Getting transparency right

This is about transparency, when it is useful and when it is not. The term is now an established part of the health care lexicon, but there is little substantive discussion about how it is being used.

As I said in an article in Business Week over three years ago:

There are often misconceptions as people talk about "transparency" in the health-care field. They say the main societal value is to provide information so patients can make decisions about which hospital to visit for a given diagnosis or treatment. As for hospitals, people believe the main strategic value of transparency is to create a competitive advantage vis-à-vis other hospitals in the same city or region. Both these impressions are misguided.

Transparency's major societal and strategic imperative is to provide creative tension within hospitals so that they hold themselves accountable. This accountability is what will drive doctors, nurses, and administrators to seek constant improvements in the quality and safety of patient care.

Now, there rises an additional misconception. The perversion of the transparency concept that has evolved rides on the desire of CMS and private insurance companies to use publicly published outcome data to financially reward or penalize hospitals. As expected, this is raising hackles. The complaints often heard from hospitals are ones we have discussed before: "The data are wrong." "Our patients are sicker."

I am not going to accept those complaints, but I am going to suggest that the usual government mandates for transparency of data provide little basis for the kind of process improvement we need in hospitals. What's wrong with these mandates?

For one thing, the data are old. While you cannot manage what you do not measure, trying to manage with data that are a year or two or more older is like trying to drive viewing the road through a rearview mirror. The principles of Lean process improvement and other such systems suggest that real time "visual cues" of how the organization is doing are essential. Why? Because that kind of data is indicative of the state of the organization right now, not what existed months or years ago. Such data are collected in hospitals on a current basis. If their main purpose is to support process improvement, they do not need external validation or auditing to be made transparent in real time.

For another thing, the choice of data in the government's approach to transparency is externally imposed. Process improvement occurs when the people who do the work jointly decide what areas of change are important. We need to trust that the clinicians and administrators in hospitals, working with their patients and boards of trustees, are better able to decide on quality and safety priorities than the government or its agents. We want the hospitals to be transparent about the metrics they choose, knowing that their doctors, nurses, other staff will value the results highly and act on them.

Finally, the payers' approach to transparency creates attention on meeting certain outcomes, rather than stimulating a desire to design and implement a comprehensive structure to achieve better outcomes. A wise colleague said recently, "Obsession with outcome without obsession with structure will fail."

Captain Sullenberger talked about this in another respect: "A checklist alone is not sufficient. What makes it effective are the attitude, behavior, and teamwork that goes along with the use of it."

In summary, transparency of data alone is not sufficient. What makes it powerful in establishing creative tension in an organization are: The currency of the data; the fact that the metrics being made transparent have been chosen by those involved in the process improvement efforts; and the fact that the transparent outcomes are supported by a structure of ongoing process improvement.

As we have seen by examples on this blog, those hospitals that have been most effective in the challenge of process improvement have not done so because a government agency is making their clinical outcomes transparent. They have done so because the administrative and clinical leadership, strongly supported and encouraged by boards of trustees, have made it clear that this kind of effort is a top priority. More and more places each month have discovered the importance of transparency in supporting their efforts. How this takes place will be specific to each hospital, but it is clear that, to be effective and sustainable, change must come from within.

Why an airline ticket agent needs a driver's license?

Access to a vehicle with a valid driver's license is sometimes necessary or recommended for many jobs as a means for the employer to ensure that they could get to work on time or sometimes someone cover change, if necessary .

Drive a car

For an airline ticket, I would assume you need a driver's license to drive one of these cars inside the airport. The license just means that you are qualified to operate a motor vehicle.

You know there are two ways to work at home

1 - A work at home work - usually hard to come by and pay very little. You are still working for someone else and only do what they want you to do. It is a job so there will be no upfront costs.

2 - A home based business. If you can find the right one, you will reap the rewards forever. This business is a business of brick and mortar, but at a fraction of the cost. Generally, you will pay an initial cost ($ 10 - $ 500).  

Usually a monthly fee to cover the above websites or from another company. What is minimal compared to if I had a brick and mortar business (electricity, sewerage, inventory, etc.) There are limits to the amount of money you can make and the business is usually willable and sellable!

What is the  difference

After trying and trying finally decided to Reply # 2. I seem to have made ​​a career out of failing home-based businesses before finding the right one. I like helping people make informed decisions about working at home.

Success

I have been very successful at work and at home for several years. It's something you have to put your mind and be determined to succeed no matter what. There are many naysayers and negative people out there. Just put the blinders on and go full speed with what you choose to do.

How I can obtain employment in the UK or in another country?

It is not easy. You can not just up and move. To get a job that is the hardest part.You have to to have a skill they need . You can look over their list of skills shortages, which I will provide links to.  

Have Skills

If you do not have one of those skills, you will have to find an employer willing to hire you, and they must demonstrate that they have published an advertisement for the post and could not hire anyone for a British or EU Nationals.  

In either case, the employer must apply for a work permit on their behalf, after which you can obtain a visa. You or your employer will pay for the visa, depending on the company.
 
Here are some links for you.

http://www.ukvisas.gov.uk/en/

http://www.skillclear.co.uk/index2.asp

http://www.ukba.homeoffice.gov.uk/workin…

Polymyalgia Rheumatica: A misunderstood but common condition.

      In the summer of 2008, as a veteran (victim?) of 33 years of medical practice, I was feeling ready to retire. I was planning to enter the world of retirees at the end of the year. But in July of that year I began getting some strange symptoms of painful knots developing over my scalp. The first of these nodules was located on my left temple and itched. But it was also sore to the touch or when compressed. At first I thought it was an insect bite because I know when we apply insect repellent we don't always apply it so close to the eyes. I reasoned that a mosquito might have found me there. But then I got another such nodule on the right side. I decided to seek out my internist. She didn't know what these were but when I mentioned the possibility of temporal arteritis, though she clearly doubted it, she ordered the confirming blood test, called a sedimentation rate. This is a non specific test but if abnormally elevated in the presence of the correct symptom complex, it makes the diagnosis of this autoimmune condition, one of a group of disorders called vasculitis, or inflammation of blood vessels. Well, at this early stage of the disease, the sed rate was normal. So we both pooh poohed my worries and I went home. But over the next month, these tender nodules began to appear all over my scalp. It became hard to put my head on the pillow while trying to avoid pressure on these nodules. Finally I decided I better take my symptom constellation to a rheumatologist in our clinic. He really didn't buy this as temporal arteritis either.
      I still ask myself why neither of these doctors thought that is what I had. The textbook description of the symptoms of temporal arteritis includes many things among them headaches, fatigue, fever, etc, but one of the classic symptoms is painful swellings over the scalp. So I don't know why these doctors had to be convinced. Maybe because I let them know what I thought I had and since I was a doctor, they had to stand defensively. I don't know ----.
     Anyway, the rheumatologist did order the sed rate and now a month later it was elevated to 3 times normal. The doctor called me back and immediately started me on 60 mgm of prednisone a day. There is a risk of blindness or stroke in temporal arteritis because this inflammation can block the blood vessel not letting oxygen get through to cause these severe complications. That is why treatment is done with such high doses of prednisone. I later had a biopsy of one of these temporal arteries and it confirmed the diagnosis. Usually this disease is self limited and eventually under the cover of the prednisone treatments goes away. The prednisone is weaned slowly down and then stopped usually over about 1 to 1 1/2 years. I was able to wean it down, but on one occasion with a return of the symptoms a little bit, I had to increase the dose back up a little. By February, 2010 I was able to get off the prednisone.
     But now a new problem raised its head. I began to get muscle pains. At the time I was changing my cholesterol medication and both I and my internist knew that those drugs could cause muscle pains. I mistakenly attributed the pains to that change in cholesterol meds. Also at that time we took our trip to Moldova and Eastern Europe. I suffered through that trip, sometimes almost unable to walk due to pains in the hips and back. Now there is a constellation of symptoms called polymyalgia rheumatica which often can be associated with temporal arteritis. The muscles hurt because there is inflammation in the small blood vessels going to the muscles, another form of vasculitis. I knew that this could be associated with temporal arteritis but I had never had these symptoms as a part of my symptom complex. Well when I got back from Moldova, I contacted the rheumatologist, we rechecked the sedimentation rate and it was back up a little bit. So apparently the very low doses of prednisone as I weaned off of it had held this disorder in check, and now my vasculitis was manifesting itself in this way only after stopping the prednisone completely. Well, the good part is that such high doses of prednisone are not required to treat this disorder and so I was able to get good relief by going just back to 10 mgm per day -- a dose that I could easily tolerate and which didn't mess up my sugar control like the 60 mgm did. I have now been slowly weaning down the prednisone over the ensuing year. (Usually like temporal arteritis, polymyalgia rheumatica take about 1 to 1 1/2 years to go away.) At a recent visit about 3 weeks ago, my rheumatologist and I decided since I had been on only 1 mgm prednisone for about 4 months without any symptoms, that I could try going off the drug which I did. Well, guess what. Within a week, my muscles were aching again. I thought to give it some time to see if this was just from working in the garden too much. (The symptoms are somewhat non specific, so sometimes it is difficult to tell them from just general achiness that we all have as we get older.) Now it has been 3 weeks and the aching is getting worse, is interfering with sleep, and is keeping me from doing the things I like to do, like my water aerobics, and my gardening. Today I put a call back in to my rheumatologist and I know I will have to go back on prednisone, probably at about 4 mgm or so and then wean down. What a bummer!

     Polymyalgia rheumatica (PMR) is confused with a number of other myalgias (muscle pains). First there is fibromyalgia which is far more common, though PMR is not uncommon. Fibromyalgia is somewhat of a mystery in cause, but it is thought to have to do with the pain nerve fibers leading from muscles which get into a habit of sending pain messages for no particular reason. Unlike PMR, there is nothing visibly or even microscopically seen to be wrong with the muscles or with the nerves. The cause of fibromyalgia is deduced more from the types of medications that helps it -- meds that are used to treat seizures, or nerve pain. There is another form of myalgia (pain in muscle) which is associated with inflammation in the muscle itself, not in the blood vessels like PMR. This is also an autoimmune disorder but the treatment is different, usually requiring medications that are used to treat rheumatoid arthritis. All of these muscle disorders and pain syndromes have one thing in common. The exact underlying cause is not known.
     I will have to let you know, but it looks like I will have to get back on prednisone. My visits to my doctors, and my encounter with the medical profession from the patient side of the desk continues.

What could I make and sell to teenagers?

Advice 1

sell soft drinks at school and is fround upon but I buy from Woolworths cheaper and sell at school for $ 2 each carry in my bag.

I bring 15 a day, I get $ 30 per day I get $ 150 per week and everyone wants more and more. if sold soft drinks have to be careful that there are no teachers to find, but make it much money. I'm saving so you can buy a vending machine so I can make even more money

Advice 2

Selling candidates like Twix bars, Snickers and Kit Kat. trust me, you will make a profit large enough over time. This girl in my school sells chocolate bars every day, she is my friend and she and tons of money, a few hundred extra dollars

Advice 3

I have a brilliant idea for you and this is what I used to do as a teenager ...

Buy some buttons, some of elastic eBay and make some bracelets and re-sell for like $ 5.00 and have only spent a few cents on each wrist if they break down. Goth and EMO Girls go for the kitsch look all the time. I think it would be a popular sale. From here you can make $ 50.00 or $ 75.00 a week.

Another thing I used to do was make my own clothes. You could get a cheap sewing machine and a "How To" Guide to Amazon and make your own clothes. Place ornaments and charms of the skull or spider / brooch pins. Add lace. Click EMO gothic clothing or appearance.

How I can cancel an order online?

Contact the company and see if it's not too late to review the application. That has not been sent, however, you may be able to do so. If you have sent, find out what the return policy is.  

If you do not allow the return / refund, you may be able to refuse the delivery. If sent by U.S. mail, you can deny anything. Then you can make a claim in writing to your credit card company.  

If they see that the item was returned, it is likely to reverse the charge, less shipping cost. You will not be able to keep the company that if withdrew from the agreement.

How I can get a license for Small Business in Georgia?

I operate a small jewelry business online. I get my business license so that eventually can expand and open a retail store. What are the steps to take to get a license? Nor have I registered my name so I have to do it before or after obtaining a license?

Have it Your Way
 
There are different requirements of the business license in the state, county and city levels. To ensure compliance with all http://www.businesslicenses.com/ visit or http://www.businesslicenses.com/Licenses/GA/ level. Business Licenses, LLC experienced licensed professionals can help you obtain all necessary licenses to operate a jewelry business in Georgia.

I would like teaching my child about credit, How to do it?

Start small.

• Teach about the early savings. Open a savings account for them.
• Then, when they are around 13-15 to open a checking account with them.
• Teach them how to handle the debit card.

Teens

So ... when they are 16 or 17 years become an authorized user on a credit card. Do this only if you pay your credit card in full eachmonth after the completion balances can now easily reduce both credit ratings.

Also

Turn it into a lesson. Give your child a credit account with you and the lender. When your child wants something they agree to buy and then "bill" to his son for the item purchased. If your child does not return the money over time begin to turn in the interest (just below their allocation or something).
 
And
 
Explain that a credit card is not free money, as portrayed. Explains that everything that is bought on credit must be paid at one time or another. And credit is the amount of people get into debt so bad that they can never leave. It's a good thing to teach a child from the beginning.

What can I do for to get off my house lease?

A lease is usually a contract in which state it will occupy for a specified period of time for a specific amount of money.  

They are used to provide the landlord with the knowledge that you have a steady cash flow from your property. It also allows the tenant peace of mind that can not be forced to move in that amount of time.

All that being said, paid money to sign the lease?  

Have you made ​​a deposit or paid money for something related to this property? You may be able to cancel the lease based on the fact that no money changed hands. If you give money, which consummated the deal.

Please read your Lease

Read your lease. It will tell you what can or can not do. Contact the owner to see if they are open to keep out of the agreement, or the penalties to be paid for breaking his contract. Think twice the next time you sign a contract.