Professional Nurse Accountability Research Paper

Professional Nurse Accountability - Research Paper Example    In addition to that autonomy and authority are administrative tools for control whereas accountability is a moral principle that governs the relationship between the givers of authority and the recipients (Mackie, Martin & Thomson, 1995). Currently, the nursing profession has made great inroads with regards to engraining accountability amongst its practitioners. Firstly, nurses have established several professional standards outlining the guidelines and principles for the all who seek to join in the profession. For example, the American Nurses Association (ANA) developed a Code for Nurses which â€Å"provides a clear framework within which nurses can seek to uphold the standards of care and protect the clients they serve† (Hood & Leddy, 2006, p.307). Also, each state in the United States has mandatory guidelines in place that distinguish professional nursing from other health professions, defines the professional nursing practice and specifies their scope of practice. In addition to the institution of professional standards, the nursing fraternity is actively pursuing methods of improving the state of the health care delivery system. This manifests maturity and professionalism within nursing because by accepting an appropriate degree of responsibility for the current situation, nurses are able to legitimize their claim for a piece of the healthcare pie. Thirdly, the profession of nursing is encouraging its members to be aware of and accountable for not only their actions but also those of their colleagues. This is done through initiatives such as reporting chemically impaired coworkers. According to Hood and Leddy (2006), there are forty state boards of nursing that offer alternatives to disciplinary actions that involve legally binding programs for detoxification, treatment, peer assistance and so on that are  geared to assist chemically impaired coworkers.

The Progressive Era Essay Example for Free

The Progressive Era Essay The Progressive Era was a period of time when mass groups of people pushed for major changes. Some became successful while others werent. Many different approaches were used to try and change four areas. They were protecting social welfare, promoting moral improvement, creating economic reform, and fostering efficiency. The Progressives believed in four major principles which are demonstrated in the actions they took to support them. One objective the Progressives enforced was protecting social welfare, which they established in many ways. These groups of people wanted desperately to fix urban problems. With this mind set, the YMCA (Young Mens Christian Association) was founded. This association opened libraries, sponsored classes, and built swimming pools/handball courts, for the good of the city. A major supporter and leader of this reform was Jane Addams. She created settlement houses in many cities; they were homes for women to stay until they were back on their feet again. Jane Addams actions inspired many other women to become involved. With all that occurred during the Progressive Era, work sometimes seemed pointless, but thanks to numerous peoples hard work and dedication, many of the organizations still exist today. One significant goal the Progressives struggled to change was promoting morals. The Womens Christian Temperance Union became very involved during this reform. Frequently they would visit inmates and mental patients to see how they were managing during their time of hardships. WCTU believed that all women should have the right to vote. Suffrage for women was a heavily debated issue during the Progressive Era. One main leader of the moral improvement reform was Susan B. Anthony. She had no limits; she would try every law available related to voting in any way. She became a woman of power and an idol for others. Another notable debate at this time was prohibition, the banning of alcohol. Reformers believed that with alcohol out of the picture, the poor could live a better life and many of the poor were immigrants. Therefore the immigrants would have an easier life when first coming to America. Alcohol was a part of the culture, so the push to ban alcohol would be a difficult task for the leaders. Promoting moral improvement became an important but laborious goal for the Progressives. Another goal for the Progressives was creating economic reform. They fought for many changes in business. Some started to question Laissez Faire; in turn other people began to move towards socialism. The Sherman Antitrust Act was also brought back into play. The government used its power to bust monopolies, therefore helping small businesses. Also, Muckrakers wrote newspaper articles that criticized big businesses and social wrongs. Upton Sinclair, author of The Jungle, tried to show the naà ¯ve public and government the truth about the meat companies. His book involved detailed and gory findings that when published aroused many people. Sinclairs book influenced Theodore Roosevelt, the current President of the United States at the time, to send officials in to the meat factories to investigate what was really going on. Upon this investigation, new laws were made and enforced. The Pure Food and Drug Act dictated that companies must print on the labels what was truthfully in the product. Efforts made to change the economy were time consuming and troublesome but yielded good results. The last principle the Progressives believe in was fostering efficiency. The reformers wanted things to be orderly and organized. To them, this was being efficient, by not wasting energy. The idea of scientific management included many practices including applying science to businesses and making things simple would produce more money. This was the main concept of scientific management. Henry Ford was a supporter of scientific management. Mr. Ford developed the assembly line, which increased production by a large amount. With the introduction of the assembly line, work for the employee became demanding and repetitive. The worker stood in one place, where they were presented with work from a conveyor belt. Ford then brought the five-dollar workday into play attracting many employees to come work for him. Fostering efficiency was a well-met goal for the Progressives. In summary, it can be stated that the Progressive Era brought many changes into our generation. Even though quite a few of these actions happened in the 1900s they still affect us today in 2001. The Pure Food and Drug Act, the YMCA, and others still exist today with few revisions. The Progressives had four main principles which they believed in and even today they continue to influence us.

Comparison and Contrast in The Great Gatsby Essay -- comparison compar

Comparison and Contrast in The Great Gatsby      Ã‚  Ã‚   The success of Francis Scott Key Fitzgerald's The Great Gatsby is in part due to his successful characterization of the main characters through the comparison and contrast of Daisy Buchanan and Myrtle Wilson, Tom Buchanan and George B. Wilson, and Nick Carraway and Jay Gatsby. The contrast is achieved through two principle means: contrasting opposite qualities held by the characters and contrasting one character's posititve or negative qualities to another's lack thereof. Conflict is generated when the characters sometimes stand as allegorical opposites. On the other hand, comparison of two characters is rather straightforward. This comparison and contrast is prevalent in Fitzgerald's The Great Gatsby. To begin with, Daisy and Myrtle have similarities and differences. The similarities revolve around the characters' marriages. First, both have an affair sometime in the novel. Myrtle's sister, Catherine, whispers to Nick: "Neither of them can stand the person they're married to" (33). Partially as a result of this intolerance, both begin affairs. Daisy says that she loves both her husband, Tom, and illegitimate boyfriend, Gatsby: "I love you [Gatsby] now -- isn't that enough? ... I did love him [Tom] once, but I loved you too" (133). Daisy says that she loves both Tom and Gatsby. Here, Daisy's character must be taken into account. Daisy might just as well love Gatsby's shirts, house, or other status symbols as she loves Gatsby as a person. Similarly, she might also only love Tom's status symbols. Myrtle certainly only loves Tom's status symbols. She tells Nick, "He had on a dress suit and patten leather shoes, and I couldn't keep my eyes off him..." (36). This is the point ... ...ization.    Works Cited Bewley, Marius. "Scott Fizgerald's Criticism of America." Mizener 125-41. Eagleton, Terry. The Function of Criticism. London: Verso, 1984. Fitzgerald, F. Scott. The Great Gatsby. Collier Edition. New York: Macmillan Publishing Company, 1925. "Fitzgerald, F. Scott." Microsoft Encarta 97 Encyclopedia. Redmond, WA: Microsoft, 1996. CD-ROM. 1997. Posnock, Ross. "'A New World, Material Without Being Real': Fitzgerald's Critique of Capitalism in The Great Gatsby." Critical Essays on Scott Fitzgerald's "Great Gatsby." Ed. Scott Donaldson. Boston: Hall, 1984. 201-13. Spindler, Michael. American Literature and Social Change. Bloomington: Indiana UP, 1983. Trilling, Lionel. "F. Scott Fitzgerald." Critical Essays on Scott Fitzgerald's "Great Gatsby." Ed. Scott Donaldson. Boston: Hall, 1984. 13-20.         

Can international law change the world Essay

Sir Christopher John Greenwood was born in 1955. Currently he is a judge of the ICC whereby he was elected to the position on 6th November 2008. Before being elected as an ICC judge, Sir Christopher John Greenwood was a professor at London School of Economics where by taught international law. In addition, he was a barrister who most often made appearance before the international court of justice, the English Courts and the European Court Of Human Rights among other tribunals. During an interview as evidenced in the video, Judge Sir Christopher John Greenwood puts it clear that the international law has the power to change the way world operates. He further argues that, while each system of the national law strives to regulate affairs within only a single society, the international law has the concern of the whole world. In contrary, judge Sir Christopher John Greenwood argues that, though the international laws has the power to change the world and the way different systems of the world operate, there is yet no methods of enforcement available to the national legal systems. According to Sir Christopher, the international law can change the security and political stability of the different nations of the globe if only there could be efficient and effective measures put in place that would ensure the different national systems comply. Moreover, Sir Christopher says that if the different national systems could comply with international laws like those concerning weapons and international peace, international health like those stipulated in the world health organization (WHO) among other laws made to ensure that the social welfare of the different socio-economic classes of people would change the world to a greater extend. In addition to this, Sir Christopher further argues that following compliance to the different international economic laws would change the way business is carried globally by different nations. Compliance to the international laws would make the transactions between different nations secure since are governed. Moreover, international economic laws would standardize how business is carried in the world. In a broad spectrum, the international laws can only change the world if the different nation systems comply. It will be of great importance if the different world systems comply to the international laws for better so as to steer development through trade standardization among other things. 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- YouTube London School of Economics and Political Science (LSE)121K subscribersSubscribeCan International Law Change the World?Watch laterShareInfoShoppingTap to unmute1:19:00If playback doesn't begin shortly, try restarting your device.More videosFull screen is unavailable. 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How the internet works Essay

Although the details of routing and software are complex, the operation of the internet from the users’ perspective is fairly straight forward. As an example of what happens when the Internet is used, consider that you type the URL www. helpmegetoutofthis. com into the Netscape browser. The browser contacts a DNS server to get the IP address. A DNS server would start its search for an IP address. If it finds the IP address for the site, then it returns the IP address to the browser, which then contacts the server for www.helpmegetoutofthis. com, which then transmits the web page to your computer and browser so you can view it. The user is not aware that of the operation of an infrastructure of routers and transmission lines behind this action of retrieving a web page and transmitting the data from one computer to another. The infrastructure of the internet can be seen as a massive array of data relay nodes (routers) interconnected by data transmission lines, where each node can service multiple transmission lines. In the general case where information must be sent across several nodes before being received, there will be many possible pathways over which this transmission might occur. The routers serve to find a path for the data transmission to occur. The routing of a file or data packets of a file is either be done by the technique of source routing or the technique of destination routing. In source routing, the path the data transmission will follow id specified at the source of the transmission, while destination routing is controlled by the routers along the path. In the modern internet, almost all routing is done by destination routing because of security issues associated with source routing. Thus, the routers must be programmed with protocols that allow a reasonable, perhaps optimum, path choice for each data packet. For the routers to choose an optimum path also requires that the interconnected routers communicate information concerning local transmission line metrics. Router communication is thus itself a massive information transfer process, given that there is more than 100,000 networks and millions of hosts on the Internet. When viewing the enormity of the problem, it is perhaps easier to understand why engineers have accepted a sub-optimal solution to the problem of efficiency in data transfer on the Internet. When initially confronting a problem, the practical engineering approach is to simplify the problem to the point where a working solution can be obtained and then refine that solution once the system is functional. Some of the simplifying assumptions used by engineers for the current internet data transmission system include. 1) A transmission line is never over capacity and is always available as a path choice. 2) The performance of the router and transmission line does not depend on the amount of traffic. These two assumptions do simplify the problem of path choice considerably because now all the transmission lines and nodes may be considered equal in capacity and performance completely independent of traffic. As such, it is a much simpler optimization problem consisting of finding the route with the shortest path length. To simplify the problem even further, another assumption is made: 3) Consider that an â€Å"Autonomous System† (AS), is a small internet inside the Internet. An AS is generally considered to be a sub-network of an Internet with a common administrative authority and is regulated by a specific set of administrative guidelines. It is assumed that every AS is the same and provides the same performance. The problem of Internet routing can now be broken down into the simpler problem of selecting optimum paths inside the AS and then considering the optimum paths between the AS. Since there are ‘only’ around 15,000 active AS’s on the Internet, the overall problem is reduced to finding the best route over 15,000 AS nodes, and then the much simpler problem of finding the best route through each AS. There is an important (to this thesis) set of protocols which control the exchange of routing information between the AS’s. The sort of routers in an AS which communicates with the rest of the internet and other AS’s are called border routers. Border routers are controlled by a set of programming instructions known as Border Gateway Protocol, BGP. A more detailed discussion of computer networking principals and the Internet facts can be found in e. g. [7]. An Introduction to Router Protocols. Routers are computers connected to multiple networks and programmed to control the data transmission between the networks. Usually, there are multiple paths that are possible for transmission of data between two points on the Internet. The routers involved in the transmission between two points can be programmed to choose the ‘best path’ based on some metric. The ‘protocols’ used to determine the path for data transmission are routing algorithms. Typical metrics used by routing algorithms include path length, bandwidth, load, reliability, delay (or latency) and communication cost. Path length. Path length is a geometric measure of how long the transmission lines are. The routers can be programmed to assign weights to each transmission line proportional to the length of the line or each network node. The path length is then the sum of the weights of the nodes, lines or lines plus nodes along the possible transmission path. Bandwidth. Bandwidth is used to describe the available transmission rate (bps) of a given section the possible transmission path. An open 64 kbps line would not generally be chosen as the pathway for data transmission if an open 10 Mbps Ethernet link is also open, assuming everything else is equal. However, sometimes the higher bandwidth path is very busy and the time required for transmission on a busy, high bandwidth line is actually longer than on a path with a lower bandwidth. Load. This data packet transmission per unit time or the percent of CPU utilization of a router on a given path is referred to as the load on this path. Reliability. The reliability of a data transmission path can be quantitatively described as the bit error rate and results in the assignment of numeric reliability metrics for the possible data transmission pathways. Delay. The delay in data transmission along a certain path is due to a combination of the metrics that have already been discussed, including geometric length of the transmission lines, bandwidth, and data traffic congestion. Because of the hybrid nature of the communications delay metric, it is commonly used in routing algorithms.

Caterpillar Mitsubishi Case Study Essays

Caterpillar Mitsubishi Case Study Essays Caterpillar Mitsubishi Case Study Paper Caterpillar Mitsubishi Case Study Paper Essay Topic: Marketing The case is about the strategies applied by George Schaefer, CEO of Caterpillar, after 1985. In 1982, Caterpillar faced with its greatest crisis because of demand fall. Its sales dropped by almost 50% between 1982 and 1984. Komatsu, the Japanese competitor, fully exploited the situation by adding new lines in U.S.A and announcing the establishment of new manufacturing operations in the U.S.A. and England. On the other hand, Caterpillar closed six plants, laid off approximately 24,000 people between 1981 and 1984. Therefore, Schaefer was taking over a very challenging task by becoming the CEO of Caterpillar in 1985. Till the time of Schaefer, Caterpillars organization structure was hierarchy dominated and the managers were not customer-oriented enough to stay strong in a competitive environment. Hence, immediately after taking the charge, Schaefer set in motion a series of strategic and organizational changes that he hoped would firmly reestablish Cats strong competitive position and rebuild its sound financial condition. The rest of this essay highlights those strategic decisions and actions under separate headings. Business Strategy Conference The purpose was to force managers to step back from the frenetic cost cutting and focus on plans to ensure long-term viability. A debate was whether to diversify or focus on core business. The result was because of slow growth opportunities on the core business market, they decided to develop additional, related products and services. The outcome of BSC was the Ten Initiatives list. This list provided a blueprint for the new directions and activities Schaefer would implement over the next few years. From Manufacturing to Outsourcing One big move was the transition from manufacturing to outsourcing. Manufacturing was once a competitive advantage for Cat but after the 1982 crisis it has been seen that it has now became a liability, because the plants were simply too costly and too inflexible. A new policy of shopping the world led to and increase in outsourcing. While decreasing the manufacturing capacity, Schaefer started the Plant with a Future (PWAF) program to make Cat the industrys lowest-cost, high-quality producer. PWAF achieved in two aspects and failed in other two aspects. The program was able to achieve manufacturing space by 28% through plant closings and achieved savings by simpler manufacturing processes. However, the 15%-20% cost cutting goal by 1990 was seen to be delayed by one year, in 1987 (the achieved cost cutting rate was 7% then). In 1988, the company stopped reporting specific cost reductions, claiming they dont work in a period of rapid production increases. The forth phase of the program which was the development of fully integrated engineering, logistics and factory operations, shortly called paperless factory. In 1986, it is postponed indefinitely due to the lack of integration software. Also, in 1988, management estimated that the cost of PWAF might be 50% more than it was first foreseen. This meant that PWAF could never earn an appropriate return. The New Approach to Markets * Cat adopted a flexible pricing approach to counter Komatsus price challenges. In addition, managers began to focus on percent of industrys sales as the primary performance measure. * The Caterpillar World Trading Corporation was formed to access particularly to closed markets. * The company developed a more flexible approach to ownership and control where it led market access. In 1985, it signed a licensing agreement selling technology to the Chinese to help them develop a national construction equipment business. In 1989, its products were being produced under license by independent manufacturers all around the world. * New product introductions to offset slow market growth. * Marketing leverage: A strategy of outsourcing products to sell through Cats existing distribution network. The backhoe loader production success story, given in the case is very interesting in the sense that the team responsible from the new product development achieved the project by violating several company practices. Also they have outsourced some of the components, even though the counterparts of those components were available from Cat, mainly because of cost reasons. Cats components were high quality designed for top-end, heavy equipment while a backhoe loaders requirements were lower hence the outsourced parts were cost wise more advantageous. The agreement with Mitsubishi Heavy Industries to transfer worldwide design responsibility to Japan was a big step for Caterpillar. The purpose of the Cats management in that deal was to penetrate to Japan market. Besides this main target, learning the Japan way of production was seen as an asset in that deal. The New Organizational Environment Schaefer saw that the root of many problems of Cat was its functionally dominated and hierarchically structured organization. He said that We dont need perfectionwhat we need is the best decision with minimum study and input. The key success factors Schaefer tried to put forward were empowerment and delegation, which was not aligned with the classical way of Cats management. Hypotheses; 1. As presented by Jeffrey R.Williams in his Renewable Advantage book, Schaefer tried to force the company to be a scale orchestrator in its environment. A successful organization has to be dynamic and continually evolving through gradual realignment with its changing environment. 2. Although not clearly said this case presents two types of management style; one manager like Schaefer, who is looking for innovation and trying to find new approaches for the future of the company, while the other is more conservative, hesitant to make changes and not open to new decisions and actions. It can be said that the future will be the managers like Schaefer, who are willing to change both themselves and the company according to their environment. Emotional attachment to the business will lead to failure. Historical Prospective on Business Development Caterpillar Introduction Caterpillar can trace its roots back to the late 1800s when Daniel Best and Benjamin Holt were both working on engine powered agricultural equipment. In April of 1925 the Best and Holt companies merged to form what was then known as the Caterpillar Tractor Co. Caterpillar Inc, headquartered is in Peoria, Illinois and is the world leading manufacturers of heavy construction, earth moving and materials-handling machinery. For more than 50 years Caterpillar dominated their market segment through huge capital investments in the year 1950 1980. It establishment in 1925 means a long history of the company. Indeed, the company experienced different conditions throughout the history. The historical review will highlight major developments of the company in the past. Major Periods of Historical Development 1900 1925: Pre-establishment period 1925 1980: Growth era !980 1985: Crisis period 1985 1990: Turnaround and come back 1990 1999: Continued transformation 2000: New challenges 1900 1925 Pre-establishment Period The heavy construction equipment industry has the root in the agriculture, as tractors were used to plough the cultivating land. From there, the earth moving equipment and vehicle was developed. Invention and technological developments led to the birth of Caterpillar in 1925. 1925 1980 The period can be considered as the most successful period of the company. The period can be further divided into; pre-war (before 1936), during the war (1936 1945) and post-war (1945 1980). The pre-war sales growth can be counted in relation to developments and growth in the agriculture sector and mining sector. The demand for the companys product was exploding during the war, as the military used Caterpillars bulldozers. The demand was tremendously increased when the ruined Europe was reconstructed after the war. The growth of the company was therefore associating with the market development. The company began manufacturing in other countries and set up subsidiaries in the major markets. Thus, the company became a multinational company. The company could position itself in the market as a premium quality products manufacturer. The company held major market shares. The company was gaining high margin as its price is high. The competitors were Komatsu, John Deere and CNH Global. The competitors increased competition through various manners, especially by improving the quality and reducing the price. The company was in fact successful, despite the increasingly threatening situation of competition. In 1931, the company created a separate engine sales group to market diesel engines to other original equipment manufacturer. This group was replaced in 1953 with a sales and marketing division to better serve the needs of a broad range of engine customers. Then in 1963, Caterpillar and Mitsubishi heavy Industries Ltd formed one of the joint ventures in Japan to include U.S. ownership. Caterpillar Mitsubishi Ltd started production in 1965 in a new facility at Sagamihara, 28 miles southwest of Tokyo. In 1987 it was renamed Shin Caterpillar Mitsubishi Ltd to reflect an expansion of the original agreement. 1980 1985 Up until 1973 Caterpillar witness little competitive pressures. This enables them to possess a dominant attitude where they began raising prices for their equipment annually, almost 10%, not expanding their product line. Caterpillars corporate environment was the essence of their problems that hindered their position in the external marketplace. Since the organization was hierarchically structured it bred parochialism and risk aversion. Komatsu, a leading Japanese competitor, began gaining valuable market share away from Caterpillar. Caterpillar also witnessed a major set back in 1982 when the energy boom ended, a major recession kick in and unfavorable currency exchange. Though CAT saw their highest sales and profits in that year, the demand for heavy equipment dropped. CAT also was enduring a long UAW strike that demanded 90% higher wages than their competitor Komatsu. Ultimately CAT suffered heavy losses in the next three years to follow with sales dropping below 50%. Komatsu took advantage of the situation and began major marketing and manufacturing efforts in the US. Komatsu ended up doubling their market share to 25%. Caterpillar was forced to react. They began closing plants which amounted to 15% of its total manufacturing space and began to reduce headcount. Inventories were cut in half and the company ultimately reported $428 million dollar loss in 1984. The company responded to the situation by formulating appropriate strategies. The strategies fall basically in the category of turnaround strategies. 1985 1990 Mr George Schaefer was the first CEO after the 1980s crisis. He was a congenial manager who encourage CAT executive to openly admit the companys past mistakes and implemented the turnaround strategy. He outlines a series of initiatives designed to bring the company out of the hole. Caterpillar was to cut annual costs by 225, or $2 billion, by the end of 1986. In 1986 the company officially recognized that it was much more than just a manufacturer of tractors, and they changed their name from Caterpillar Tractor Company to just Caterpillar Incorporated. Along with this change and the reestablishment of the organization as a world leader and profitable growing company, they changed their trademark Block C logo, for a newer, more modern look. * Global outsourcing * Boarder product line * Labor relations * Employee involvement (ESP) Launched a daring factory-wide plant modernization program termed Plant with a Future, or PWAF. Initial forecasts estimated capital expenditures of $1 billion, which was revised to $1.8 billion, spread between 1986 to1992. The objective was to shift from traditional mass manufacturing to forms of advanced, flexible production through the use of just-in-time inventory techniques and sophisticated factory automation, resulting in estimated savings on manufacturing costs of 20% by late 1992. This would result in about $1.5 billion a year in savings. The long-standing functional arrangement of people and machine on the factory floor was to be dismantled. Instead, all manufacturing work was to be arranged in product and sub-product dedicated cells or modules. Looking back at Schaefers five year-long tenure, the turnover strategy and efforts were effective and successful. Caterpillar had reemerged as a global competitive company, lean, flexible and technology advanced. Caterpillars world market share rebounded up by 7 percent (from 43 percent to 50 percent), while increased the revenues by 66 percent. The success was greatly credited to the good leadership by Schaefer and his adoption of consensual approach. Though the company was in good standing in 1989, Schaefer still had a number of issues to deal with in order to ensure long term growth. 1990 1999 Donald V Fites, born on a farm in Tippecanoe, Indiana, was appointed as CEO in 1990 succeeding George Schaefer. Transformation was continued as the situation was not yet fully recovered because the stock price was lagged behind the earning. During the first two years of Mr. Schaefers retirement, the company actually lost money $2.4 billion in 1992. The reasons behind this situation were an industry-wide downturn in its domestic and international market and the increase in dollar value. Fitess leadership style was totally different from previous CEO, George Schaefer, he expects people to challenge him forcefully, his focus was more aggressive and towards customer orientation. His strategic approaches were towards reorganization, downsizing through cutting thousands of management and production jobs, expansion of worldwide computer network and diversification. Under Fitess leadership, sales had increased by approximately 85% between 1991 and 1997, with annual net income moving from a negative $404 million to a positive $1,665 million during the same period. CATs stock price reflected these financial results, showing an increase of nearly 300% from December 1992 to December 1997. Caterpillars record sales revenue came to an end in 1998-1999, as the industry sliding into a recession. Revenues and profits declining as a result of a strong dollar coupled weak demand for CAT products. The overall sales in 1999 fells by 6% and profit fell 37% below $1 billion and the return on equity fell to 17.9%. Overall, this period was not an absolutely successful period. The situation was also unstable. External shocks came and impact more frequently upon the company than previous period. The company was however more responsive to the changing situations. The company could therefore defend its position in the market. 2000 Glen Barton The year of 2000 and later was very critical to the company, as the company faced many unfavorable situations, such as downturn in the U.S. construction market and despite the rising demand in Asia and Latin America. The new CEO Glen Barton realized that he needed to ensure the future of Caterpillar in the long run and therefore embarked in the following growth strategies: * He believed that the downturn of the US market could be eliminated by an upturn in the international market. * He increased sales of Caterpillars equipment to the developing nations such as Asia, Latin America, and Eastern Europe. By doing this he created new markets for the company. * He made non truck engines incase of a decline in the truck engines. Such diversification enabled the company to produce engines even the truck engine part offset. * Under the leadership of Barton, Caterpillar started to sell mobile power modules. * Caterpillar started to rent business equipment. Barton made efforts to make dealers diversify into rentals. As successful as it is the rental distribution segment of the fastest growing segment. * He also used joint ventures to expand into new markets, and he was very successful. He formed joint ventures with Daimler Chrysler and started to produce medium duty engines. He also started to manufacture fuel systems. Those fuel systems were designed to increase efficiency of diesel engines and thereby reduce diesel emissions. Conclusion The historical analysis of the companys changes and development reveals the changing environment and the need of strategic approach. The slow reaction by the company in early days before 1980 (crisis) shook the position of the company in the industry. Aggressive approach was therefore necessary in such rapid changing environment.

Bowel cancer is the third most common cancer in the United Kingdom The WritePass Journal

Bowel cancer is the third most common cancer in the United Kingdom Introduction Bowel cancer is the third most common cancer in the United Kingdom IntroductionReferences Related Introduction Bowel cancer is the third most common cancer in the United Kingdom with approximately 35,000 new cases diagnosed each year.   1 in 16 men and 1 in 20 women will develop colorectal cancer at some point in their lives. It is also the second most common cause of cancer death, with just over 16,000 (approximately 9,000 men and 7,000 women) deaths per year (ONS, 2010) Incidence rates for colorectal cancer increased by 28 per cent for men and 11 per cent for women between 1971 and 2007.   Rates peaked at 57 per 100,000 in men in 1999 and 38 per 100,000 women in 1992. In the ten year period from 1998 to 2007, incidence rates for men and women have remained relatively stable (ONS 2010). Being overweight, having an inactive lifestyle and a low fibre diet can increase the risk of colorectal cancer. Eating red and processed meat, and insufficient amounts of fruit and vegetables, smoking and drinking excess alcohol are contributing factors. People with Crohn’s disease in the colon, ulcerative colitis, polyps in the colon or a family history of colorectal cancer may also be at an increased risk (Department of Health, 2000). More than four out of every five new cases of colorectal cancer are diagnosed in people aged 60 and over, with most cases presenting in the 70-79 age group in men and in the 75 and over age group in women (ONS, 2010). Survival from cancers of the colon and rectum has doubled in 30 years.   For colon cancer, five-year survival was 50% for men and 51% for women diagnosed in 2001-2006 and followed up to 2007.   Five-year survival for those diagnosed in 1971-1975 and followed up to 1995 was 22 per cent for men and 23 per cent for women (Rachet et al 2009). Differences in survival rates are based on how early, or at what ‘stage’, a patient presents for treatment.   This ‘staging’ is a method (first developed in 1932) of evaluating the progress of the cancer in a patient. The classification considers the extent to which the cancer has spread to other parts of the body. Once established, the best course of treatment is then decided.   There are currently for categories: Dukes Stage A: The tumour penetrates into the mucosa of the bowel wall but no further Dukes Stage B: The tumour penetrates into, but not through the muscularis propria (the muscular layer) of the bowel wall. Dukes Stage C: The tumour penetrates into, but not through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. C2: tumour penetrates into and through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. Dukes Stage D: The tumour, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone). Five year survival rates according to the Dukes’ stage of classification are:   Dukes’ Stage A 85–95%, B 60–80%, C 30–60%, D less than 10%.   These significant differences in survival rates were the basis for the introduction of a national screening programme for bowel cancer (Rachet et al 2009). The NHS Bowel Cancer Screening Programme in England began in July 2006, as part of the NHS National Cancer Plan (2000).   Patients aged between 60-69 were initially offered screening every two years and people 70 and over could request it via their GP. The criteria has since changed (from January 2010) with screening now offered to those aged 70-75 years. The objective of bowel screening is to detect bowel cancer at an early stage and get these identified patients into an appropriate treatment pathway.   The screening programme can also detect polyps, which, although are not cancers they may develop into cancers over time. They can easily be removed which reduces the risk of bowel cancer developing. This essay outlines the process of the UK bowel screening programme and from this provides a critical analysis of the test, performance and cost-effectiveness leading to a broader discussion considering   whether to implement the screening programme in relation to UK NSC criteria. Description and critical analysis of the evidence about the test performance (15 marks) Screening is defined by Raffle Gray (2007) as; ‘The systematic application of a test, or inquiry, to identify individuals at sufficient risk of a specific disorder to warrant further investigation or direct preventive action, amongst persons who have not sought medical attention on account of symptoms of that disorder.’ There is a distinct difference between screening and case finding (e.g. NHS Health Check) In clinical practice, patients approach healthcare professionals to ask for medical advice and help, in contrast with screening programmes, where professionals actively encourage people to undergo an investigation on the basis that it may benefit them. The performance of a screening programme is based on its ‘sensitivity’ and ‘specificity’.   The sensitivity of a screening test is the percentage of the screened population that has the disease and tests positive.   For instance, a sensitivity of 70% means that for every ten participants with the disease, seven will test positive and the other three will be false negatives.   A test with poor sensitivity results in a high percentage of the population with the disease escaping detection. These people will be falsely reassured and could delay presenting important symptoms. The specificity of a test is the percentage of the screened population that is disease free and also tests negative. For instance, a specificity of 80% means that eight out of ten people who do not have the disease will have a negative result. Two out of ten will have a false positive result and require further assessment before the possibility of disease can be eliminated.   A test with poor specificity will have an important effect for the individual, including increased anxiety and unnecessary clinical follow up. The ideal screening test would have a high sensitivity (to reduce the number of false negatives) and a high specificity (to reduce the number of false positives). It is usually difficult to achieve this as there is a trade off between the two measures; limiting the criteria for one results in a decrease in the other. Another key feature of a screening test is the predictive value for which there are two key aspects. The positive predictive value (PPV) of a test is the percentage of people who test positive who have the disease. The negative predictive value is the percentage of those who test negative who are disease free. The predictive value is influenced by both the sensitivity and specificity of the test, as well as the prevalence of the condition being screened for. In the UK the screening test used for the bowel screening programme is the ’faecal occult blood test’ (FOBT).   In terms of operational delivery there are approximately 20 Hubs across the country responsible for coordinating the screening programme, each Hub sends out letters of invitation to the eligible population, explaining about bowel cancer screening.  Ã‚   Standard practice ensures that within a week of receiving a letter a FOBT kit will be sent to patients.   The kits are used by the patient, samples taken and returned to the Hub, who then send normal results to individuals, and inform GPs via a standards letter.   For positive tests, the Hub contacts the individual directly, and an appointment is them made for the patient to have further investigations (colonoscopy) with the commissioned provider of colonoscopy services. The test and the framework for its operational delivery are based on a number of large scale trials which were undertaken to assess whether FOB testing of asymptomatic people could be useful in detecting individuals with early bowel cancer the largest trial conducted in Nottingham. The trials and the subsequent UK pilots (2008) found: uptake of approximately 60%, subsequent pilots returned a lower uptake which decreased with deprivation sensitivity was approximately 60% for cancer and 80% for adenomas biannual testing was as effective as annual testing screening of asymptomatic 55-75-year-olds reduced mortality from bowel cancer by 16%   overall, or by 25% in those 60% of individuals who return an FOBT there was no reduction in all-cause mortality from FOB screening. These results meant that FOBT can detect 60% of all colon cancers.   Alternatively, this also means that 40% are not routinely detected.   This lower sensitivity rate is a trade off based on the fact that FOBT screening is non-invasive, easily performed without the need for bowel preparation, and can be performed on transported specimens and of low cost.   A higher sensitivity rate could be achieved through once-only flexible sigmoidoscopy screening in prevention of colorectal cancer but uptake, patient acceptability and cost would be a barrier to population roll-out. Description and critical analysis of the evidence about the cost-effectiveness (15 marks) There are a number of research publications that compare specific models of bowel screening through the application of different these will be described, but from a public health perspective, this essay will also consider the wider opportunity cost in relation to bowel screening. Agreement relating to how cost-effective an intervention is depends on what the intervention is being compared against. For instance, a starting point in the evaluation of the UK pilot for Bowel Screening Cost-effectiveness (2003) states ‘Analysis found that the cost-effectiveness of a national programme compared well with other forms of cancer screening such as breast and cervical cancer screening.’ This statement is all about comparison with associated interventions that are deemed reasonable and safe with a generally fair return on investment this is more about acceptable levels of investment producing acceptable levels of return compared to similar interventions of the same type rather than considering whether the programme can be delivered more efficiently or could the resource be allocated in a different way to achieve the desired results. The issue of whether the programme could be delivered more cost effectively has been reviewed in a number of publications (Allison et al. 2006.   Rozen et al. 2000.   Levin et al 1997).   These comparisons have, in particular, considered the merits of; FOBT alone, flexible sigmoidoscopy and FOBT combined, and one-off colonoscopy with cost-effectiveness more often defined as the cost per cancer death prevented.   Of all the screening tests, FOBT alone prevents fewer cancer deaths than the other interventions, but the addition of a flexible sigmoidoscopy to the FOBT increases the rate of cancer prevention. One-off colonoscopy has the greatest impact on colorectal cancer mortality.   Although purported to be the most cost effective the outcomes are all based on clinical outcome alone but when considering cost FOBT returns better broader population results (in terms of patient acceptability and absolute cost to deliver) than any other of the interventions outlined. One of the most popular measures of cost effectiveness is considered through estimating the lifetime NHS costs and potential health benefits (defined as cost per QALY quality-adjusted life-years).   For bowel screening this equates to comparing the population not offered screening but treated according to current practice compared with a sample of the population who are offered screening as per the protocol used in the pilot study.   The cost per QALY is the additional costs of screening, after allowing for treatment cost savings, and the gain in survival and quality of life. The problem with QALYs has always been the question of what is the upper limit on what society is prepared to pay for health gains.   Ã‚  The National Institute for Clinical Excellence (NICE) provides some limited information about upper limits in this context.   It has been suggested that  £30,000 per QALY might represent an acceptable threshold (NICE, 2008).   Studies (Young et al, 2005. Lieberman, 2005. Khandker RZ, 2000) have returned a cost per QALY for bowel screening of between  £2,000 to  £3,000 which is well within the acceptable cost guidance offered through NICE but this does not mean that it is the more cost effective or efficient way of delivering the service. Raffle Gray (2007) touch on the issue of broader public health view and the influence of single issue groups, they outlined that; ‘If information for policy making is to serve the health needs of the public to best effect, then it must enable policy makers to keep a sense of perspective and context.   Doing this requires policy questions that are concerned with whole programmes of care, not just the single issue being considered.’ If we consider this in the context of a UK bowel screening programme costing  £50 million per year can we justify its delivery on the associated reduction in mortality of up to 16%? On face value, it seems we can (e.g. economic analysis and QALY returns etc) but that is assuming 60% uptake.   PCTs in the West Midlands are currently delivering the programme at between 28% and 42% uptake. As public health policy makers at what point do we consider the low uptake at sustained high cost as a reasonable return on investment?   There may be a greater return on investment if the  £50 million was invested in broader public health programmes targeted at reducing the population risks by changing behaviour (e.g. smoking cessation, diet, exercise). Taking this even further, could we reinvest the total  £50 million in another, unrelated, public health issue such as falls prevention programmes and tackle the risk factors associated with bowel cancer through legislation and regulation (e.g. increased taxation of tobacco or introducing a more challenging approach to price per unit for alcohol)?   In the long term, this may have more effect on a population effect on bowel cancer mortality at a lower cost. Description and analysis of the ethical issues associated with implementing this screening programme including accessibility, equity, the balance of harm and good and informed choice (15 marks) The benefits of bowel screening include a modest reduction in colorectal cancer mortality and a possible reduction in cancer incidence through the detection and removal of colorectal adenomas.   These benefits need to balanced against the potential harm of the programme.   One of these identified harms is the psycho-social consequences of receiving a false-positive result or a false-negative result, the possibility of over diagnosis (leading to unnecessary investigations or treatment) and the complications associated with treatment. Another key possible harm relates to the possibility of bowel perforation for those patients who have with a positive FOBT and require further investigation.   The UK National Bowel Cancer Screening evaluation (2003) suggested a perforation rate of 1 in 1500 colonoscopies.   This compares well with other bowel screening programmes in Australia and France which have returned a rate of 0.96 per 1000 procedures .   Following a diagnosis of perforation, most patients (over 90%) require surgery, and a significant number (30%) require colostomy or ileostomy. From a health inequalities viewpoint there are a number of issues relating to accessibility and equity that are cause for concern.   The first of these is the issues of uptake in the context of deprivation. Data for 2004-2008 shows us that there is a 11% of higher incidence rate of colon cancer for males in the most deprived population compared with the least deprived population (ONS 2008). This can be compared with uptake of screening which has demonstrated that males and younger age groups have lower uptake rates (Weller et al, 2007).   In the long term this pattern has the potential to further increase inequalities in health. There is also strong evidence that suggests certain ethnic sub-groups have lower participation rates of bowel screening than the general population (Robb et al, 2008; Szczepura et al, 2008). The reasons for these differences are complex ranging from health beliefs, misunderstanding and cultural attitudes. This defined lack of uptake by ethnic group is not evident in all screening programmes, for example, South Asian women are significantly less likely to undertake bowel screening compared to breast screening   (29% compared to 49%)   (Price et al. 2010).   This suggests more research needs to be undertaken to try and understand the key factors involved. Literacy can also be linked to deprivation and ethnicity and is a critical factor in participation in colorectal cancer screening.   As with many screening programmes a great deal of resource has been allocated to producing information and materials for the bowel cancer screening programmes – but we know that health literacy varies a great deal in the population (Von Wagner et al, 2009), and many patients will have limited comprehension of the material provided. Equity of access to diagnostic services is also a possible issue to manage. For two of the hospitals participating in the UK bowel screening pilot, there were significant differences between waiting times for colonoscopy for screened and symptomatic patients. For example, in Scotland the average waiting times for pilot patients was between 2 and 7 weeks, whereas for symptomatic patients they rose from around 10 weeks to between 16 and 20 weeks within the first year of the Pilot (Scottish Executive Health department 2006). Description of how to implement programme quality assurance and an assessment of the practical issues with implementation (15 marks) There are a number of frameworks for assessing and assuring the quality of healthcare service.   Examples include Deming’s 14 principles of management and Donabedian’s seven components of quality.   Raffle and Gray build in these two models and advocate six key points in applying quality assurance to screening. These are; Defining the objectives of the programme in a way that encapsulates what a ‘good’ screening programme will look like. Devise ways of measuring quality that will ensure these objectives are met. Set standards for each measurement; this is a subjectively chosen level that you will want the programme to achieve. Give responsibility to the local programmes for monitoring, how well they are doing in meeting the standards, and for working to improve quality in meeting those standards. Collate information about performance against standards and publications nationally for all the local programmes Provide support mechanisms for overseeing quality and for assisting local programmes with training and quality improvement. One way of doing this is by creating regional quality assurance teams. From personal experience, working with breast screening a cervical screening programmes, the need for clear standards and an overarching review process (the support mechanism) is essential.   A ‘deep dive’ approach to some of the key performance indicators is also very useful.   For example, if the target for local uptake is 60% a PCT, with the help of public health team, should approach this in terms of ensuring this uptake is achieved within the hardest to reach populations. In terms of the practical issues of implementation issues such as ease of completing the kit can be an important factor in determining uptake (The UK CRC Screening Pilot Evaluation Team, 2003).   Uptake can also be greatly affected by simple mistakes in postal address –so intended recipients do not receive the testing kit. This is one of the biggest factors associated with the uptake of an Australian trail where 20% of respondents in an Australian study claimed that they had not completed a FOB test because it had never been received in the post (Worthley at el., 2006). The Australian study also identified a preference by patients for increased GP involvement or promotion in the bowel cancer screening procedure (Salkeld et al., 2003; Worthley et al., 2006).   Many patient may prefer to have been offered screening through their GP, while almost half of those patients suggesting an alternative method of invitation wanted greater GP involvement (Worthley et al., 2006).   Similar evidence findings have emerged in the US, where a physician’s recommendation has been cited as the ‘strongest predictor’ of compliance with screening among men and women (Rabeneck, p. 1736, 2007). Overall discussion and conclusions about whether to implement the screening programme in light of the considerations already discussed and the UK NSC criteria (20 marks) Evidence suggests there is a reduction in colorectal cancer mortality as a result of introducing the UK bowel screening programme.   Following the national evaluation, it is also indicated that there was a beneficial shift towards identifying colorectal cancer at an earlier stage (e.g. Dukes Stage A).   Other benefits of screening that were not explored in this essay include the reduction in colorectal cancer incidence through detection and removal of colorectal adenomas, and potentially, less invasive treatment of identified early-stage colorectal cancers. These outcomes alone may be justification enough to continue to implement the programme in the UK. Several important additional areas require further research when deciding whether to continue with the programme or not. First, there is limited information currently available concerning the information needs and psychosocial consequences of screening for colorectal cancer.   Secondly, there is limited research on patient acceptance of colorectal cancer screening or on how best to involve particular socio-economic or ethnic groups who, as outlined previously, are often under-represented in uptake. Thirdly, the accuracy of other methods of the faecal occult blood test (e.g. RHNA) for colorectal cancer screening also requires further investigation. Maybe conclusions could be drawn through assessing the programme against the The UK NSC criteria which are considered below. NSC criteria states that all the cost-effective primary prevention interventions should have been implemented as far as practicable before consideration is given to proceed with the screening programme. This has not been the case in the UK. As outlined in this essay, greater effort could have been made to tackle the population risk factors before decision on implementing a  £50 million programme.   The screening programme could also be seen to negate the need for individuals to take responsibility for lifestyle behaviour and the risks associated with colorectal cancer. In terms of ‘The test’, it is simple, safe, precise and validated as per NSC guidance, and is generally acceptable in the population. Although, the essay has outlined the differences in uptake by socio-economic group and ethnicity. When considering ‘The Treatment’, there are effective treatments for patients identified through early detection, and this evidence has shown to lead to better outcomes than late treatment. The Screening Programme is based on good evidence from high quality Randomised Controlled Trials that the screening programme is effective in reducing mortality or morbidity and there is evidence that it is   clinically, socially and ethically acceptable to health professionals and the public. The benefits from the screening programme also outweigh the physical and psychological harm (caused by the test, diagnostic procedures and treatment).   The opportunity cost of the screening programme resource has been touched upon in this essay. The view is that all other options for managing the condition have not been fully considered, particularly primary prevention. 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