The Short Second Life of Bree Tanner Chapters 10

Before I could process this, Riley roared out an animalistic shriek of rage. He was staring down at the ashy remains on the floor, his eyes bulging in fury. Everyone stood silent, immobile. We'd al seen Riley lose his temper, but this was something different. Riley spun and raked his fingers through a blaring speaker, then ripped it from the wal and hurled it across the room. Jen and Kristie dodged out of the way as it exploded into the far wal, sending up a cloud of pulverized drywal dust. Riley smashed the sound system with his foot, and the thudding bass went silent. Then he leaped to where Raoul stood, and grabbed him by the throat. â€Å"I wasn't even here!† Raoul yel ed, looking afraid – I'd never seen that before. Riley growled hideously and threw Raoul as he'd thrown the speaker. Jen and Kristie jumped out of the way again. Raoul's body crashed right through the wal, leaving an enormous hole. Riley caught Kevin by the shoulder and – with a familiar screech – ripped off his right hand. Kevin cried out in pain and tried to twist out of Riley's grip. Riley kicked him in the side. Another harsh shriek and Riley had the rest of Kevin's arm. He tore the arm in half at the elbow and threw the pieces hard into Kevin's anguished face – smack, smack, smack, like a hammer striking stone. â€Å"What is wrong with you?† Riley screamed at us. â€Å"Why are you al so stupid?† He made a grab for the blond Spider-Man kid, but that kid leaped out of his way. His jump left him too close to Fred, and he stumbled back toward Riley again, gagging. â€Å"Do any of you have a brain?† Riley smacked a kid named Dean into the entertainment center, shattering it, then caught another girl – Sara – and tore her left ear and a handful of hair from her head. She snarled in anguish. It became suddenly obvious that Riley was doing a very dangerous thing. There were a lot of us in here. Already Raoul was back, with Kristie and Jen – usual y his enemies – flanking him defensively. A few others banded together in clusters around the room. I wasn't sure if Riley was aware of the threat or if his rant came to an end natural y. He took a deep breath. He tossed Sara her ear and the hair. She recoiled away from him, licking the torn edge of her ear, coating it with venom so that it would reattach. There was no remedy for the hair, though; Sara was going to have a bald spot. â€Å"Listen to me!† Riley said, quiet but fierce. â€Å"Al our lives depend on you listening to what I'm saying now and thinking! We are al going to die. Every one of us, you and me, too, if you can't act like you have brains for just a few short days!† This was nothing like his usual lectures and pleadings for control. He definitely had everyone's attention. â€Å"It's time for you to grow up and take responsibility for yourselves. Do you think you get to live like this for free? That al the blood in Seattle doesn't have a price?† The little clusters of vampires no longer seemed threatening. Everyone was wide-eyed, some exchanging mystified glances. I saw Fred's head turn toward me in my peripheral vision, but I didn't meet his gaze. My attention was focused on two things: Riley, just in case he started to attack again, and the door. The door that was stil closed. â€Å"Are you listening now? Real y listening?† Riley paused, but no one nodded. The room was very stil . â€Å"Let me explain to you the precarious situation we are al in. I'l try to keep it simple for the slowest ones. Raoul, Kristie, come here.† He motioned to the leaders of the two largest gangs, al ied for this brief moment against him. Neither of them moved toward him. They braced themselves, Kristie baring her teeth. I expected Riley to soften, to apologize. To placate them and then persuade them to do what he wanted. But this was a different Riley. â€Å"Fine,† he snapped. â€Å"We're going to need leaders if we're going to survive, but apparently neither of you is up to the task. I thought you had aptitude. I was wrong. Kevin, Jen, please join me as the heads of this team.† Kevin looked up in surprise. He had just finished putting his arm back together. Though his expression was wary, it was also unmistakably flattered. He slowly got to his feet. Jen looked at Kristie as if waiting for permission. Raoul ground his teeth together. The door at the top of the stairs did not open. â€Å"Are you not able, either?† Riley asked, irritated. Kevin took a step toward Riley, but then Raoul rushed him, leaping across the long room in two low bounds. He shoved Kevin against the wal without a word and then stood by Riley's right shoulder. Riley permitted himself a tiny smile. The manipulation wasn't subtle, but it was effective. â€Å"Kristie or Jen, who wil lead us?† Riley asked with a hint of amusement in his voice. Jen was stil waiting for a sign from Kristie as to what she should do. Kristie glowered at Jen for an instant, then flipped her sandy hair out of her face and darted to stand on Riley's other side. â€Å"That took too long to decide,† Riley said seriously. â€Å"We don't have the luxury of time. We don't get to fool around anymore. I've let you al do pretty much whatever you feel like, but that ends tonight.† He looked around the room, meeting everyone's eyes, making sure we were listening. I held his gaze for only a second when it was my turn, and then my eyes flipped back to the door. I corrected instantly, but his glare had moved on. I wondered if he'd noticed my slip. Or had he seen me at al, here beside Fred? â€Å"We have an enemy,† Riley announced. He let that sink in for a moment. I could tel the idea was shocking to several of the vampires in the basement. The enemy was Raoul – or if you were with Raoul, the enemy was Kristie. The enemy was here, because the whole world was here. The thought that there were other forces out there strong enough to affect us was new for most. Would have been new to me, too, yesterday. â€Å"A few of you might be smart enough to have realized that if we exist, so do other vampires. Other vampires who are older, smarter†¦ more talented. Other vampires who want our blood!† Raoul hissed, and then several of his fol owers echoed him in support. â€Å"That's right,† Riley said, seeming intent on egging them on. â€Å"Seattle was once theirs, but they moved on a long time ago. Now they know about us, and they are jealous of the easy blood they used to have here. They know it belongs to us now, but they want to take it back. They are coming after what they want. One by one, they'l hunt us down! We'l burn while they feast!† â€Å"Never,† Kristie growled. Some of hers and some of Raoul's growled, too. â€Å"We don't have a lot of choices,† Riley told us. â€Å"If we wait for them to show up here, they wil have the advantage. This is their turf, after al . And they don't want to face us head-on, because we outnumber them and we are stronger than they are. They want to catch us separated; they want to take advantage of our biggest weakness. Are any of you smart enough to know what that is?† He pointed at the ashes at his feet – now smeared into the carpet and unrecognizable as a former vampire – and waited. No one moved. Riley made a disgusted sound. â€Å"Unity!† he shouted. â€Å"We don't have it! What kind of a threat can we pose when we won't stop kil ing each other?† He kicked the dust, sending up a smal black cloud. â€Å"Can you imagine them laughing at us? They think taking the city from us wil be easy. That we're weak with stupidity! That we'l just hand them our blood.† Half the vampires in the room snarled in protest now. â€Å"Can you work together, or do we al die?† â€Å"We can take them, boss,† Raoul growled. Riley scowled at him. â€Å"Not if you can't control yourself! Not if you can't cooperate with every single person in this room. Anyone you take out† – his toe nudged the ashes again – â€Å"might be the one who could have kept you alive. Every one of your coven that you kil is like handing our enemies a gift. Here, you're saying, take me down! â€Å" Kristie and Raoul exchanged a glance as if they were seeing each other for the first time. Others did the same. The word coven was not unfamiliar, but none of us had applied it to our group before. We were a coven. â€Å"Let me tel you about our enemies,† Riley said, and al eyes locked on his face. â€Å"They are a much older coven than we are. They've been around for hundreds of years, and they've survived that long for a reason. They are crafty and they are skil ed and they are coming to retake Seattle with confidence – because they've heard the only ones they'l have to fight for it are a bunch of disorganized children who wil do half their work for them!† More growls, but some were less angry than they were wary. A few of the quieter vampires, the ones Riley would have cal ed tamer, looked skittish. Riley noticed that, too. â€Å"This is how they see us, but that's because they can't see us together. Together, we can crush them. If they could see al of us, side by side, fighting together, they would be terrified. And that's how they're going to see us. Because we're not going to wait for them to show up here and start picking us off. We're going to ambush them. In four days.† Four days? I guessed our creator didn't want to cut it too close to the deadline. I looked at the closed door again. Where was Diego? Others reacted to the deadline with surprise, some with fear. â€Å"It's the last thing they'l expect,† Riley assured us. â€Å"Al of us – together – waiting for them. And I've saved the best part for last. There are only seven of them.† There was an instant of incredulous silence. Then Raoul said, â€Å"What?† Kristie stared at Riley with the same disbelieving expression, and I heard muttered whispers around the room. â€Å"Seven?† â€Å"Are you kidding me?† â€Å"Hey,† Riley snapped. â€Å"I wasn't joking when I said this coven is dangerous. They are wise and†¦ devious. Underhanded. We wil have power on our side; they wil have deception. If we play it their way, they will win. But if we take it to them on our terms†¦Ã¢â‚¬  Riley didn't finish, he just smiled. â€Å"Let's go now,† Raoul urged. â€Å"Let's get 'em out of the picture fast.† Kevin growled enthusiastical y. â€Å"Slow down, moron. Rushing into things blind isn't going to help us win,† Riley chided him. â€Å"Tel us everything we need to know about them,† Kristie encouraged, shooting Raoul a superior look. Riley hesitated, as if deciding how to word something. â€Å"Al right, where to begin? I guess the first thing you need to know is†¦ that you don't know everything there is to know about vampires yet. I didn't want to overwhelm you in the beginning.† Another pause while everyone looked confused. â€Å"You have a little bit of experience with what we cal talents.' We have Fred.† Everyone looked at Fred – or rather they tried to. I could tel from Riley's expression that Fred did not like being singled out. It looked like Fred had real y turned up the volume on his â€Å"talent,† as Riley cal ed it. Riley cringed and looked away quickly. I stil didn't feel anything. â€Å"Yes, wel, there are some vampires who have gifts beyond the usual super strength and super senses. You've seen one aspect in†¦ our coven.† He was careful not to say Fred's name again. â€Å"Gifts are rare – one in fifty, maybe – but every one is different. There's a huge range of gifts out there, and some of them are more powerful than others.† I could hear a lot of murmurs now as people wondered if they might be talented. Raoul was preening like he'd already decided he was gifted. As far as I could tel, the only one around here that was in any way special was standing next to me. â€Å"Pay attention!† Riley commanded. â€Å"I'm not tel ing you this for entertainment.† â€Å"This enemy coven,† Kristie interjected. â€Å"They're talented. Right?† Riley gave her an approving nod. â€Å"Exactly. I'm glad someone here can connect the dots.† Raoul's upper lip twitched back over his teeth. â€Å"This coven is dangerously talented,† Riley went on, his voice dropping to a hushed whisper. â€Å"They have a mind reader.† He examined our faces, looking to see if we got the importance of this revelation. He didn't seem satisfied with his assessment. â€Å"Think, guys! He'l know everything in your head. If you attack, he'l know what move you're going to make before you know it. You go left, he'l be waiting.† There was a nervous stil ness as everyone imagined this. â€Å"This is why we've been so careful – me, and the one who created you.† Kristie flinched away from Riley when he mentioned her. Raoul looked angrier. Nerves strained universal y. â€Å"You don't know her name, and you don't know what she looks like. This protects us al . If they'd stumbled across one of you alone, they wouldn't realize that you were connected to her, and they might have let you be. If they knew you were part of her coven, there would be no delay in your execution.†

Suggestions Canada health care

This essay will discuss the budget constraint model to understand the consumer behaviors towards health care and the Issue of adverse selection will also be analyzed, followed by the production of health care and the role f the government in the production of health care. This essay will conclude with suggestion of the lessons that policy makers in Canada can learn. Any of the economic models that exist must have assumptions; assumptions must be fulfilled to assert constancy.In the standard budget constraint model, there are three assumptions: (1) consumers are rational and have perfect information about quantity, pricing and the key players in healthcare, (2) there Is no uncertainty about the future, and (3) Important decisions are made as If the future Is known with certainty. Consumers can choose any affordable combination of healthcare and other odds. Among these bundles, consumer has a set of preference which provided different levels of satisfaction. The budget constraint model states that the demand for medical services is derived from the demand for health care and how the consumer produces health.Consumers do not purchase health. Indeed, they medical care inputs. An example of the Indian health market supports this model. India has a universal health care system of which government covers most medical services provided, similar to Canada. In India, many of the healthcare consumers are not able to produce health. Their ability to produce health is reduced by the poor vying conditions and living style. Patina in India is a slum; it is characterized with poverty, which encompasses low levels of health and income. People in this town are suffering in poverty and disease.Patina has been hit by the epidemics and develops symptoms that are attributed to tuberculosis due to poor sanitation and ventilation. They repeatedly require medical care. However, public-health system lacks the medical resources, leaving poor people at risk. This has forced consumer to sw itch to the private healthcare, but they cannot afford it. These poor people are often the cities, caught between lousy care and unaffordable care (Specter, 2010). Consumers have limited budget and, hence, healthcare production is restricted by their budget, so they have to look for the best affordable bundle of goods to meet their needs.Under lousy universal health care system, consumers are very much constrained in their choices. Policy makers must understand the budget constraints that the consumer faces. To formulate successful policies, policy makers must also consider the bundles that the consumer is permitted and regulate the private healthcare services to reasonable price (Specter, 2010). Government should also devote sufficient resources to improve the quality of care in the public sector and raise the level of nutrition and the standard of living of its people to reduce healthcare costs.Similar policies could also apply in Canada to improve our public healthcare system. Pr ivate companies that offer health insurance often encounter adverse selection. This phenomenon can be explained by asymmetric information when insurance attracts higher than average utilizes than an actual fair premium suggest. Clients purchasing insurance know their actual expenditures whereas the insurance many only knows the distribution of expected expenditures. In this market, the higher health risks tend to drive out the lower health risk people until no market is left; this is known as the Lemons Principle.This is inefficient since insurance company is not able to sufficiently pool its risks. In the U. S, congress passed the Genetic information Nondiscrimination act. This act prohibits insurance company from using genetic information to determine rates (Coursework, 2010). Genetic testing provides the insurance company with pre-existing conditions, which gives insurer incentive to deny coverage or set a higher premium. This bill was unanimously supported by congress such that insurer cannot charge higher premiums based on pre-existing conditions.The main idea of this bill is to protect the community from exploitation by insurance companies, which lead to community rating. At this time, private insurers cannot rely on medical underwriting. However, this act turns the insurance companies into oppression. The only factors they will be allowed to take into account in determining rates will be age, region, and whether or not someone smokes. While the government supports the community rating and universal access, it conflicts with its insistence of that the healthcare reform is dependent on private insurance companies (Coursework, 2010).Yet, the fact is that healthcare system could do Just fine without an insurance system with community rating. Medicare is a and people with disabilities. It may be true to say that private sectors are better in terms of managing costs and providing services, but Medicare's spending on healthcare over the past decade has risen m ore slowly than that of private sectors (Coursework, 2010). Economists all agreed that Medicare is a successful program, but that it needs efficiency improvements to be sustainable in the future (Walker, 2010). Canada can imitate from the success of Medicare in the US.Medicare in Canada is framed by the Canada Health Act; it is designed to ensure that all residents have reasonable access to medical services, on a prepaid basis. Using our existing insurance system, policy makers should expand the government-run health care regardless of risks. Instead of replacing private insurance companies, it would be more sensible to turn them into public utilities. Netherlands and Switzerland have adopted this proposal, which turns out with reasonably good results. Government has a very large role to play in the production of health services.Production of health services is the relationship between health and the health inputs that are needed to produce health. The Case in most developed countri es is that the government plays a significant role in health production (Coursework, 2010). The government provides health care which is either paid with taxes it collects or subsidy that are given to individuals. The government provides other inputs such as controlling pollution and legislation to regulate health safety. The government also carries out health promotion. This is done by promoting healthy lifestyles such as exercise and also raising awareness about diseases.The government also puts regulation on excessive consumption of harmful substances. All this defines the role the government is supposed to play in the provision of healthcare. In conclusion, policymakers in Canada can learn from the lessons discussed. Starting with the example of the Indian health market, policy makers should consider budget constraints particularly for the poor people to devote sufficient resources into public health care to improve the laity and regulate the private health care system with reas onable prices.Government could also raise the level of nutrition and the standard of living of its people to reduce healthcare costs. Secondly, from the US example, it is proven that the healthcare reform does not depend on private insurance companies. Medicare in Canada should also be expanded and private insurer can be turned into public utilities. Finally, though the Canadian government provides medical care, it is important for them to promote health as well. Provision of medical care must go hand in hand with the promotion of health as the case with other developed entries.

Knowledge Management Essay

It involves applying the collective knowledge and abilities of the entire workforce to achieve specific organizational objectives. State agencies should feel free to adapt and use information and tools on the following pages as necessary within their organization. It is provided to be a starting point for sharing knowledge and experience, allowing those who remain with the organization to continue providing quality service. Capturing and sharing critical knowledge and expertise should be occurring continuously among employees. In many cases, however, it is not and this need becomes pressing when a valued employee is preparing to retire or change positions. When an organization is considering implementing a knowledge transfer plan it is important to answer several questions: 1. Is the organization going to fill the vacant position or reassign the duties? 2. Are all the duties of the position still important to the mission of the organization? 3. Is there a need to update the position description? 4. Will the position change, remain as is, or be eliminated once the employee leaves? What is knowledge transfer? David DeLong’s book â€Å"Lost Knowledge† describes knowledge as the â€Å"capacity for effective actions or decision-making in the context of organizational activity†. Accordingly, lost knowledge would decrease this vital capacity and help undermine organizational effectiveness and performance. The goal of transferring knowledge to others [known as Knowledge Transfer] is to: 1. Identify key positions and people where potential knowledge loss is most imminent. 2. Assess how critical the knowledge loss will be. Develop a plan of action to ensure the capture of that critical knowledge and a plan of action to transfer it. Why is knowledge transfer important? A significant percentage of the state’s workforce is nearing retirement age over the next ten years. These employees have acquired a tremendous amount of knowledge about how things work, how to get things done and who to go to when problems arise. Losing their expertise and experience could significantly reduce efficiency, resulting in costly mistakes, unexpected quality problems, or significant disruptions in services and/or performance. In addition, faster turnover among younger employees and more competitive recruiting and compensation packages add significantly to the mounting concern about the state’s ability to sustain acceptable levels of performance. What are the benefits of a knowledge transfer program? Knowledge transfer [KT] programs prevent critical knowledge loss by focusing on key areas. Some of the immediate benefits of KT programs are: 1. They provide reusable documentation of the knowledge required in certain positions or job roles. 2. They result in immediate learning and knowledge transfer when carried out by individuals who can either use the transferred knowledge themselves or have responsibility for hiring, training, mentoring, coaching or managing people within an organizational unit. 3. They reduce the impact of employee departure. 4. They integrate staffing, training, job and organization redesign, process improvements and other responses. 5. They aid in succession planning. 6. They prevent the loss of knowledge held only in employees’ heads when they leave the organization or retire. They enhance career development. Generally Accepted Definitions for Knowledge Management and Transfer Knowledge Management (KM) refers to practices used by organizations to find, create, and distribute knowledge for reuse, awareness, and learning across the organization. Knowledge Management programs are typically tied to organizational objectives and are intended to lead to the achievement of specific outcomes such as shared intelligence, improved performance, or higher levels of innovation. Knowledge Transfer (an aspect of Knowledge Management) has always existed in one form or another through on-the-job discussions with peers, apprenticeship, and maintenance of agency libraries, professional training and mentoring programs. Since the late twentieth century, technology has played a vital role in Knowledge Transfer through the creation of knowledge bases, expert systems, and other knowledge repositories. To understand knowledge management and knowledge transfer, it is helpful to examine the differences between data, information, and knowledge. Data is discrete, objective facts. Data is the raw material for creating information. By itself, data carries no judgment, interpretation or meaning. Information is data that is organized, patterned and/or categorized. It has been sorted, analyzed and displayed, and is communicated through various means. Information changes the way a person perceives something, thus, affecting judgment or behavior. Knowledge is what is known. It is richer and more meaningful than information. Knowledge is gained through experience, reasoning, intuition, and learning. Because knowledge is intuitive, it is difficult to structure, can be hard to capture on machines, and is a challenge to transfer. We often speak of a â€Å"knowledgeable person,† and by that we mean someone who is well informed, and thoroughly versed in a given area. We expand our knowledge when others share theirs with us. We create new knowledge when we pool our knowledge together.

Improving Communication for People with Learning Disabilitie

learning zone CONTINUING PROFESSIONAL DEVELOPMENT Page 58 Improving communication for people with learning disabilities Page 66 Learning disabilities multiple choice questionnaire Page 67 Read Annette Martyn’s practice profile on type 2 diabetes Page 68 Guidelines on how to write a practice profile Improving communication for people with learning disabilities NS336 Godsell M, Scarborough K (2006) Improving communication for people with learning disabilities. Nursing Standard. 20, 30, 58-65. Date of acceptance: February 6 2006. Summary Patients with learning disabilities have higher healthcare risks than the general population. Similar essay: Collate Information About an Individual's Communication and the Support ProvidedHealth professionals need to develop skills that enable them to communicate effectively with this patient group. Identifying barriers to communication is the first step to reducing or removing them. Suggested strategies to improve healthcare access for patients with learning disabilities include: developing individualised health action plans, simplifying communication styles and providing accessible facilities and tailored resources. learning activities you should be able to: Understand the impact of communication on interaction between healthcare providers and patients with learning disabilities.Describe the relationship between communication and the health inequalities experienced by people with learning disabilities. Identify strategies to improve communication between health providers and patients with learning disabilities. Authors Matthew Godsell and Kim Scarborough are senior lecture rs, Faculty of Health and Social Care, University of the West of England, Bristol. Email: Matthew. [email  protected] ac. uk Introduction Learning disability is not a diagnosis but a term used to describe people with a wide range of strengths and needs.Eighty per cent of children and 60 per cent of adults with learning disabilities live with their families (Gravestock and Bouras 1997), and many people with learning disabilities exceed the expectations of families and professionals in their capacity to learn new skills and develop their talents (NHS Executive 1999). The term ‘learning disability’ says little about an individual’s strengths and needs but it does incorporate three elements that appear in most definitions (Box 1). Emerson et al (2001) state that the number of people with learning disabilities in the UK has not been determined.They estimate that in the UK there could be as many as 350,000 people with severe learning disabilities (intelligence quotie nt (IQ) 50). This means that 2 per cent of patients are likely to have a learning disability (NHS Executive 1999). The ways in which people with learning disabilities are described have changed. Terminology and related facts are listed in Box 2. NURSING STANDARD Keywords Communication; Learning disabilities nursing: attitudes These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review.For related articles and author guidelines visit our online archive at www. nursing-standard. co. uk and search using the keywords. Aims and intended learning outcomes The aim of this article is to explore the impact of communication on health care for people with learning disabilities. The article discusses how cognition and communication influence interactions between healthcare providers and patients. It also examines how poor communication can contribute to health inequalities that separate people with learning disabilities f rom the rest of the population.The article explores communication strategies that can overcome or reduce barriers to effective health care. After reading this article and completing the 58 april 5 :: vol 20 no 30 :: 2006 Time out 1 Based on a figure of 2 per cent of patients having learning disabilities, it is likely that 40 per 2,000 patients registered with GP services are likely to have learning disabilities. How many patients with learning disabilities are you aware of in your practice area? List some of the reasons that might prevent people with learning disabilities from accessing local health services. Health inequalitiesAlthough people with learning disabilities are living longer, the gap that separates the health status of people with learning disabilities and the general population has increased. Cohen (2001) asserted that gross inequalities in health are politically, socially and economically unacceptable. An investigation into health inequalities by the Disability Rights Commission (Nocon 2004) found that people with learning disabilities have: An increased risk of early death compared with the rest of the population; mortality rates are particularly high for those with more severe impairments.A greater variety of healthcare needs. Many needs that are not met. High rates of unrecognised or poorly managed medical conditions including: hypertension, obesity, heart disease, abdominal pain, respiratory disease, cancer, gastrointestinal disorders, diabetes, chronic urinary tract infections, oral disease, musculoskeletal conditions, osteoporosis, thyroid disease, and visual and hearing impairments.A briefing paper produced by the NHS Service Delivery and Organisation (SDO) Research and Development Programme (NHS SDO 2004) identified barriers to appropriate and timely BOX 1 Definition of a learning disability A person with learning disabilities has: Significant reduction in the ability to understand new or complex information. Reduced ability to cope inde pendently. Impairment starting in childhood that will have a lasting effect on development. (DH 2001) access to health care within and outside services.Many people with learning disabilities find that identifying their healthcare needs is a major challenge. Proactive strategies are required to encourage people to access the full range of services that are available. Some people with learning disabilities have said that negative and unhelpful attitudes from healthcare workers have prevented them from seeking medical help (Bristol and District People First 2003). Support and encouragement are required by carers, allies and friends before people with these concerns are ready to engage with services again.People are more likely to trust service providers when they are convinced that services and practitioners have responded to their needs by improving communication skills and producing information in an accessible format. People with learning disabilities have the same right to access m ainstream services as the rest of the population (Department of Health (DH) 2001). However, mainstream services have been slow to develop the capacity and skills to meet their needs.In the document Valuing People (DH 2001) it was acknowledged that the wider NHS had failed to consider the needs of people with learning disabilities and that overcoming this source of inequality was the most important issue for the NHS to address for this patient BOX 2 Terminology and facts related to learning disabilities ‘Mental handicap’ was a term used to describe people with learning disabilities. It is no longer used in the UK. ‘Mental retardation’ is a term used internationally, however, it is not an accepted term in the UK and some may find this term offensive. Learning difficulty’ is the term used in education to define individuals who have specific learning needs, for example, dyslexia. Some people who are identified as having learning difficulty by education s ervices may also be considered to have a learning disability, but this is not necessarily the case. ‘Mild’, ‘moderate’, ‘severe’ and ‘profound’ are terms to describe different degrees of disability (Figure 1). A person with mild learning disabilities might communicate effectively, learn, live and work with little support.However, a person with profound learning disabilities will require support with activities of daily living, for example, communication, dressing, feeding, washing and mobility. A diagnosis of ‘mental illness’ is not the same as having a learning disability, but people with learning disabilities may have mental health issues as well. Not everyone with learning disabilities requires a social worker or a community nurse. People with learning disabilities may have multiple diagnoses resulting in complex health needs. People with the most profound physical or sensory impairments do not always have the most profound cognitive impairments.NURSING STANDARD april 5 :: vol 20 no 30 :: 2006 59 learning zone nursing attitudes group. The briefing paper produced by the NHS SDO (2004) provided key action points for removing barriers and improving access to health care, which included: Using specialist learning disability teams to aid adaptation of mainstream services to meet the needs of patients with learning disabilities. Developing strategies for health education and health checks for people with learning disabilities that promote timely access to health care.Families and paid carers have an important role in helping people with learning disabilities to access health care. Some people will need assistance to recognise mental health problems and to identify gradual changes in health. Time out 2 Make a list of the ways that you communicate with patients about their health, for example, through appointments and telephone calls. Take three examples from your list and consider reasons why communi cation with a person with learning disabilities might be difficult.Give an example of effective communication between a practitioner and a person with learning disabilities. Policies should address the use of technology to support communication, and the development and dissemination of accessible information. Jones (2003) suggests that managers and commissioners of services should liaise with health, social care and education agencies to ensure consistency in communication policies throughout the lives of people with learning disabilities. Communication can be broadly defined as the exchange of information between a sender and a receiver (Figure 2).Where a person has learning disabilities they may be communicating with an intention to attract a communication partner and commence a two-way dialogue. However, for some people with profound learning disabilities sending a message might be a response to their body and feelings. Their level of cognition might be such that they are unaware of possible communication partners and of how to take the communication further. This is called pre-intentional communication, in which the individual says or does things without intending to affect those around them.It is important to remember that everyone communicates and that the role of communicator and communication partner swaps from one person to the other so that a conversation can develop. The challenge for health professionals is to develop skills that enable them to interpret the messages they receive and make the messages they send understandable. Communication is not only about verbal communication; it is also about nonverbal communication, for example, the use of body language, words and pictures. CommunicationRecommendations have been made to improve communication and access to health services for people with learning disabilities. Jones (2003) states that services supporting people from birth to older age should develop communication policies. FIGURE 1 Estimated pe rcentage of people with learning disabilities according to level of severity Mild Moderate 12% Severe Profound 80% 7% 1% Augmentative and alternative communication systems Systems of communication, such as sign language, symbols and eye pointing, are known as augmentative and alternative communication systems (AACs).AACs can be used to enhance or replace customary pathways, such as speech or writing. The use of photographs of everyday objects, picture boards, line drawing and real objects are good ways to enhance communication with people with learning disabilities (American Speech-Language-Hearing Association (ASHA) 2005). You do not need to attend specialist training to be able to use AACs such as these. More formal AACs, such as Makaton (a form of sign language for people who have learning disabilities that uses keywords to enhance understanding), require preparation but learning a basic vocabulary does not require extensive training.Cognition and communication (Winterhalder 1997 ) Understanding complex information People with learning disabilities have a reduced ability to NURSING STANDARD 60 april 5 :: vol 20 no 30 :: 2006 understand new or complex information (DH 2001), and those who experience difficulties when processing information may find it hard to learn new skills. Intelligence can be quantified as a figure related to an individual’s IQ. However, it might be more useful to think about intelligence in relation to cognitive processes.Smith and Mackie (2000) describe cognitive processes as: ‘†¦the way in which our memories, perceptions, thoughts, emotions and motives guide our understanding of the world and our actions. ’ Intelligence exerts a powerful influence over the ability to process information, the capacity to learn new skills and to adapt knowledge to different situations. Intelligence is an attribute that can guide our understanding of the world, but it is not fixed or static. Teaching and learning strategies can be used to stimulate cognitive processes so that people can approach information, or potentially confusing situations, with more confidence.Similarly, complicated tasks and information can be broken down into small, simple steps so that people can approach them in stages. Attempting to understand another person’s cognitive processes can help practitioners to develop a more empathetic and person-centred approach to care, and can provide an incentive to develop the teaching and learning strategies that are best suited to the individual needs of patients. Coping independently People with learning disabilities may have a reduced ability to cope independently (DH 2001). Independence is defined according to levels of social functioning.Assessment of a patient’s strengths and needs in social functioning is a fundamental stage in developing planned care that is familiar to practitioners from all branches of nursing. Making an accurate assessment of social functioning provides val uable information about the range of activities that a person can undertake on his or her own as well as those activities where a person requires support. Some people with learning disabilities may require assistance with tasks such as washing and dressing, and many need help to have their mode of communication understood.Learning disability and development Learning disability starts before adulthood, affects people of all ages and has a lasting effect on development (DH 2001). A majority of younger people with learning disabilities are living in the community with their parents or carers. Older people with learning disabilities also live in the community but they may have periods of institutional care. Some people will have frequent contact with health services and others have irregular contact. People with learning disabilities are not a homogeneous group. Their perceptions of nurses, NURSING STANDARDFIGURE 2 A model for communication Person communicating: we take turns in this ro le of sender of information. Depending on the person’s cognitive ability, this may be intentional or pre-intentional communication Communication barriers: can be present in the environment as well as being caused by the communicator and communication partner Communication partner: we take turns in this role of the person who receives the information sent, makes sense of it and responds appropriately doctors, health centres, clinics and hospitals will have been shaped by their formative experiences with staff and services.Providing encouragement for people with learning disabilities to attend health checks and to make use of healthcare services can involve changing their perceptions of health professionals. Some people with learning disabilities have not received the treatment they need because they are reluctant to engage with services where they have had bad experiences in the past. To encourage people with learning disabilities to make effective use of healthcare services t hroughout their lives, practitioners need to use their communication skills to initiate and maintain positive relationships. Time out 3Think about the last time you communicated with a person with learning disabilities, or someone who has communication difficulties. Refer to the list you made in Time out 2 about the communication systems you use in your workplace. What are the main barriers to communicating about health with a person who has learning disabilities? How do you remove or reduce barriers to communication? Which environmental factors impede communication? Identify any barriers that you had not previously considered. april 5 :: vol 20 no 30 :: 2006 61 learning zone nursing attitudes Barriers to communicationThere are barriers to communication which can be identified in relation to the person with learning disabilities, the health professional and the environment (Box 3). When barriers have been identified, health professionals can start to think about ways of reducing or removing them. Health professionals exchange information by using terminology that reflects their specialised knowledge. Patients and other people who are not involved in the day-to-day delivery of health care BOX 3 Barriers to communication The person with learning disabilities may: Have limited understanding.Have limited vocabulary or difficulty speaking. Have sensory impairments that limit ability to hear requests or instructions. Have poor understanding of health and healthy living. Be scared of people in uniforms. Be stressed because of illness. Not like new places. Have difficulty waiting and may not understand the concept of time or queuing. Have limited literacy and numeracy skills to read health advice and information, for example, instructions, letters, dosages. Expect contact with nurses to be unpleasant because of previous experiences. The nurse may: Be rushed because of heavy workload.Have biases and assumptions about people with learning disabilities. Have poor listeni ng and attending skills. Be unable to understand augmentative and alternative communication systems. Have limited knowledge of the individual. Have insufficient time to develop a good relationship with the individual or carer. Not use visual aids to support understanding. Use technical jargon and/or long words. Provide written information without thinking of the patient’s ability to read it. Provide information about the next appointment in a way the patient will not understand or remember.The environment may: Be crowded. Busy. Uncomfortable. Have strange smells and noises. Bring back bad memories. Have limited physical access, for example, no hoists. Include unhelpful people. Have poor signage, relying on literacy skills and good sensory abilities. Have no area to sit quietly with limited sensory stimulation while waiting. Be filled with machines and instruments that a person with learning disabilities may not understand. may find it difficult to comprehend the terms and ide as they encounter in healthcare settings. They can find it hard to follow advice or instructions.This could result in patients making inappropriate decisions or exposing themselves to unnecessary risks. For example, patients with learning disabilities who take their own medication may be at risk of overdosing or taking an ineffectual dose, particularly if the route and dosage of a newly prescribed medicine has not been explained clearly and/or recorded in an accessible format. Time out 4 Consider the list of potential barriers to communication and categorise them according to: Barriers that have been addressed for patients with learning disabilities using the services you work in.Barriers that can be remedied quickly. Barriers that need planning to be reduced or removed. Barriers that require financial investment to be reduced or overcome. Discuss this list with your colleagues. Identify strategies for removing barriers and improving communication. Good practice in communication In South Warwickshire, health passports have been developed for people with learning disabilities (Leamington Spa Today 2005). These provide detailed information about an individual’s health, strengths and needs so that practitioners can provide patient-centred care.They are used to improve communication across a range of healthcare providers. Having an alert system incorporated into patient notes which provides individual communication needs could be beneficial, especially where staff do not know individual patients. Health practitioners may use and be involved in developing health action plans. These are plans specific to individuals and are developed to meet their access needs. Health action plans are a way of overcoming some of the barriers to high quality health care (DH 2001).Plans are produced by a group of people including the patient. They encourage the development of a shared understanding about an individual’s health needs. Where training in health action plann ing has been provided for GP surgeries, improvements have been shown in the health of patients with learning disabilities (Smith et al 2004). There are benefits to having a lead person to deal with learning disability issues. In primary healthcare services, a lead person takes an interest in learning disability issues, collates information, NURSING STANDARD 62 april 5 :: vol 20 no 30 :: 2006 ives support and advice to health staff and develops links with specialist services for people with learning disabilities and other agencies (NHS Executive 1999). Time out 5 Does your organisation have a lead person who is involved in initiatives such as joint communication policies and the development and sharing of accessible health information? If yes, find out how he or she is supporting your team to develop skills in communicating with people who have learning disabilities. If no, how might developing this role benefit your team and improve access to health care for patients with learning d isabilities?To improve communication with people with learning disabilities, more time should be allocated to appointments so that there is more time for them to express themselves and understand any information they have received (DH 1999). This is particularly the case if AACs are being used. Reception staff are often aware of people who have difficulties using services. Supporting these key staff to develop effective communication skills and flexibility can improve access to health services (NHS Executive 1999).For example, if staff in reception are aware that someone finds it difficult to wait in a queue, they may offer that person the first appointment. Several resources have been developed by trusts to improve communication. Some examples of these include: Hambleton and Richmondshire Primary Care Trust (PCT), in partnership with Mencap, has developed an accessible ‘Choose and Book’ guide for hospital appointments that uses a combination of pictures and words to ex plain how patients can make choices about hospitals and appointments.Bristol South West PCT, as part of its ‘Expert Patient Programme’, has developed plans that help prepare people with learning disabilities for a visit to the doctor. The Health Facilitation Team at Gloucestershire Partnership NHS Trust (2004) has produced a ‘traffic light assessment’ that conveys information about individuals on admission to hospital. This ensures that important information is clearly communicated to health professionals. Camden PCT (2005) has used this work to develop an online resource. Although people may appear to have limited communication skills, they should not be ignored.These patients should be addressed directly and NURSING STANDARD the information they receive should be provided in a simple way without being patronising. Effective communication often depends on how the information is delivered. Practitioners may have to talk to carers, but they should not forget to address the person with learning disabilities. Practitioners should examine their beliefs about people with learning disabilities and avoid making assumptions about an individual’s strengths and needs. This will help to make health assessments more accurate (DH 1999).It is useful to invite a speaker with learning disabilities to talk to healthcare staff about living with a learning disability and his or her experiences of accessing health services. Time out 6 What beliefs and values do you think society holds about people with learning disabilities? Some examples of negative beliefs and values are that people with learning disabilities: Have a poor quality of life. Have higher pain thresholds. Are dangerous and promiscuous. Will not understand anything. Should not get married or have children. Cannot care for their children. Need institutional care. Cannot work.Are like children not adults. What are your feelings about these statements? How might the presence of any or al l of these beliefs influence the care given to a person with learning disabilities? People with learning disabilities can have additional physical or sensory impairments that should be considered. They are also more likely to have more mental health needs than the general population (DH 2001). Where a patient has additional impairments or health issues these need to be considered during communication. The healthcare environment should be adapted to accommodate people with physical or sensory impairments.Time out 7 In your work place: Do you have a private area to talk to a person who has a large wheelchair? Do you have rooms where glare is controlled and the environment is suitable for people with limited vision? Do you consider the needs of interpreters/ carers and ensure they fully understand information before they pass it on? april 5 :: vol 20 no 30 :: 2006 63 learning zone nursing attitudes Accessible information Accessible information comes in many forms, such as videos, CDs, DVDs and audiotapes. Pamphlets can be produced with accessible information about the services offered.Written information needs to be in plain language, with short sentences and one subject per sentence. Photographs, drawings, symbols and other visual information can be used to support written information. It is important to keep pages uncluttered on plain backgrounds so that text does not detract from graphics. Letters should be large, 16-18 point type size, and fonts that do not have serifs, such as Arial and Comic Sans, should be used. Graphic text, underlining and italics should be kept to a minimum because they can impede readability. Many trusts are now producing resources to enhance accessibility.Some of these include: The United Bristol Healthcare NHS Trust has produced a leaflet called ‘You are coming to the Bristol Royal Infirmary about your heart’, TABLE 1 Using terminology that is easy to understand Health issue Common words that are used Epilepsy Investigat ions EEG (electroencephalogram) Strategies or words that improve understanding Find out more about This word would have to be used, but a photograph of someone having an EEG may help understanding Medicine tablets to help control your epilepsy Having two or more seizures straight after each other or whatever describes status for the individual Taking your medication as we have agreed Things that might make you have a seizure Not being able to have a poo for three days Things you feel in your head and body that make you think you will have a seizure Having a fit or turn, whichever word the person uses which uses pictures and words to introduce some of the staff and explain what happens when patients are admitted to the cardiology department.The Learning Disability Partnership Board in Surrey has developed ‘The Hospital Communication Book’ that combines words, pictures, signs and symbols. Trafford North and South PCTs have produced a toolkit for people with learning disab ilities called ‘Cancer and You’ (Provan 2004). Contact your local Community Learning Disability Team or People First organisation for information about local resources. Simplifying conversation When talking to people with learning disabilities, use approaches similar to those used for written text. Plain language, the use of keywords, short sentences and one subject per sentence should be used. Give people time to process what is being said and to formulate a reply.Use openended questions to assess a person’s understanding and rephrase the question if necessary, as repeating the same question rarely improves understanding. When information is presented during a consultation it is important to check that the person with learning disabilities has understood it. If there is insufficient time during the initial consultation, it may be necessary to make a further appointment to check what the person has understood and retained. For an individual who processes informat ion slowly this might be essential to ensure an accurate assessment and the effective implementation of a treatment plan. Examples of terms that are easier to understand are presented in Table 1.Such terms are only beneficial if the person understands them so, for example, ‘constipation’ could be described as ‘not being able to have a poo’, but the health practitioner needs to know whether the person uses this term to describe defecation. Anti-epileptic drugs Status epilepticus Drug compliance Triggers Constipation Aura Time out 8 Think of four common illnesses that are likely to make a person visit your service. Write these in the first column of a table (see Table 1). Identify the language you use when discussing these illnesses and record these words or phrases in column two. These might be medical terms, health terms or long words. Now spend some time identifying words that are easier to understand and record them in the third column. NURSING STANDARD S eizure 64 april 5 :: vol 20 no 30 :: 2006 ConclusionPeople with learning disabilities may have communication difficulties that have restricted their access to health care and prevented them from receiving the information required to maintain their health. In addition to learning disability, they are more likely to have complex healthcare needs leading to multiple diagnoses. Steps towards better health for people with learning disabilities can be made by providing encouragement and support to attend regular health screening and reviews, and by developing a range of strategies to improve communication between practitioners and individuals with learning disabilities NS RECOMMENDED RESOURCES British Institute of Learning Disabilities (2001) Factsheet No. 005 Communication. www. bild. org. uk/pdf/factsheets/communication. pdf (Last accessed: March 10 2006. British Institute of Learning Disabilities (2005) Your Good Health (a set of 12 illustrated booklets). www. bild. org. uk/publication s/your_very_good_health_details. htm (Last accessed: March 10 2006. ) Communication Matters (updates 2005) What is AAC? www. communicationmatters. org. uk (Last accessed: March 10 2006. ) Communication Matters (updated 2005) How to be a good listener. www. communicationmatters. org. uk (Last accessed: March 10 2006. ) Department of Health. www. dh. gov. uk (Last accessed: March 10 2006. ) Foundation for People with Learning Disabilities (2004) Communication and people with learning disabilities. www. learningdisabilities. org. uk/page. cfm? agecode=ISSICMMT (Last accessed: March 10 2006. ) Foundation for People with Learning Disabilities (2005) Patients with learning disabilities in South Warwickshire have been given a new type of passport to help with their medical appointments. www. learningdisabilities. org. uk/profilenews. cfm? pagecode=ISSICOLN&are acode=ld_communication_news&id=7231 (Last accessed: March 10 2006. ) MENCAP (2003) You and your health: a basic guide to being heal thy. www. mencap. org. uk/download/you_and_your_health. pdf (Last accessed: March 10 2006. ) Plymouth Hospitals NHS Trust (2005) Living with cancer. www. learningdisabilitycancer. nhs. uk/ (Last accessed: March 10 2006. ) Time out 9Complete a SWOT analysis (strengths, weaknesses, opportunities and threats) of your skills and knowledge when communicating with and supporting access to health care for people with learning disabilities. Time out 10 Now that you have completed this article, you might like to consider writing a practice profile. Guidelines are on page 68. References American Speech-LanguageHearing Association (2005) Introduction to Augmentative and Alternative Communication. www. asha. org/public/ speech/disorders/acc_primer. htm (Last accessed: March 9 2006. ) Bristol and District People First (2003) We are People First. (Film) People First, Bristol. Camden PCT (2005) What You Need to Know About Me in Hospital. www. camden. gov. k/ (Last accessed: March 17 2006. ) Cohen J (2001) Countries’ health performance. The Lancet. 358, 9285, 929. Department of Health (1999) Facing the Facts: Services for People with Learning Disabilities: A Policy Impact Study of Social Care and Health Services. The Stationery Office, London. Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the 21st Century. The Stationery Office, London. Emerson E, Hatton C, Felce D, Murphy G (2001) Learning Disabilities: The Fundamental Facts. Foundation for People with Learning Disabilities, London. Gloucestershire Partnership NHS Trust (2004) Traffic light assessment. Unpublished document.Gloucestershire Partnership NHS Trust, Gloucester. Gravestock S, Bouras N (1997) Emotional disorders. In Holt G, Bouras N (Eds) Mental Health in Learning Disabilities: A Training Pack for Staff Working with People who have a Dual Diagnosis of Mental Health Needs and Learning Disabilities. Second edition. Pavilion Publishing, Brighton, 17-26. Jones J (2003) Th e Communication Gap. www. learningdisabilities. org. uk /page. cfm? pagecode= FBFMCHTP04 (Last accessed: March 10 2006. ) Leamington Spa Today (2005) Patients with learning disabilities in South Warwickshire have been given a new type of passport to help with their medical appointments. Leamington Spa Today. January 19, 2005.NHS Executive (1999) Once a Day One or More People with Learning Disabilities are Likely to be in Contact with Your Primary Healthcare Team. How Can You Help Them? Department of Health, Leeds. NHS Service Delivery and Organisation (SDO) Research and Development Programme (2004) Access to Health Care for People with Learning Disabilities. Briefing paper. NHS SDO, London. Nocon A (2004) Background Evidence for the DRC’s Formal Investigation into Health Inequalities Experienced by People with Learning Disabilities or Mental Health Problems. Disability Rights Commission, Stratford upon Avon. Provan K (2004) Cancer and You: Toolkit for Working with People with Learning Disabilities. www. cancerandyou. info/docs/ FullToolkitNov04. pdf (Last accessed: March 9 2006. Smith ER, Mackie DM (2000) Social Psychology. Second edition. Psychology Press, Hove. Smith C, Giraud-Saunders A, McIntosh B (2004) Healthy Lives: Health Action Planning in a Person Centred Way; Including Health in Person Centred Planning. www. valuingpeople. gov. uk/ HealthHealthyLives. htm (Last accessed March 10 2006. ) Winterhalder R (1997) An overview of learning disabilities. In Holt G, Bouras N (Eds) Mental Health in Learning Disabilities: A Training Pack for Staff Working with People who have a Dual Diagnosis of Mental Health Needs and Learning Disabilities. Second edition. Pavilion Publishing, Brighton, 1-6. NURSING STANDARD april 5 :: vol 20 no 30 :: 2006 65

Medtronic External and Internal Analysis Essay

Medtronic Inc. can easily be compared to le Concorde, a turbojet supersonic passenger airliner first flown in 1976. This jet was more than twice as fast as any other airliner ever created, flying at speeds of up to 1,350 mph. The capability to fly at more than twice the speed of a regular airliner equates to twice the flights and premium prices for this astonishing service. The resulting profitability of le Concorde is what puts this machine at the top of its class. In 1957, Medtronic founder Earl Bakken created Medtronic’s Pacemaker, the first wearable device to treat abnormally slow heart rates. The Pacemaker is now the staple product of Medtronic and can be compared to le Concorde for its innovation, efficacy, and profitability. This is just one example of Medtronic’s ability to use its innovation to transform the treatment of chronic disease worldwide. The firm has been a leader in the Medical Device Manufacturing industry for over two decades, developing and manufacturing innovative medical devices to treat more than seven million patients each year. Its products include pacemakers, defibrillators, heart valves, and stents, among others. Medtronic’s drive for excellence is best summed up by its corporate mission, â€Å"To contribute to human welfare by application of biomedical engineering in the research, design, manufacture, and sale of instruments or appliances that alleviate pain, restore health, and extend life† (Medtronic. com). To achieve its goals and maintain success, Medtronic must constantly monitor and evaluate its external environment and the forces in it that could affect the company. The Medical Device Manufacturing industry is exposed to numerous forces and trends that can generate opportunities for firms to exploit as well as threats for firms to avoid. Of note are the effects of rivalry, buyers, regulation, and globalization trends. The Medical Device Manufacturing industry, as a whole, has grown at an annual rate of 18. 9% since 2005, contributing to a high level of industry attractiveness (ibisworld. com). Medtronic is the clear leader with 17. 2% market share. Its closest rivals, Boston Scientific and St. Jude Medical, have market shares of 2. 8% and 4. 8%, respectively (ibisworld. com). Recently, the industry has seen a dramatic increase in consolidation as larger firms have cquired smaller operations in an effort to diversify their portfolios and gain market share. This shrinkage has resulted in greater industry concentration, increasing the rivalry among these key players. Focusing on a more narrow analysis of the Cardiovascular Device segment reveals a similar, more intensified, environment for rivals. Compared to the overall industry, this specific segment has recently witnessed much lower growth rates because the market is saturated with products that have little differentiation and limited innovation possibilities. For this reason, merger & acquisition activity is especially prominent among top firms seeking to create strategic competitiveness. They have identified the threat of rivals and are looking to gain additional resources and capabilities through diversification. The role of buyers is very unique in this industry. While individual patients are the ultimate consumers of medical devices, firms often focus on healthcare providers when selling products. This is because patients in the market have low brand recognition of the devices they use. Instead, they rely on their hospitals and physicians to recommend products for treatment. It is important for manufacturers to understand this distinction since it is these physicians and other providers that have the greatest brand loyalty. That said, individual patients still drive demand for products, and their satisfaction remains the ultimate goal. One key demographic trend of buyers is the aging U. S. population. As life expectancies continue to rise, and the baby boomer generation ages into their late sixties and seventies, this expanding age group will create a great opportunity for medical device manufacturers. For example, elderly patients experience a higher occurrence of health issues compared to the aggregate market, driving demand for medical devices upward. In fact, 40% of all patients diagnosed with heart disease or arthritis are 65 or older (ibisworld. com). The Medical Device Manufacturing industry is also subject to tight regulations, both domestically and internationally. For example, a new device may require a four-year trial before it appears on the market so that the Food and Drug Administration (FDA) can test its long-term effects. Products in Europe, meanwhile, undergo a different regulatory process; products are often introduced in Europe two to four years before they are available for patients in the U. S. Furthermore, compliance with these regulations requires firms to devote significant additional resources, often detracting from investments such as Research and Development. Along with these initial requirements, devices are constantly monitored for defects, which can result in product recalls that damage brand reputation and hurt profits. Globalization trends will certainly continue to have a strong impact on the industry, creating both opportunities and threats. Research shows that exports account for 21. 6% of industry revenue with an expected 2010 growth rate of 3. 9% (ibisworld. com). By developing these export markets, firms can work to maximize capacity utilization as they expand their distribution channels to reach more customers and generate more revenue. This is especially true of developing economies, in which 80% of chronic-disease-related deaths occur. Large portions of these markets are greatly underserved and demand is not being met. In addition, by diversifying into different geographic markets abroad, firms are able to mitigate the risks associated with being too dependent on the domestic market. The emergence of globalization also introduces several threats that firms must be aware of. For one, the competitive landscape changes as companies establish operations sites in foreign countries. When this happens, the demand in export markets declines since customers can purchase devices locally. Exporting firms must then reevaluate their international strategies and consider establishing similar operations of their own. Another threat globalization brings is that of increased competition. Manufacturers constantly fight to expand their geographic reach and to gain control of underserved markets. Given the effects of strong forces and emerging trends in the Medical Device Manufacturing industry, firms should strive to possess a key group of success factors in order to gain strategic competitiveness. The first factor is employees; they must be highly skilled and knowledgeable since the devices they design and produce are very complex. Second, economies of scale allow firms to improve profitability by reducing variable costs in manufacturing, which, in turn, lowers prices for customers. Third, as previously mentioned, the importance of global positioning cannot be understated. In order to compete in the industry, firms must make a global presence, expanding geographic scope and penetrating underserved markets. Finally, access to the latest innovations is imperative. To acquire new technologies, firms must invest considerable resources into Research and Development. Not only must they develop new technologies, but they must also look for ways to continuously improve existing products through high levels of innovation. This understanding of the industry environment is essential when considering a firm’s internal strategies. At the business-level, Medtronic possesses a number of strengths and competencies that are used to create a competitive advantage and contribute to the overall performance of the company. In particular, its research and development efforts along with its superior human resources drive the firm’s differentiation strategy in the Cardiac Rhythm Disease Management (CRDM) unit (see appendix for more strengths). This sector remains the firm’s most profitable product market, accounting for $5. 268 billion of Medtronic’s $15. 817 billion total net sales in 2010 (Medtronic). As a percentage of those sales, Research and Development expenses equated to 9. 23%, a total of $1. 46 billion. Moreover, this expense has seen a Compound Annual Growth Rate of 8. % in the last 5 years, indicating Medtronic’s continued confidence in its ability to create value through the investment in research and development. The innovation fostered by research and development in CRDM has allowed Medtronic to create many new products; the complex nature of these products makes them rare and costly to imitate. They often even trump and replace the existing technology in the mar ket, making them highly valuable and unsubstitutable. These key innovations, therefore, give Medtronic a significant competitive advantage in research and development. For example, the CRDM unit recently introduced a new leadless pacemaker. Once implanted into the heart via catheter, the penny-sized device permanently latches into the flesh with tiny claws. Doctors can then wirelessly monitor and control the pacemaker. Medtronic’s demonstration of reduced size and wire elimination will create a new standard for such devices in the industry, making current, bulky pacemakers obsolete, and giving Medtronic a sustainable competitive advantage. Medtronic’s 40,000 employees also play a key role in the success of CRDM and of the company as a whole. They are the source of one of Medtronic’s most valuable intangible assets: knowledge. With a thorough understanding of human physiology and a breadth of technical skills, employees are a driving force behind the company’s groundbreaking innovations. They generate ideas and implement processes that create new or improved products or therapies. These advancements require that employees are well trained and possess a high degree of knowledge about the products or therapies they develop. In addition to the actual production of products, employees extend their knowledge to customers. By educating healthcare providers and users about the devices, employees ensure that patients safely receive the full benefits of Medtronic’s products. One way Medtronic optimizes its human resources is through collaboration blogs and internal grants. The company’s Quest program awards project grants that encourage employees to test their own ideas for product innovation. Nearly 25% of these projects eventually become a product or some part of a therapy. For example, employee Brain Lee had an idea to create an effective diagnostic tool for patients who suffered from unexplained fainting. With funding from the Quest program, Lee modified a pacemaker by adding self-contained electrodes. The device could be implanted just below the skin, recording electrocardiogram (ECG) signals in an endless loop. Much more effective than existing external tools, Lee’s device received additional funding, leading to successful clinical trials, and, eventually, a commercial release. This is just one example of how Medtronic’s strong workforce creates a core competency for the firm, one that is unmatched by its rivals. Furthermore, the innovations developed by employees and through research and development efforts can often be protected with patents, generating competencies that are not only distinctive, but also sustainable. At the corporate level, Medtronic is very well positioned. The firm outperforms its rivals in terms of market share with 17. 2%, compared to Boston Scientific and St. Jude Medical, which hold 2. 8% and 4. 8% market share, respectively. Since 2007, Medtronic has experienced an 8. 75% compound annual growth rate. While lower than St. Jude’s growth rate of 12. 3% in the period, it is noticeably higher than that of Boston Scientific’s, 6. 84% (See appendix for further financial comparisons). Medtronic’s corporate-level strategy defines which businesses it will be in as well as how it will integrate those businesses to grow and deliver value to stakeholders. The firm currently operates in seven business units: CRDM, Spinal, CardioVascular, Neuromodulation, Diab etes, Surgical Technologies, and Physio-Control, all of which are largely related. Because of Medtronic’s strong war chest, it has been able to focus its growth strategy around acquisitions. Since 2009, the firm has purchased nine companies, including ATS Medical Inc. and CoreValv Inc. , requiring a significant cash investment. In fact, Medtronic spent $370 million when it bought heart valve maker ATS Medical. The firm’s acquisition strategy specifically targets two types of purchases: those that will add immediate revenue to existing businesses, and those that add to Medtronic’s technology portfolio by providing expertise the company does not have. Of late, the firm has been focusing on the former, targeting smaller companies that lack the resources to complete clinical trials and gain FDA approval. Chad Cornell, vice president of corporate development at Medtronic, notes, â€Å"Size is obviously a factor, but it’s not what we start with. † Instead the question is â€Å"how can we add value? That’s the key lens† (Lee). Medtronic’s international strategy is best characterized as a global strategy whereby it develops devices in the United States to be distributed across country markets. To support this strategy, it uses a worldwide product divisional structure. Medtronic has recently changed its strategy, implementing a Global Realignment Initiative in 2008. The goal of the initiative is to reorganize the firm’s resources to focus on areas that add the most value and have the most attractive growth opportunities. Prior to 2008, the company had segmented its global market into the United States market and international markets. Under this new strategy, Medtronic will focus around developed markets and emerging markets, using its resources and capabilities to effectively meet each segment’s unique needs. Developed markets include regions such as the United States and Europe where trained healthcare professionals are familiar with current devices, and new, innovative products are readily accepted. Medtronic relies on its strong innovation capabilities and Research and Development investments to meet the demands of this segment. For example, patients with pacemakers are often denied potentially life-saving MRI scans due to possible pacing interference. Medtronic used its superior innovation and product knowledge to address the concern, manufacturing the world’s first pacemaker that is compatible and safe to use with MRI systems. Introduced in Europe in 2008, this innovative device provides a much-needed solution to millions of people who will now be able to receive the full benefit of a safe MRI scan. Emerging markets, meanwhile, include regions such as China, Brazil, Africa, and the Middle East, where access to care is often limited, and physicians may be unfamiliar with certain medical devices and hesitant to accept new products. In this segment, Medtronic depends on its employees and its reliable, high-quality products. Using these strengths, it focuses on training and educating healthcare providers so that products and treatment are much more accessible to underserved patients. At present, Medtronic operates in more than 120 countries, with more than 16,000 employees in communities outside the United States (Medtronic. om). These employees provide immense value to the company by using their extensive knowledge and skills to educate and collaborate with physicians around the world. Currently, 41% of total revenues are realized outside of the United. Medtronic plans to continue its geographic diversity strategy, aiming to become a â€Å"truly boundaryless organization† an d maintain its commitment to â€Å"making a sustained, global impact in the fight against chronic disease† (Medtronic). In order to keep its world-class status, Medtronic executes various tactics at each of its organizational levels in order to protect its strategic competitiveness. For example, the company uses a frontal assault on its biggest competitor, Boston Scientific. By using revenues created from CRDM, they have the capability to invest large investments into research and development in ways that Boston Scientific cannot. In doing so, they maintain continuous development and improvement of innovative products. Another tactic that Medtronic uses is the pre-emptive strike, identifying and evaluating a valuable opportunity and seizing it before a rival does so. This increases sales, differentiates Medtronic from competitors such as Boston Scientific, and helps foster innovation. Based on the analysis of Medtronic’s external environment and internal strategies, it is clear that the firm is a leader in the Medical Device Manufacturing Industry. However, there are also some key problems and issues the firm should address. Medtronic has had litigation issues over the past few years with recalls in various different product offerings as well as patent and licensing disputes. As noted on the 2010 annual report their litigation charges amounted to nets of, $374 million in 2010, $714 million in 2009, and $366 million in 2008 (36-37). This has been an industry wide issue as seen by Boston Scientifics 2009 litigations charges amounting to $2. 022 billion, $334 million in 2008 and $365 million in 2007 (Boston Scientific Annual Report pg. 69). With these industry wide litigation issues, the FDA is currently creating new standard procedures for testing products and time required to introduce them into the market, which creates a separate challenge in dealing with the new health care reform. In a recent interview with Brian Johnson from Massdevice. om, the CEO of Medtronic, Bill Hawkins outlines the challenges ahead with the new health care reform. â€Å"The new medical device tax will cost us $150 to $200 million per year when introduced in 2013. In 2010 we spent $1. 5 billion on R&D and this tax will directly affect that budget for us which hurts our innovation, or possibly investments in emerging markets†. Cleary the health care reform will be one of the toughest challenges ahead for Medtronic and the rest of the medical device industry.

How to become a good leader Essay Example | Topics and Well Written Essays - 2250 words

How to become a good leader - Essay Example A lot of researches have been done to understand the definition and essence of leadership, to identify the differences between the managers and the leaders. Management of organizational behavior defines leaders as the "Men and women who saw the need for action, believed in what they were doing, inspired others and, in spite of incredible odds, changed the world." (Hersey, Blanchard & Johnson, 1). Many theories and meanings of leaders and leadership have been developed throughout the world. All these theories have not been providing with same results however they do agree on certain grounds. All the theories agree that a leader has a clear set of goals and is capable of setting examples. He is a person with strong beliefs and vision for the future. A leader bravely voices his opinions and takes actions on his beliefs and passions. Leadership is a quality or ability that a person possesses to influence and guide others. There are various theories that define and explain leadership. The major ones are the Trait theory, Behavioral theory, Contingency theory and the Transformational theory. The Traits theory identifies certain traits or behavior in a person. This theory believes that human are born with the traits of becoming a leader. The theory suggests that if a person posses the specified traits he is a leader. The Behavioral theory suggests that leaders have a specific behavior towards their followers and that makes them distinct from others. This theory specifies the style and the behavior of the leaders. The contingency theory acts as the critic of the above theories and specifies that the styles and the traits of the individuals can be different in different dynamic situations. This theory suggests that the leaders are defined by their activities and abilities. The characteristics or the behaviors cannot be defined or specified. The transformational theory stresses on the effective interaction of the leaders with their

Visual Perception Essay Example | Topics and Well Written Essays - 750 words

Visual Perception - Essay Example In the myopic eye, the point forms before the fovea centralis of the retina, and therefore, distant objects seem blurry. From a pathophysiological viewpoint, myopia is usually caused because of an elongated eyeball, but it can result from a too much refractive power in the lens system of the eye. There are two types of myopia, benign and malignant. Benign myopia usually occurs around puberty and it is usually stabilized by the end of 25 years of age, but malignant myopia occurs in early childhood, during which slow but steady elongation of the sclera occurs. This elongation occurs in the back of the eye, while the frontal part does not change, and this can lead to a serious elongation of the internal membrane of the eye, causing atrophy of the pigmented epithelium and the chorioidea, or the layer of blood vessels in the eye, and the appearance of a myopic cone. Visual acuity is measured using the Snellen chart, where the letters (optotypes) decrease in size in each row, from top to bottom. The smallest row that can be read accurately indicates that person's visual acuity in that eye. The patient is placed at 6 meters distance from the chart and asked to read the letters. Near each row there is a number, indicating the length at which a person with normal visual acuity would be able to read it, or the distance at which a person can discern 2 separate points on the chart. A patient with 6/6 visual acuity means that he has normal vision, while the results show us that the person we measured has slight myopia. It is easily treatable by placing concave spherical lenses in front of the eyes, reducing the excessive refractive power and diverging the rays to fall on the retina. In modern times, refractive surgery is also available, which uses laser to reshape the curvature of the cornea and reduce the refractive power. 2. The person obviously is healthy, as it is able to observe motion, even though he was unable to observe shape during the motion. This is normal eye physiology, as there are more rod cells that detect motion, than cone cells that detect color in the periphery of the fovea centralis. While not in motion, more cones are stimulated and therefore, can detect color and shape. 3. Miosis is the process of decreasing the size of the pupillary aperture. It is caused by the stimulation of the parasympathetic nerves, which excite the pupillary sphincter muscle, and it represents an integral part of the pupillary light reflex. When light hits the retina, some of the impulses pass through the optic nerves to the pretectal nuclei. Secondary impulses then arrive at the Edinger-Westphal nucleus, which send signals through parasympathetic nerves to the papillary sphincter muscle. The reason why the pupil of the other eye remains the same when light is shined in one eye is because the two separate signals coming from the two eyes are relayed through separate nerves and neuronal layers, even after they arrive at the dorsal lateral geniculate nucleus, which then sends the signals to the visual cortex. This separation of signals throughout the entire visual neural pathway allows for an independent miosis in each eye. 4. When a sudden pulse of light strikes the retina, the receptor potential that occurs in the rods reaches a peak in 0.3 seconds and lasts for more than a second. It is also