality of the productivity (Collins et al. 2012). This helps the company to have the positive impact towards the employee and helps in gaining employment relations within the workplace as a whole. Dependants Leave: Depend on leave refers to the reasonable time off by the workers or the employee where and individual need to help the family, friends or dependents in case of emergency. This helps the employee to satisfy their basic needs and thus help to retain with positive employee relations. Importance of equal pay: The equal pay strategy helps the organization to gain employment relations which help in further profitability and retention strategy within the workplace. The equal pay also helps the employee within Saudi Aramco to enjoy equal benefits which help in motivating employees within the company. As per the Labour Laws of UK, the equal payment structure needs to be implemented within the organization to have the positive impact towards the employee relations (Alvesson and Willmott 2012). The equal pay also helps the employee to output effective and improved efforts more towards the productivity of the company as a whole. This helps the company to increase the rate of sales in the market as well. The equal pay structure is also important to avoid dispute within the workplace and also helps to abide the workers under the UK Labour Laws as well (Williams and Nadin 2012). It helps to avoid race discrimination and thus helps in retaining loyal employees within the organization as well 2.4 Equalities legislation: Direct or indirect discrimination: The equal discrimination stated under the Equality Act 2010 refers to the gender discrimination within the organization. The direct discrimination also refers to the individual who is treated badly within the workplace due to the sexual orientation of the employee or the workers. This led the employee towards direct discrimination by the company as a whole. The direct discrimination affects the employee benefits and salary of the employee or the workers (Arnold and Bongiovi 2012). It also affects the retirement of the labor or employees within the business and thus deals to direct discrimination. As per the UK Labour Laws, the employee needs to enjoy equal benefits which help Saudi Aramco to have the positive impact towards employee relations. The indirect discrimination also deals towards the bisexual individual, Gay or lesbian and thus affects the employee relations with the management in the organization. Saudi Aramco as the UL Laws needs to avoid any kind of direct and indirect discrimination. Harassment: The discrimination stated by UK Labour Laws avoids any kind of harassment within the workplace which helps the organization as a whole to retain employees and workers within the company as well. The harassment might deal with the sexual harassment which disrupts the productivity and security of the employee which further affects the satisfaction of the employee within the workplace (Chandra 2012). Saudi Aramco needs to implement laws that help the employee to feel secure and comfortable to work with the company as a whole. Victimization: Victimization is the problem which is faced by the employee or workers mostly within the workplace. According to the Labour Laws of UK, it states that the bullying may lead the employee towards depression which affects the productivity of the company (Benach et al. 2012). Saudi Aramco needs to implement the effective strategy to avoid victimization and helps to develop employment relations as well. Psychological Contract: The psychological contract also leads to the unwritten expectation of the employee towards the organization and the employer expectation towards the employee as well. The psychological contract as per the Labour Laws of UK states that the psychological contract gets influenced through social changes which affect the expectation of both the parties to a great extent (Pot et al. 2012). The policies and procedures thus remain untold, but implementation and maintenance help the company to retain employees and maintain positive employment relations as well. The various policies and procedures stated by the UK Laws help to maintain a transparent communication within the workplace. It also helps to motivate employees and thus attain employee satisfaction. This also helps the employee to retain the implementation of commitment by the company which helps in increased productivity and profitability as a whole. Difference between fair and unfair termination: The termination or discrimination by the company may lead the employee or the workers towards the unfair dismissal of the employee (Appelbaum 2012). As per the UK Laws, the fair discrimination leads the employee to terminate the ineffective employee which affects the productivity of the organization. The unfair discrimination may lead the employee towards the court for justice which affect the brand value of the company and Importance of Exit interviews: The exit interviews conducted by the organization help the employer to analyze the issues within the workplace, and it helps the company to improve the need for the employee as well. The importance of the exit interview thus plays a vital role in considering the employer improvement which further helps in the improvement of the skills and potential of the employee as well. According to the UK Labour Laws, the exit interview thus helps the employer with a platform for further development and helps in retaining efficient employee or workers within the workplace (Spence and Hlatshwayo 2012). The exit interviews also help the employee to create a transparent communication with the management which helps the employee to gain trust and thus might get retain within the organization as well. The exit interview also helps the employee to improve the work culture as well as the areas that create a constraint for the continuation of the employee within the workplace. Thus, it helps the employee to gain motivation and might also help in retention of the employee as well. Stages towards managing redundancy: The company with effective implementation of the UK labors Laws manages redundancy through certain strategies which involves: Preparation The preparation refers to the need of the process before starting and also helps to analyze the time management for implementing the strategy. Selection The selection helps the workplace to select fair individual within the company which further helps in improvement of the potentialities of the employee as well. Individual Consultation The consultation also helps the employee to realize the importance of the selection (Appelbaum 2012). This also helps the employer to analyze the importance and also consider the alternative of the individual within the workplace. Redundancy notice and Appeals The redundancy helps the employee through written information regarding the redundancy and thus helps to appeal as well. Termination The termination helps the employee to get the information regarding the redundancy payment as well. The employees with two years of experience also help the employee with written record and thus help the employer with transparent communication as well. Impact of redundancy: The redundancy helps the company towards the employee relations regarding keeping updated the employee through written record of every activity within the organization (Spence and Hlatshwayo 2012). The impact of redundancy also helps the company to inform the employee regarding the profitability of the company which further helps to gain employee satisfaction as well. Thus, Saudi Aramco with effective implementation of UK Laws helps the employers to retain more employees. Conclusion: The employment relations also help in gaining quality production of the employee which helps the business to gain the competitive advantage in comparison to the competitive market. The UK labor law also provides right to equal wages of the employee and helps in providing wages to the labor as per the performance. The effective labor law also helps the company towards the development of employee relations. This further helps the company to sustain its position in the market and thus helps in gaining competitive scenario as a whole. Reference List: Al Rajhi, A., Al Salamah, A., Malik, M. and Wilson, R., 2012.Economic Development in Saudi Arabia. Routledge, 12(1), pp. 34-39. Alvesson, M. and Willmott, H., 2012.Making sense of management: A critical introduction. Sage, 44(1), pp.77-94. Appelbaum, E., 2012. Reducing Inequality and Insecurity Rethinking Labor and Employment Policy for the 21st Century.Work and Occupations,39(4), pp.311-320. Arnold, D. and Bongiovi, J.R., 2012. Precarious, informalizing, and flexible work: Transforming concepts and understandings.American Behavioral Scientist, p.0002764212466239. Benach, J., Puig-Barrachina, V., Vives, A., Tarafa, G. and Muntaner, C., 2012. The challenge of monitoring employment-related health inequalities.Journal of epidemiology and community health, pp.jech-2012. Chandra, V., 2012. Worklife balance: eastern and western perspectives.The International Journal of Human Resource Management,23(5), pp.1040-1056. Collins, H., Ewing, K.D. and McColgan, A., 2012.Labour law. Cambridge University Press, 12(1), pp.28-35. de Graaf-Zijl, M., 2012. Job satisfaction and contingent employment.De Economist,160(2), pp.197-218. Gallie, D., Zhou, Y., Felstead, A. and Green, F., 2012. Teamwork, skill development and employee welfare.British Journal of Industrial Relations,50(1), pp.23-46. Hartley, J.F. and Stephenson, G.M.E., 2012.Employment relations: The psychology of influence and control at work. Blackwell Publishing, 72(1), pp.124-132. Hecker, D.E., 2012. Occupational employment projections to 2012.Monthly Lab. Rev.,127, p.80. Holgate, J., Abbott, S., Kamenou, N., Kinge, J., Parker, J., Sayce, S., Sinclair, J. and Williams, L., 2012. Equality and diversity in employment relations: do we practise what we preach?.Equality, Diversity and Inclusion: An International Journal,31(4), pp.323-339. Hutchinson, J., 2012. Rethinking workplace bullying as an employment relations problem.Journal of Industrial Relations,54(5), pp.637-652. Huws, U. and Podro, S., 2012.Outsourcing and the fragmentation of employment relations: the challenges ahead. Acas,32(2), pp.62-74. Lieber, L.D., 2012. Considerations for attracting and retaining a qualified, diverse workforce.Employment Relations Today,38(4), pp.85-92. McGovern, P., Hill, S., Mills, C. and White, M., 2012. Market, class, and employment.OUP Catalogue, 43(1), pp.55-63 Pot, F., Dhondt, S. and Oeij, P., 2012. Social innovation of work and employment. InChallenge Social Innovation(pp. 261-274). Springer Berlin Heidelberg. Shutes, I., 2012. The employment of migrant workers in long-term care: dynamics of choice and control.Journal of Social Policy,41(01), pp.43-59. Spence, M. and Hlatshwayo, S., 2012. The evolving structure of the UK economy and the employment challenge.Comparative Economic Studies,54(4), pp.703-738. Twomey, D., 2012.Labor and Employment Law: Text Cases. Cengage Learning, 22(1), pp.64-76 Van Wanrooy, B., Bewley, H., Bryson, A., Forth, J., Freeth, S., Stokes, L. and Wood, S., 2013.Employment Relations in the Shadow of Recession: Findings from the 2011 Workplace Employment Relations Study. Palgrave macmillan,34(2), pp.88-94. Wanrooy, B.V., Bewley, H., Bryson, A., Forth, J., Freeth, S., Stokes, L. and Wood, S., 2013. The 2011 workplace employment relations study: first findings, 43(1), pp.78-84. Wilkinson, A. and Wood, G., 2012. Institutions and employment relations: The state of the art.Industrial Relations: A Journal of Economy and Society,51(s1), pp.373-388. Williams, C.C. and Nadin, S., 2012. Work beyond employment: representations of informal economic activities.Work, Employment Society,26(2), pp.1-10.

Drug Abuse In America Essays - Anabolic Steroids,

Drug Abuse In America Dangers of Anabolic Steroids In the past three decades, steroids has been becoming a serious problem more than ever in the athletic field. Steroids are anabolic drug to build growth hormones that include the androgens (male sex hormones) principally testosterone and estrogen and progestogens (female sex hormones). Steroids were first developed for medical purposes. They're used in controlling inflammation, strengthening weakened hearts, preventing conception, and alleviating symptoms of arthritis and asthma. Unfortunately research has shown that steroids have been abused in almost every kind of sport. Although steroids contribute to a muscular body, usage should remain illegal because they physically deteriorate and mentally destroy the body. Many people are fascinated about steroids because of their ability to build up the body. Whether taken by injection or the pill it increases strength and endurance. Steroids also help in the healing process of muscular tissue by first injuring them, then the muscles heal quicker adding more fiber increasing their bulk. Many athletes turn to steroids more often because they're cheaper then marijuana or cocaine. A ten week cycle of testosterone cypinate and methandrostone costs only about one hundred dollars. Steroids are also very hard to trace because of their water base composition. They can pass through the body within two days. All these benefits of steroids help an athletes become more competitive and increase their chance of being a winner. Of course everybody wants better biceps and triceps but when using steroids to achieve this goal there is a large price to pay. However, steroids should remain illegal because they physically deteriorate the whole body system. When injected one risks the chances of developing hematoma and contracting AIDS. In women steroids contribute to the growth of facial hair, enlargements of the clitoris, shrinkage of the uterus, sterility, deepening of the voice, decrease in breast size and irregularity of the menstrual cycle. In men steroids cause shrinkage of the testicles, decrease in sperm count, sterility, impotence, prostate enlargement and growth of female breast. In both men and women hair loss, liver ailments, acne, atherosierosis and cancer are very common. This dangerous drug shortens the life span up to twenty years and increases the chance of obtaining diabetes, cardiovascular diseases and hypertension. The side effects and reactions from enduring anabolic steroids are endless. Along with the physical problems there are also mental reactions associated with the usage of steroids. This drug becomes very addictive and damaging to the mind. It causes violent episodes which an athlete can claim a legal insanity defense to it. They get so wrapped up psychologically that the negative effects doesn't matter to them. Research has also discovered that steroids cause psychotic side effects sometimes referred to as roid mania. Along with these are wild aggressive, combative behavior, depression, listlessness and delusions during and after performance. Even though the game is over athletes want to continue competing. Steroids mentally destroy the brain and ability to reason. Overall the usage of steroids is very damaging to the human body. Even though it physically builds up the body for better performance the risks of use are enormous. Steroids physically deteriorate and mentally destroy the body. The usage of steroids provides an unfair advantage to non-user athletes and therefore should remain illegal for non-medical use. Social Issues Essays

Active Transport Essays - Cellular Respiration, Metabolism

Active Transport Essays - Cellular Respiration, Metabolism Active Transport Since the cell membrane is somewhat permeable to sodium ions, simple diffusion would result in a net movement of sodium ions into the cell, until the concentrations on the two sides of the membrane became equal. Sodium actually does diffuse into the cell rather freely, but as fast as it does so, the cell actively pumps it out again, against the concentration difference. The mechanism by which the cell pumps the sodium ions out is called active transport. Active transport requires the expenditure of energy for the work done by the cell in moving molecules against a concentration gradient. Active transport enables a cell to maintain a lower concentration of sodium inside the cell, and also enables a cell to accumulate certain nutrient inside the cell at concentrations much higher than the extracellular concentrations. The exact mechanism of active transport is not known. It has been proposed that a carrier molecule is involved, which reacts chemically with the molecule that is to be actively transported. This forms a compound which is soluble in the lipid portion of the membrane and the carrier compound then moves through the membrane against the concentration gradient to the other side. The transported molecule is then released, and the carrier molecule diffuses back to the other side of the membrane where it picks up another molecule. This process requires energy, since work must done in transporting the molecule against a diffusion gradient. The energy is supplied in the form of ATP. The carrier molecules are thought to be integral proteins; proteins which span the plasma membrane. These proteins are specific for the molecules they transport. Chemiosmosis Populating the inner membrane of the mitochondrion are many copies of a protein complex called an ATP synthase, the enzyme that actually makes ATP! It works like an ion pump running in reverse. In the reverse of that process, an ATP synthase uses the energy of an existing ion gradient to power ATP synthesis. The ion gradient that drives oxidative phosphorylation is a proton (hydrogen ion) gradient; that is, the power source for the ATP syntheses is a difference in the concentration of H+ on opposite sides of the inner mitochondrial membrane. We can also think of this gradient as a difference in pH, since pH is a measure of H+ concentration. The function of the electron transport chain is to generate and maintain an H+ gradient. The chain is an energy converter that uses the exergonic flow of electrons to pump H+ across the membrane, from the matrix into the intermembrane space. The H+ leak back across the membrane, diffusing down its gradient. But the ATP synthases are the only patches of the membrane that are freely permeable to H+. The ions pass through a channel in an ATP synthase, and the complex of proteins functions as a mill that harnesses the exergonic flow of H ' to drive the phosphorylation of ATP Thus, an H+ gradient couples the redox reactions of the electron transport chain to ATP synthesis. This coupling mechanism for oxidative phosphorylation is called chemiosmosis, a term that highlights the relationship between chemical reactions and transport across the membrane. We have previously used the word osmosis in discussing water transport, but here the word refers to the pushing of H+ across a membra! ne. Certain members of the electron transport chain must accept and release protons (H+) along with electrons, while other carriers transport only electrons. Therefore, at certain steps along the chain, electron transfers cause H+ to be taken up and released back into he surrounding solution. The electron carriers are spatially arranged in the membrane in such a way that H+ is accepted from the mitochondrial matrix and deposited - the intermembrane space. The H+ gradient that results is referred to as a proton-motive force, emphasizing the capacity of the gradient to perform work. The force drives H+ back across the membrane through the specific H+ channels provided by ATP synthase complexes. How the ATP synthase uses the downhill H+ current to attach inorganic phosphate to ADP is not yet known. The hydrogen ions may participate directly in the reaction, or they may induce a conformation change of the ATP synthase that

Applications of EHR on Inpatient Nursing Essay Example | Topics and Well Written Essays - 1750 words

Applications of EHR on Inpatient Nursing - Essay Example This paper seeks to discuss application of electronic health record system in inpatient nursing. The paper will explore application of the technology in inpatient nursing’s assessment, medication, and documentation. It will also explore successful implementation of the electronic health record system and its importance in the scope of inpatient nursing. Application of electronic health record in documentation The core function of electronic health record is the development of a reliable information system for efficiency. This has led to transition, alongside technological developments, from a manual record keeping system to the electronic system through computer technology. The information system has further enhanced the health record system through networking involved instruments, departments, and personnel in the electronics record systems. Documentation is, as a result, one of the applications of electronic health record system through a variety of system applications that includes provision of information in facilities such as inpatient nursing facilities. The scope of documentation, based on its definition, includes recording of information and availing the recorded information for necessary use. The â€Å"nursing information system,† an incorporated system in inpatient nursing institutions is for example used in documenting information for administrative purposes (Carter, 2008, p. 4). The system manages all information relating to inpatients such as patient’s admission that provides relevant details of a patient to the hospitals system (Carter, 2008). Guite et al further explains that electronic health record is used to capture and communicate a patient’s details for determination of patients’ needs and evaluation of the patients’ utility while in the nursing facilities. Coordination also facilitates knowledge of patients’ needs among personnel on duty (n.d.). Documentation in electronic health record is al so used to facilitate management of information for timely discharge of patients and even transfer of patients to other facilities for specialized attention. Like in admission, documentation, through a centralized operated system facilitates inter departmental communication to relay the need for either discharge or transfer. Similarly, documentation as an element of electronic health record facilitates accounting aspects of health care institutions, a role that is achieved through recording and organization of financial transactions and communication of the information to managers for administration (Carter, 2008). Inpatient nursing facilities also use electronic health record’s documentation to facilitate direct personal communication among nurses through online chats for instant communication. The application of electronic health record in documentation is therefore based on its ability to develop a bank of necessary and relevant information to inpatient care and to communi cate such information to relevant departments and personnel for efficient operations and management. Standardized terms and systems for uniformity in documentation facilitate the efficiency by eliminating language based communication barrier (Carter, 2008). Application of electronic health record in nursing’s documentation is however subject to legal considerations that aim at preventing malpractices such as fraud. Such rules apply to both EHR technology developers and users in inpatient nurs

Marx's View of Material Abundance Essay Example | Topics and Well Written Essays - 250 words

Marx's View of Material Abundance - Essay Example Karl Marx demonstrates extremely negative attitude to the bourgeois type of society. He points out that the bourgeoisie has turned ordinary people, in particular workers in goods because they have has a market value and can be sold:In proportion as the bourgeoisie, i.e., capital, is developed, in the same proportion is the proletariat, the modern working class, developed—a class of labourers, who live only so long as they find work, and who find work only so long as their labour increases capital. These labourers, who must sell themselves piece-meal, are a commodity, like every other article of commerce, and are consequently exposed to all the vicissitudes of competition, to all the fluctuations of the market.The bourgeoisie can be seen as a huge mechanism that destroys all that hinders its market trade and the accumulation of capital. In this respect, Marx drew attention to the fact that the strengthening of the bourgeoisie led to the fact that society has become divided into two classes: a class of the poor and a class of the rich. The rich exploit the simple workers and as a result, they increase their capital and become even richer. In turn, the workers do not have the opportunity for capital accumulation, since they give their work and in return receive lower wages. Marx criticizes the unequal distribution of wealth because he believes that the society should be fair. This justice requires equal opportunities for all people as well as the removal of any social oppression that is observed in bourgeois society.

Statistics in Business Essay Example for Free

Statistics in Business Essay Statistics is the science of learning from data, and of measuring, controlling, and communicating uncertainty; and it thereby provides the navigation essential for controlling the course of scientific and societal advances. Statisticians apply statistical thinking and methods to a wide variety of scientific, social, and business endeavors in such areas as astronomy, biology, education, economics, engineering, genetics, marketing, medicine, psychology, public health, sports, among many. Statisticians provide crucial guidance in determining what information is reliable and which predictions can be trusted. They often help search for clues to the solution of a scientific mystery and sometimes keep investigators from being misled by false impressions. Some examples that statistics are used are Statistics also provide the reasoning and methods for producing and understanding data. Statisticians are specialists, but statistics demands they be generalists, too. One advantage of working in statistics is that you can combine your interest with almost any other field in science, technology, or business. Another is Studies of the environment require data on the abundance and location of plants and animals, on the spread of pollution from its sources, and on the possible effects of changes in human activities. The data are often incomplete or uncertain, but statisticians can help uncover their meaning. One last example is the future of many industries and their employees depends on improvement in the quality of goods and services and the efficiency with which they are produced and delivered. Improvement should be based on data, rather than guesswork. More companies are installing elaborate systems to collect and act on data to better serve their customers. Statisticians must know more than statistics. A statistician who works in medicine or in a manufacturing plant or in market research must learn enough medicine or engineering or marketing to understand the data in their setting. Statisticians need the ability to work with other people, to listen, and to communicate. References; http://www.amstat.org/careers/whatisstatistics.cfm

Grapes of Wrath :: Essays Papers

Grapes of Wrath: In the beginning of the novel The Grapes of Wrath, the Joads are faced with the challenge of traveling rout 66 all the way to California. This is their solution for being tractored off their land and having no way to support the large family. This challenge is similar to the depression in 1929, when many people lost their jobs, home, and their whole life. The last of the family, the few left in end of the book represent the survivors of the depression. I don’t believe that the ending was adequate because it could have stated the struggle much more dramatically to prove a stronger point. In the beginning of the Joads journey they have their arms ready with hope of a brighter life and a little over a hundred bucks. Their journey truly begins when they are tractored off the land by a man on a machine. â€Å" The man was an extension of the machine.† This quote demonstrates the loss of individuality; the man was nothing but a pawn in industrial game. Throughout the journey to California they run across many other people just like them, aiming for the same goal, California. This parallels to the depression again in how the large amounts of people, that were broke, hungry, and homeless, were all looking for the same goal, a better life. Ma’s quote, â€Å" Use’ ta be the fambly was fust. It ain’t so now. It’s anybody worse off we get, the more we got to do.† ,shows how the family lost it’s â€Å"fire† or strive. Ma is saying that even when the â€Å"fambly† was fussing about things they still were lively, unlike now, they have no motivation and they are in a dead state of overwhelmed foresight. Ma is doing all that she can to not only keep the family together, but also keep the family going in the right direction while dealing with her own issues of constant overwhelming defeat. The novel closes with Rosa of Sharon offering her dead baby’s breast milk to a stranger, the father of a boy the Joads found leaning over him. While committing the gesture a â€Å"mysterious† smile crosses her lips. These closing lines signify the Christian belief that Jesus gave holy communion, his own flesh and blood, like Rosa of Sharon gave her milk.

Shouldice Hospital Limited. Case Study Analysis

EXHIBIT 1 Acceltion,s Service Guarantee Quaury oF Srnvlcn GueneNTEE TheAccelIionQualitvofServiceGuaranteedefines,AcceI1ion,sassurance*, Ifj:r:fl†. ‘,f†,iljtm3;:ru:mlFj *-Hiri,†Ã¢â‚¬ Ã¢â‚¬  dil;;affi,. irn † 1. Perfonnance Guarantee a†ri,,iuo. , or'te-. *r,sea ne. â€Å"i,, is the same as Accellion guarantees that the performance of the. Net-work uproading and downloading content, Accellion service' will be no t*t p†. â€Å"*t of that w1n hich';;. hr;†*d by a benchmik origin as a resurt of usine the site being accessejfrom r. ‘ ‘r†Ã¢â‚¬ Ã¢â‚¬Ëœibii , ffi,ltji'fi ::,Ti:T:t ‘u p†Ã¢â‚¬Ëœf†Ã¢â‚¬ËœÃ¢â‚¬ Ã¢â‚¬ ilffi, p†,ro. *u,'†Ã¢â‚¬  *iTly*il? ::T::#? Jr:[:il:,:xHi. il:ilabilitv, 3.Customer Service -â€Å",****,L,;;tr o;;;,%li o, o†. ;r,o. ,. excludingForce Maieureand schedured Maintenance for customers Guarantee should Accellion fail to meet the service levels set out in section s 1 and 2 with one (L) month's service fee ror Accenion will credit ttre monttirir†Ã¢â‚¬ tua-*n†r,,n† r†,i†[Gl3bove account .;;†d;;;;iili,i†t*. mer the customer,s ritten notice to Accellion of such failure gives w withi'ii;;6) aays rrom ttre J* ,†Ã¢â‚¬ r1 rrrr†re occurred. with this requirement,wil r†rr†it. rt†t†;il;;/r The Customer's rrii†* t†. â€Å"*fry right to receive such credit. Accellion will notify the c†ttom†Ã¢â‚¬Ëœ. ,o L:::I†frffixirabre or anv other iI* ir'i1 ;s r,or. , liauyrf;;;y*. J of scheduled Maintenance. I reas†Ã¢â‚¬ ;;;ni†;;ii p;fi;', ffir;tn† c,,i. -,†Ã¢â‚¬ . 1;J;;i;;ii,†Ã¢â‚¬ Ã¢â‚¬ ,saryf the service acrion to *†fffflflffi[rffi;';::lJ;:,Ji;:;†*,†. :il$J;t3i:J:fl*f;::il::#*il::::†* 4. Security and privacy policy ,o any inquiry in re,a,ion,o Accellion has comolete respect for the Customer's privac y and that of any custome,r data stored in Accellion service does not require Acce,ion servers. The Customers i† prtJa† i†y;a:lr'r†i;;te servers' All information provided details for the data being stored on the to a†. â€Å"uio†iy' tLr† c†. r. i',†r';;;r†i'i;, he Customer,, ;il:ilT I†v r,u,,† u†t†,, ,or† b†r,†rit. A,ccerion w,I not hat the Disclosure of Customer's itrtt'†Ã¢â‚¬Ëœti. † 5. iui]'i. A. â€Å"†[ion's ;t;il:;,,, &:i:T†Ã¢â‚¬ ,t:ffi:1nir. ;r',1;li:ffi;d##Hi; ilJ'A'ff1†³Ã¢â‚¬ËœX;1T'. |,H:†fiH^dr:1[:o'aut, to possession shalr i-tu†t *'† . ifntI . ,*p. ffity onlybe made where such disclosure is *a to the terms or use or â€Å",,]o,† Accellion will ensure-that th† ct'stom†Ã¢â‚¬ s informatiorr and data [areJ ke{1cur9 or imProPer use' which includes t'trqg;ii*r;uur† rt†p, io rr. ri,fil,tr1r,. mer,s adenrity d protected from unauthorized access i before granring access. EXHllBlr Dear Team, 2 orAcclrionEmail to All Accellion staff Announcing the Launch of the oos Guarantee [T X':i'ji:#:ffi11:;J:T? ,i? :]†#t'^Y^:l:1*8 vua,ry ot ervlce guarantee read it over very carefully. vo† iulLri†Ji;;;;;1/†;†*u16 Quarirvof service suarantee (Qos). prease Please ancr puts t ‘† ownership o in this company to deliver. C†r,o. â€Å"†. , ompanf c ustomers aon,r wen+ . â€Å"J9,flT? ‘L†l31d irt nuts *he -o*r,†rrnipi†n ever d o,. ,;t;;t-;1q6btcDDrve' ;†;;;;† ,;;h#; theirnetwo'rkrip;*;;irr†rilrhcfi–,*–. –. ,f1. ‘-t-â€Å",LevelAgreement(sLA);ttruy;†rt**i *::::;ilffl:r. H,ffi :Slfl a*Xi A;::#J:ffi â€Å"‘,,*:mf :'†**:*;$ii+,r,fr;y:'^,'†j,:nTffi 18,. #,†l*iF:iqd-. i†Ã¢â‚¬ ;'ffi â€Å"H? ::1H:J:†H:'†;T†;1f 3†³tr:; As a member of the Accellion –Lt, vl\_. 1. team, you are key to our client,s satisfaction. Thanks in advance for your suPport in making our clients and ourselves successful. |.. 4? j:|ir!. -. ‘!. ii. ‘,l:*||-:i;:1:†|:|i||::l.. ;:::1,;:::;:;j::i. ];::|:i:]i::::::jl:]]j:::::]:. :::]] L. what is the marketing impact of a well-designed guarantee? 2. Eaaluate Exhibit the_ seraice design of Acceilion,s guarantee shown in r-. How ffictiae wilr it ui rn communicating seraice exceuence to potentiar and current customers? would you recommend any changes to its design or imple_ mentation? 3†² will he guarantee be successfut in creating a curture for seraice exceilence within Aiceilion? whit erse may be needed for achieoing such a culture? . Do you 4' think customers mEht take adaantage of this guarantee and â€Å"stage† seraice f;ilures to inaokeTlrr'grorantee? If yes, how could Acceuion minimize potentiar iheating on its guarantee? The Accellion Service Guaran tee Sg1r Case 16 Shouldic e Ho spit al Limite d (Abri dge d) JeuEs Hpsrprr AND Rocnn HellowELL A Canadian hospital specializing in hernia operations is considering whether and how to expand the reach of its seraices, including expansion into other specialty areas.Various proposals haae been adaanced to increase the capacity of the hospital without demotiaating the staff or losing control oaer seraice quality, which, in addition to achieoing excellent medical outcomes, has created a aery deaoted base of patient â€Å"alumni. † Options include adding Saturday surgical operations, building an extension, and constructing a neTD hospital in another location, perhaps in the United States. TWo shadowy figures, enrobed and in slippers, walked slowly down the semi-darkened hall of the Shouldice Hospital. They didn't notice Alan O'Dell, the hospital's managing director, and his guest.Once they were out of earshot, O'Dell remarked good nature dLy, â€Å"By the way they act, you'd think our patients own this place. And while they're here, in a way they do. † Following a visit to the five operating rooms, O'Dell and his visitor once again encountered the same pair of patients still engrossed in discussi. g their hernia operations, which had been performed the previous morning. HrsroRY An attractive brochure that was recently printed, although neither dated nor distributed to prospective patients, described Dr. Earle Shouldice, the founder of the hospital: Dr. Shouldice's interest in early ambulation stemmed, ffi:.? :T,]1;5,T? j:T]:J†H-â€Å",H,::,T#|'^# the girl's subsequent refusal to stay quietly in bed. In spite of her activity, no harm was done, and the experience recalled to the doctor the postoperative actions of animals upon which he had performed sur gery. They had all moved about freely with no ill effects. By 1,940, Shouldice had given extensive thought to several factors that contributed to early ambulation following surgery. Among them were the use of a local anesthetic, the nature of the surgical procedure itself, the design of a facility to encourage movement without unnecessarily causing discomfort, and the postoperative egimen. With these things in mind, he began to develop a surgical technique for repairing herniasl that was superior to others; word of his early success generated demand. Dr. Shouldice's medical license permitted him to operate anywhere, even on a kitchen table. However, as more and more patients requested operations, Dr. Shouldice created new facilities by buying a rambling 130acre estate with a 17,}}0-square foot main house in the Toronto suburb of Thornhill. After some years of planning, a large wing was added to provide a total capacity of 89 beds. Dr. Shouldice died in 1965. At that time, ShouldiceHospital Limited was formed to operate both the hospital and clinical facilities under the surgical direction of Dr. Nicholas Obney. In 1999, Dr. Casim Degani, an internationally-rec o g nrzed autho rity, b ecame surge on-inchief. By 2004,7,600 operations were performed per year. THr SHouLDtcE METHoD Only external (vs. internal) abdominal hernias were repaired at Shouldice Hospital. Thus most first-time repairs, â€Å"primaries,† were straightforward operations requiring about 45 minutes. The remaini. g procedures involved patients suffering recurrences of hernias previously repaired elsewhere. Many of the recurrences and very difficult hernia repairs required 90 minutes or more. In the Shouldice method, the muscles of the abdominal wall were affanged in three distinct layers, and the opening was repaired-each layer in turn-by overlapping its margins as the edges of a coat might be overlapped when buttoned. The end result reinforced the muscular wall of the abdomen with six rows of sutures (stitches) under the skin cover, which was then closed with clamps that were later removed. (Other methods might not separate muscle layers, often involved feH,er :ilil';,†#:1â⠂¬ ³3i*:ffi':T,'†:nvorvedtheinsertionotCoPyright O 2004 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800515-7685, write Harvard Business School Publishing, Boston, MA021,63, or go to http://www. hbsp. harvard. edu. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadshee! or transmitted in any form or by any means–electronic, mechanical, photocopying, recording, or otherwise-without the permission of Harvard Business School. Professor James Heskett prepared the original version of this case, â€Å"Shouldice Hospital Limited,† HBS No. 583-068.This version was prepared jointly by Professor James Heskett and Roger Hallowell (MBA 1989, DBAI997). HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illusfrations of effective or ineffective management. 592 A typical first-tim e repair could be completed with the use of preoperative sedation (sleeping pill) and analgesic (pain killer) plus a local anesthetic, an injection of Novocain in the region of the incision. This allowed immediate post-operative patient ambulation and facilitated rapid recovery. THe PaTIENTS' ExpERIENcEMost potential Shouldice patients learned about the hos- pital from previous shouldice patients. Although thousands of doctors had referred patients, doctors were less likely to recommend shouldice because of the generally regarded simplicity of the surgery, often considered a â€Å"bread and butter† operation. Typically, many patients had their problem diagnosed by upersonal physician and then contacted Shouldice directly. Many *tru made this diagnosis themselves. The process experienced by shouldice patients depended on whether or not they lived close enough to the hospital to visit the facility to obtain a diagnosis.Approximately 10% of shouldice patients came from outside t he province of ontario, most of these from the United States. Anoth er 60†³/o of patients lived beyond the Toronto area. These out-of-own patients often were diagnosed by mail using the Medical Information Questionnaire shown in Exhibit L. Based on information in the questionnaire, a shouldice surgeon would determine the type of hernia the respondent had and whether there were signs that some risk might be associated with surgery (for example, an overweight or heart condition, or a patient who had suffered a heart attack or a stroke n the past six months to a year, or whether a general or local anesthetic was required). At this point, a patient was given a operating date and sent a brochure describing the hospital and the shouldice method. If necess ary, a sheet outlining a weight-loss program prior to surgery was also sent. A small proportion was refused treatment, either because they were overweight, represented an undue medical risk, or because it was determined that they di d not have a hernia. Arriving at the clinic between 1:00 p. M. and 3:00 p. M. the duy before the operation, a patient joined other atients in the waiting room. He or she was soon examined in one of six examination rooms staffed by surgeons who had completed their operating schedules for the day. This examination required no more than 20 minutes, unless the patient needed reassurance. (patients typic ally exhibited a moderate level of anxiety until their operation was completed. ) At this point it occasionally was discovered that a patient had not corrected his or her weight problem; others might be found not to have a hernia at all. In either case, the patient was sent home. After checking administrative details, about an hour fter arrivin 8 at the hospital, a patient was directed to the room number shown on his or her wrist band. Throughout the process, patients were asked to keep their luggage (usually light) with them. All patient rooms at the hospital were semiprivate, containi^ g two beds. patients with similar jobs, backgrounds, or interests were assigned to the same room to the extent possible. upon reaching their rooms, patients busied themselves unpack ing, getting acquainted with roommates, shaving themselves in the area of the opera- tion, and changing into pajamas. At 4:30 P. M. , a nurse's orientation provided the roup of incoming patients with information about what to expect, including the need for exercise after the opera- tion and the daily routine. Accordi. g to Alan OiDell, â€Å"Half are so nervous they don't remember much. ,, Dinner was then served, followed by further recreation, and tea and cookies at 9:00 p. M. Nurses emphasized the importance of attendance at that time because it provided an opportunity for preoperative patients to talk with those whose operations had been completed earlier that same duy. Patients to be operated on early were awakened at 5:30 A. M. tcl be given preop sedation. An attempt was ade to schedule operations for roommates at approximately the same time. patients were taken to the preoperating room where the circulating nurse administered Demerol, an analgesic, 45 minutes before surgery. A few minutes prior to the first operation at 7:20 A. M. , the surgeon assigned to each patient administered Novocain, a local anesthetic, in the operati. g room. This was in contrast to the typical hospital procedure in which patients were sedated in their rooms prior to being taken to the operating rooms. upon the completion of their operation, during which a few patients were â€Å"cha tty', and fuily aware of hat was going on, patients were invited to get off the operating table and walk to the post-operating room with the help of their surgeons. According to the director of nursing: Ninety-nine percent accept the surgeon,s invitation. while we use wheelchairs to return them to their rooms/ the walk from the operating table is for psychological as well as physiologicai [blood pressure, respiratory] reasons. patients prove to themselves that they can do it, and they start their all-important exercise immediately. Throughout the day after their operation, patients were encouraged to exercise by nurses and housekeepers alike. By 9:00 P. M. n the duy of their operations, all patients were ready and able to walk down to the dining room for tea and cookies, even if it meant climbing stairs, to help indoctrinate the new â€Å"crass† admitted that duy. on the fourth morning, patients were ready for dis- charge. During their stay, patients were encouraged to take advantage of the opportunity to explore the premises and make new friends. Some members of the staff felt that the patients and their attitudes were the most important shouldice Hospital Limited (Abridged) 593 (HIBIT ;†EF 1 Medical lnformation O,uestionnai re 5 ‘n,ti,rBER (or Rural Route or P. O. Box) Province/StateTown/City SHOULDICE HOSPITAL 7750 Bayview Avenue Box 379, Thornhill, Ontario L3T 4A3 Canada Ph one (418) 889-1 125 Telephone # (Thornhill – One Mile North Metro Toronto) tq-Frhrr. 1^i il3$-1- rr=CBlv'lATlON: Please give name of lnsurance Company and Numbers. MEDICAL .nS,-IANCE: (Please bring hospital certificates) INFORMATION nLR3r:,r- ‘. a – r. l IJCE: (Please bring insurance certificates) OTHEH SURGICAL INSURANCE Patients who live at a distance often prefer their examination, admission and operation to be arranged all on a single visit – to save making two lengthy journeys. The whole kEl&anr:r Name of Business Are you the owner? f Retired Yes – purpose of this questionnaire is to make such arrangements possible, although, of course, it cannot replace the examination in any way. Its completion and return will not put you Former Occupation No under any obligation. Do you smoke? Please be sure to fill in both sides. tr-! n? -? : asr,ssrcn date? (Please give as much advance notice as possible) ry*esi:,-s =-(–, Sa:-‘:a;' cr Sunday. ffiEr h ,s *crJ FOR OFFICE USE ONLY Type of Hernia This information will be treated as confidential. ;I†EXIEEIEEIRIE: ffi iMEfrgles ory' cqJd n=trr [email  protected] :rE] cr*en rr d yotrr operatirn a tir lrctrr ru=ight EXHIBIT 1 (ConttnueolPLEASEBEACCURATE! :Misleadrngfuures.. *fiâ‚ ¬rl. cFeoxâ‚ ¬Ã¢â€š ¬]r3†² admissionday,couldmeanposFonementolyqJropeGlhontrlll†,yc'-,,[e,Etri Waist (muscles THIS IS YOUR CHART – PLEASE MARK IT! APPROXIMATE SIZE. † Walnut (or less) Hen's Egg or Lemon GraPefruit (or more) INFORMATION ESSENTIAL EXTRA and put that apply to your hernias Use only the sections v. lu H a / in each relaxed)†Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬ Ã¢â‚¬Ëœins' is your health now E treatment: Pressure Excess bodY fluids Chest Pain (â€Å"angina†) lrregular Heartbeat Ulcers Anticoagulants (to delaY blood-clotting or to â€Å"thin the blood†) F t ‘ Name of anY Prescnbe: pills, tab lets or caPsutres 1otake regularlY – A nY condition Please tick regular for which You are having Diabetes Asthma & Bronchitis Y ,JI GOOD ; Blood ,JI Chest (not exPancld' il il t] t] I il I il still be finished in time for a 12:30 P. M. lunch in the staff dining room. Upon finishing lunch, surgeons not scheduled to operate in the afternoon examined incoming patients. A surgeon's day ended by 4:00 P. M. In addition, a surgeon could expect to be on call one weekday night in ten and one weekend in ten. Alan O'Dell commented that the position appealed to doctors who â€Å"want to watch their children grow up. A doctor on call is rarely called to the element of the Shouldice Program.Accordi^g to Dr. Byrnes Shouldice, son of the founder, a surgeon on the staff, and a 50% owner of the hospital: Patients sometimes ask to stay an extr a day. Why? Well, think about it. They are basically well to begin with. But they arrive with a problem and a certain amount of nervousness, tension, an d anxiety about their surgery. Their first morning here they're oPerated on and experience a Sense of relief from Something that's been botheri. g them for a long time. hospital and has regular hours. † Accordi. g to Dr. They are immediately able to get around, and they've got a three -duy holiday ahead of them with a Per- Obney:When I interview ProsPective surgeons, I look for experience and a good education. I try to gain some insight into their domestic situation and personal interests and habits. I also try to find out why a surgeon wants to switch positions. And I try to determine if he's willing to perform the repair exactly as ,::it i ? ffi : †'il† JilI% IL:x *,x'*#: have the run of the 3 patients, make friends easily, and hospital. In summer, the most common after-effect from the surgery is sunburn. he's told. This is no place for prima donnas. Tue NuRsEs' ExPERtENcE Dr. Shouldice added: 34 full-time-equivalent nurses staffed Shouldice each 24 hour period.H owever, during non-oPerating hours, only six full-time-equivalent nurses were on the premises at any given time. While the Canadian acutecare hospital average ratio of nurses to patients was 1,:4, at Shouldice the ratio was 1:15. Shouldice nurses spent an unusually large proPortion of their time in counseli. g activities. As one suPervisor commented, â€Å"We don't use bedpans. † According to a manager, â€Å"shouldice has a waiting list of nurses wanting to be hired, while other hospitals in Toronto are short-staffed and perpetually junior resident in surgery performs. Hernia repair Tiaditionally recruiting. † hernia is often the first operation thatThe hospital employed 10 full-time surgeons and other major operations. This is quite wrong, ES is borne out by the resulting high recurrence rate. It is a tricky anatomical area and occasionally very complicated, especially to the novice or those doing very fer*hernia repairs each year. But at Shouldice Hospital a surgeon learns the Shouldice technique over a periol of several months. He learns when he can go fast anc when he must go slow. He develops a pace and a L?. xli;J!. T,:i'†Ã¢â‚¬ *11:1†²-x1'*:1i#;il'It;. TJ: geons. We teach each other and try to encourage a 8 each duy. a scrubbing scheduled operation at 7:30 A. M. hortly before the first If the first operation was routine, it usually was completed by 8:15 A. M. At its conclusion, the surgical team helped the patient walk from the room and summoned the next patient. After scrubbrng, the surgeon could be ready to operate again at 8:30 A. M. Surgeons were advised to take a coffee break after their second or third operation. Even So, a surgeon could complete three routine operations and a fourth involving a recurrence and Shouldice Hospital Limited (Abridged) tr– achieve absolute perfection. Excellence is the eneml' of good. part-time assistant surgeons. TWo anesthetists were also on site.The anesthetists floated among cases e xcept when general anesthesia was in use. Each operating team required a surgeon, an assistant Surgeofl, d scrub nurse, and a circulating nurse. The operatirg load varied from 30 to 36 operations per duy. As a result, each surgeon typically performed three or four oPerations A typical surgeon's duy started with a L' regarded as a relatively simple operation compared to group effort. And he learns not to take risks Tne DocroRs' ExPERIENcE 595 ‘ a Chief Surgeon Degani assigned surgeons to an oPerating room on a daily basis by noon of the preceding da1†² This allowed surgeons to examine the specific patienE hat they were to operate on. Surgeons and assistants H-ere rotated every few days. Cases were assigned to give do. tors a non-routine operation (often involving a recurrencâ‚ ¬ several times a week. More complex Procedures ^'erâ‚ ¬ assigned to more senior and experienced members of th† staff. Dr. Obney commented: If something goes wrong, we want to make sure t ha: we have an experienced surgeon in charge. Experience is most important. The typical general surgeon mai perform 25 to 50 hernia operations per yeaL Ours Perform 750 or more. The L0 full-time surgeons were paid a straight salan' typically fi,aa,000. In addition, bonuses to doctors 'ere distributed monthly. These depended on Profit, indir-icual productivity, and performance. The total bonus Pc-‘i paid to the surgeons in a recent year was aPProximate-‘r $400,000. Total surgeon compensation (including benefir was approximately 15% more than the average income for kitchen staff several times a d,ay, and the hospitar staff to o'D efi, â€Å"weuse arl fresh ingredients and prepare the food from scratch in the kitchen. ,, The director of housekeeping pointed out: a surgeon in Ontario. Training in the shouldice technique was important eat together. Accordi^g to ecause the procedure could not be varied. It was accomplished through direct supervision by one or more of the seni or surgeons. The rotation of teams and frequent consultations allowed for an ongoing opportunity to appraise performance and take corrective action. where possibre, I former shouldice patients suffering recurrences were assigned to the doctor who performed the first operation â€Å"to allow the doctor to rearn from his mistake. ,, Dr. obney commented on being a shouldice surgeon: ilH:*XX##'#Hlti:iJf mx;^:†x$::: ing notes [for confidence], e.. oriaging eachither, and walking around, getting exercis.. briourse, e,re in the rooms straightenirg ,p throughout the day. This gives the housekeepers ; chancl to josh with the patients and to encourage them to exercise. A doctor must decide after several years whether he to do this for the rest of his liie because, just a Iultt in other speciarties-for exampre, radiology_h. s loses touch with other medical disciplines. If h; stays for five years, he doesn't leave. Even among younger doctors , few elect to leave. ?,. i. |. 1.. lrt|ii;. ; |ii|:. :. ||::)|:|ii||. |i::|||||:. :|::||:::|:::|:::::::::::::::::::::::::::::::::: The shouldice Hospital contained two facilities in one uilding-the hospital and the clinic. On its first-level, the hospital contained the kitchen and dining rooms. The sec_ ond level contained a large, open tounge area,the admis_ sions offices, patient rooms, and a spacious grass-covered Florida room. The third revel had aaaitiond fatient rooms and recreational areas. patients could be seln visiting in each others'rooms, walking up and down hallways, loung_ irg in the sunroom, and making use of light recreational facilities ranging from a pool table to an exercycle. Alan o'Dell pointed out some of the features of the hospital: The rooms contain no telephone or television ets. If a patient needs to make a call or wants to watch terevi_ sion, he or she has to take a walk. The steps are designed specialry with a smalr rise to alow patients recently operated on to negotiate the stairs without undue dis comfort. E-â€Å"†Iy rqluru foot of the hospital is carpeted to reduce the hospital feeling and the possi_ bility of a fall. Carpetir,g urro gives tf,e phce a smell other than that of disinfJctant. ‘ This- facility was designed by an architect with input from Dr. Byrnes shouldice and Mrs. w. H. uiquhart (the daughter of the founder). The facility was discussed for years and many changes in the lans were made before the first concrete was poured. A number of unique policies were also instituted. For example, parents accompanying children here for an operation stay free.. you may wonder why we can do it, but we learned that *. rrre more in nursing costs than we spend for the parent's room and board. have- only three on my housekeeping staff for the entire facility. one of the reasons for ; f†* housekeep_ that we don't need to change rinens during a ::? ,tr patient's four- duy stay. Arso, the medical staff doesln,t The clinic housed five operating rooms, a labor ator y, and the patient-recovery room. In totar, the stimated cost to furnish an operating room was $30,000. This was con_ siderably less than for other hospitals requiring a bank of equipment with which to administer anesthetics for each room. At shourdice, two mobile units were used by the anesthetists when needed. In addition, the complex had one â€Å"crash cart† per floor for use rf a patient should suffer a heart attack or stroke. ilin|,4|'i|4? l|:j:i|'i|:|j|!. :||i:|. |::::::|||:::;:i. :|:::):':|::::::|::::|::::):::::::::':1: Alan O'Dell described his job: we try to meet people's needs and make this as good a place to work as possible. There is a strong concern or employees here. Nobody is fired. [This was later reinfor. â€Å"-d by Dr. shouldice, who described a situa_ tion involvirg two employees who confessed to theft in the hospital. They agreed to seek psychiatric help and were allowed to remain on the itu. l As a resurt, turnover is low. our administrative and suppor t staff are non_ union,. b†, we try to maintain a pay scale higher than the union scale for comparabl. Jou, in the area. we have a profit-sharing prin that i, ,. prrate from the docto*: year the administrative and support -LTt staff divided up $60,000. If work needs to be done, peopre pitch in to herp each other.A unique aspect oi o,,r, administration is that I insist that each secretary is trained to do another's work and in an emergency is able to switch to another function immediatlly. we don,t have an organization chart. A chart tends io make people think they're boxed in jobs . a r try to stay one night a week, having dinner and ristening to the patientJto find out how things are really goinf uro. rnd here. Patients and staff were served food prepared in the same kitchen, and staff members picked up iood from a cafeteria line placed in the very .. r,t. , of the kitchen. This pro'ided an opportunity for everyone to chat with he Operating Costs The 2004 budgets for the hosp ital and clinic were close to $8. 5 millions and $3. 5 million, respectively. 6 Shouldice Hospital Limited (Abridged) Sgz EXH lB lT FIoor Supenisor 2 Organization Chart Lab (4) Operating Laundry Room Housekeeping Office Accounting Medical Grounds (3) (2) Supervisor I Head Head Nurse urse (2) Record (2) Dietary (r7) I5 (2) (3) i al[eets three limes a year or as needed. bUeets as needed (usually twice a month). lnformallv reports to Executive Committee. Physical Surgeons Assistant Plant (12) Surgeons (7) Anesthetist (t) pared to an average charge of $5,240 for operations per_ ormed elsewhere. if. l. rlii. ,i. l. ,,:::. ::i:ll|::::l. ::. :::l:.. ::::|:. :|:::|::. :::::|:'. ::|::):|::::::::::: Hernia operations were among the most common per_ formed on mares. In 2000 an estimated r. ,000,000 such operations were performed in the united states alone. Round-trip fares for traver to Toronto from various major cities on the North American continent ranged from roughly $20A to $600. when our backlog of scheduled operations gets too large, we The hospitar arso provided annual checkups to alumni, free of charg.. Muny occurred at the time of the According to Dr. Shouldice: wonder patient reunion. The most recent eunion, featuring dinner and a floor show, was held at afirst-class hotel in down_ town Toronto and was attende d by 1,000 former patients, many from outside Canada. ho* many peopre decide instead to p†rfor* the operation. Every have their rocal doctor time we've expandea o11 capacity, th† backrog has declined briefly, onry to climb or,. u again. Right now at 2,400,]1 ir rarger than it has ever been and is grow_ irg by 100 every six months. The hospitar relied entirely on word-of-mouth adver_ tising, the importance of which was suggested by the results of a poil carried out by i. :i|,i. ]||,)|:i. ||. ;|,. ii:. ||:||:. |,. )||:|:||. :||,.. |:|||::::||:::'. ::::::::::::: when asked about major questions confronting the man_ agement of the hospital, Dr. s hourdice cited I aesire to seek ways of increasing the hospitals capacity while at the same time maintaining . oriror over the quatity of service delivered, the future role of government in the operations of the hospital, and the use of the shouldice name by potential competitors. As Dr. shouldice put it: Im a doctor first and an entrepreneur second. For students of Depaul lrxiriuit 3 shows a portion results). Although little systematic data about university as part of a project of these atients had been collected, Alan o'Dell remarked that ,,if we had to rery on wearthy patients onry, our practice would be much smaller. ,, Patients were attracted to the hos pitar, in part,by its reasonable rates. Charges for a typical operation were four days of hospital sta y at $? 20 p. iau anda $650 surgical fee for a prim ary inguinar (the most common example, we courd refuse permission to other doctors ah. – hospitar. The y may copy our technique and Tisappry it or misinform *,. i. pati ents about the use of it. rni, resurts in failure, and we are f, who want to visit hernia). An additional fee of $300 was assessed f generar anesthesia was required (in about 20% of cases). These charges com_ ExHlBlr Direction: you. 5. B concerned that the technique will be blamed. But Shourdice Hospitar Annuar Patient Reunion Data For each question, please place a check mark as it applies to 4 /7 22 Nationalitv Directions: please place a check mark in nation you represent and please write in your province, state or country where it applies. Canada America Europe J6 -]] province sate a†*r, ee 2 /o ua'rl ,o/ // 63% 5 /6 /960 7 5†² %dt 39. 54% 5/. /6% fl. 63% 4/. 56% 30. 23% /6. 26% occupation Ilave you been overnight in a hospital other than u*@' houldice befone your operation? !* j! _ No lZ What brought Shouidice Hospital to your attention? Friend 8†² ,1 Doctor Rerative . . , 6r. 1//o _0. %% EzW,/. rticre ,9 , Did you have a si',gle 26; or double /6 other 4 ,iiJ†#Zw hernia operation? 56,/4% fi. s6% 9. Is this your first Annual Reunion? yes No fi .10 . , If no, how many reunions have you iiM ,,a†fz',fl ^tt 10. Do you feel that Shouldice Hospital to, ,* * – per,son? â€Å"r†Ã¢â‚¬ 0 Most definitely Definitety 6 JZ Very iittle Not 66,05% /a%% 7 Z_. reaubrc _fl 42. 6J% 6-/0 ruo,rn,re – 5 z17J% !:;::::; :'r'; #, at all Shouldice Hospital Limited (Abridged) 599 EXHIBIT 3 (Continued) fhat impressed you the most about your stay at Shouldice? check one answer for each of the following. for operation and hospital P1ease s Not Somewhat 27. 9d1 Imporiant /4 Somewhat Imporbant 32. 56% // Somewhat Important 25. 5/l /5 Somewhat Important 34. 5E% Not 7 /6. 26% Important 32. 56% Not ImPortant 6 /S,6dl 3 6,96% Not 27,9/k Somewhat 5 /0 Important 25 Important n. fi% 23,2fl1 56. /5% † sbouldice Hospital hardly seemed like a hospital at all. † Somewhat Very 5 /3 Importani 25 Importani Important //. 63% 30. 23% 55. /4% gi ve the MAIN REASON why you reiurned for this annual In a few words, reunion. Very Important 2 4. 65% SomewhaiVery 39. 53% Friendships witb Patients Not Important / 2. 3? l Not Important 3 6'96% Not ImporLant we're doctors, and it is our obligation to help other Alan O'Dell added his own concerns: surgeons learn. On the other hand , it's quite clear that others arc tfying to emulate us. Look at this ad. [The advertisement is shown in Exhibit 4. ) This makes me believe that we should add to our capacity, either here or elsewhere. Here, we could go to Saturday operations and increase our caPacity by 2O%. Throughout the year, no oPerations are sched- How should we be marketing our services? Right now we don't advertise directly to patients.We're uled for Saturdays or Sundays, although patients whose operations are scheduled late in the week remain in the hospital over the weekend. Or, with an investment of perhaps $4 million in new sPace/ we even afraid to send out this new brochure we' ve pu: together, unless a potential patient specificallrrequests it, for fear it will generate too much demand. Our records show that just under 1% of our EXHIBIT 4 Advertisement by a Shouldice Competitor could expand our number of beds by 50%, and schedule the operating rooms more heavily. On the other hand, given Sovernment regulation, do we want to invest more in Toronto?Or should we establish another hospital with similar design, perhaps in the United States? There is also the possibility that we could diversify into other specialties offering similar opportunities such as eye surgerf, yancose veins, or diagnostic services (e. 9. , colonoscopies). For now we're also beginnirg the process of groomirg someone to succeed Dr. Degani when he retires. He's in his early 60s, but at some point we'll have to address this issue. And for good reason, he's resisted changing certain successful procedures that I think we could improve on. We had quite a time changing the schedule for the admi nistration ofDemerol to patients to increase their comfort level during the operation. Dr. Degani has oPPosed a Satutday operating program on the premise that he won'tbe here and won't be able to maintain proper control. 500 Shouldice Hospital Limited (Abridged) Canadian Hernra Ctinic Hernias (Ruptures) Required Under local anesthesia as by Canadian method. No Overnight Hospital Stay, Co nsult atio n s Witho ut Char ge 23061St. Rd. 7 BOCA R{ION, FLA. 33433 482-7755 patients are medical doctors, a significantly high percentage. How should we capttahze on that? I'm also concerned about this talk of Saturday operations.We are already getting good utrltzation of this facility. And if we expand further, it will be very difficult to maintain the same kind of working relationships and attitudes. Already there are rumors floatirg around among the staff about it. And the staff is not pleased. The matter of Saturday operations had been a topic of conversation among the doctors as well. Four o f the older doctors were opposed to it. While most of the younger doctors were indifferent or supportive , at least two who had been at the hospital for some time were particularly concerned about the possibility that the issue would drive wedge between the two groups. As one put it, â€Å"I'd hate to see the practice split over the issue. † EruDNOTES Most hernias, knows as external abdominal hernias, are protrusions of some part of the abdominal contents through a hole or slit in the muscular layers of the abdominal wall which is supposed to contain them. Well over 90% of these hernias occur in the groin area. Of thes e,by far the most common are inguinal hernias, many of which are caused by u slight weakness in the muscle layers brought about by the passage of the testicles in male babies through the groin area shortly before birth.Aging also contributes to the development of inguinal hernias. Because of the cause of the affliction, 85oh of all hernias occur in males. 2. Ba sed on tracking of patients over more than 30 years, the gross recurrence rate for all operations performed at Shouldice was 0. 8%. Recurrence rates reported in 1†³. the literature f or these types of hernia varied greatly. However, one text stated, â€Å"In the United States the gross rate of recurrence for groin hernias approaches 70†³/†. † monet ary references in the case are to Canadian dollars. $1 US equaled $1. 33 Canadian on February 23, 3. A11 2004. n Exhibit 2 was prepared by the casewriter, based on conversations with hospital personnel. 4. The chart 5. This figure included a provincially mandated return 6. on investment. The latter figure included the bonus pool for doctors. SIUDY OuEsrtoNs L. What is the market for this seraice? Hout successful is 2. Shouldice Hospital? Define the seraice model for Shouldice. How does each of its elements contribute to the hospital's success? 3. As Dr. Shouldice, what actions, if any, would you take to expand the h ospital's capacity and how utould you implement such changes? Shouldice Hospital Limited (Abridged) 601