Teenage Pregnacy Essay Example for Free

Teenage Pregnacy Essay Every single country in the world that the people live in is important and each country has its own nature and significance. The United States of America is known as the most powerful country and many other countries support America. These countries become America’s alliances. The Philippines is one of its alliances. The Philippines have certain factors that make it known. Some of this is the so-called â€Å"wonders of the Philippines.† An example of which is the Banaue Rice Terreces that were created by the Ifugaos The presence of the Chocolate Hills is also a wonder in this country. The beaches are also famous in the Philippines. The Philippines have great beaches wherein foreigners tend to sit often. Even if there are many things that could be praised in the Philippines, it has also issues that are known to the world. Its corruption is one of those issues that is known bout the Philippines. Another issue is its population. The population is an important factor in a certain country or place. Population could give a positive or a negative outcome depending on how it is utilized. Some countries make certain measures to make sure that the population would not be causing a problem On the other hand; others do not give much empha Even if the government is planning to adopt such this kind of law, many people are against it especially the Church. If the population were not provided with the right amount of food, they would be malnourished. There is also a positive effect regarding the increase in the population. Future researchers should focus more on the methods and implementations that will help on lessening the Philippine current population rather that concentrating on other topics. The environment has different aspects. 6 deaths for every 1000 population (http:www. It is much colder here compared to the lower land areas. Around 40 percent of those people who are poor have been able to study in elementary, while only 10 percent of the families were able to send their children to study in high school (www. Overpopulation could also lead to congestion. Some topics in this essay: Census Statistics, Philippines Philippines, According Jose, Commission Population, Filipinos Church, Metro Manila, United America, , increase population, rapid increase, Chocolate Hills, rapid increase population, Rice Terreces, philippine population, death rate, country population, positive negative, people living, continuous increase,negative effects, family planning, negative effects increasing, effects increasing population, increase population lead,increase philippine population, Population Growth Overpopulation has become an enormous crisis facing society today. Overpopulation is distinguished by the numbers of people in an area relative to its resources and the capacity of the environment to sustain human activities; that is, to the areas carrying capacity. When is an area overpopulated? When its population cant be maintained without rapidly depleting nonrenewable resources, or converting renewable resources into nonrenewable ones, and without degrading the capacity of the environment to support the population. In short, if its current human occupants are clearly degrading the long-term carrying capacity of an area, that area is overpopulated. By this standard, the entire planet and virtually every nation is already vastly overpopulated. Africa is overpopulated now because, among other indications, its soils and forests are rapidly being depleted—and that implies that its carrying capacity for human beings will be lower in the future than it is now. The United States is overpopulated because it is depleting its soil and water resources and contributing to the destruction of global environmental systems. Europe, Japan, the Soviet Union, and other rich nations are overpopulated because of their Dolan believes that an increase in population will not lead to an ultimate decline in the standard of living of humans. Also, scientists further this notion by bringing up the fact that humans, in much the same way as cancer, produce toxic metabolites. Simon believes that there is no population crisis and no environmental crisis that is due to the rapid growth of humans. We must learn to take care of the natural resources and be aware of the fact that we, as humans, will continue to reproduce and our population will continue to grow. Such a massive and still increasing population, combined with the environmentally detrimental repercussions of industrialization, as a result of the need to sustain such a large population, namely pollution from fossil fuels, has begun to take a serious toll on our planettms ecosystem. In conclusion, I believe that we must all work together to be able to live in a better environment and have a better quality of life. This meant that at some point human beings would experience a scarcity of land, food and jobs, leading to human misery and catastrophe (Southwick 159). (Dolan, 69) In short, Dolan believes that humans can decrease overall pollution while still growing in overall population. Some scientists have likened the effects that human population growthhas had on the earth to the effects of cancer on human beings (Southwick 161). Similarly, poor living conditions and sanitation, especially the lack of clean water, leads to serious outbreaks of disease. In addition, advances in agricultural and industrial technology have effectively increased the size of the globe over the last two centuries, in terms of the maximum population which it will support. For many families in poverty conditions, children are essential for the overall familys survival; more income is needed that comes with more children working. These effects in turn lead to increases in hunger and malnutrition. Some topics in this essay: Dolan Dolan, Soviet Union, Human Perspective, Paper Overpopulation, Warren Hern, Principle Population, Simon Simon, Agricultural Revolution, Edwin Dolan, population growth, Malthus Anglican, standard living, carrying capacity, reasonable standard living, reasonable standard, health care, human population, disease famine,southwick 161 scientists, poverty disease, food jobs, rich nations overpopulated, growth human, especially third world, human population growth, Population growth rate: 1.903% (2011 est.) Definition: The average annual percent change in the population, resulting from a surplus (or deficit) of births over deaths and the balance of migrants entering and leaving a country. The rate may be positive or negative. The growth rate is a factor in determining how great a burden would be imposed on a country by the changing needs of its people for infrastructure (e.g., schools, hospitals, housing, roads), resources (e.g., food, water, electricity), and jobs. Rapid population growth can be seen as threatening by neighboring countries. Source: CIA World Factbook Unless otherwise noted, information in this page is accurate as of July 12, 2011 http://www.indexmundi.com/philippines/population_growth_rate.html Indeed the population of the Philippines is expected to increase at a rate faster than that even of India. Implications for the Philippines Will The Philippines be one of a handful of countries to achieve â€Å"least-developed† status by the year 2050? There are no doubt some who will argue that the continued unchecked population growth being experienced by the Philippines is actually a blessing. Certainly it is one of the few countries that has failed to sustain any form of population policy – a consequence both of the extreme poverty experienced in much of the countryside as well as the political influence of certain religious groups who remain adamantly opposed to any form of birth control. Indeed with a number of regions – Japan and Europe most notably, facing declining populations and the United States continuing to grow largely through immigration, there are some who may see advantage in the Philippines being the baby factory of the world. But is that really what the country wants? Taking the range of projections provided by the latest data, the population of the Philippines in the year 2050 will (according to the United Nations) probably lie in the range between 154 million (high estimate) to 103 million (low estimate and based on a declining birth rate). The median predicted value is a population of 154 million. But do these figures tell the whole story? Probably not. Certainly with regard to the Philippines, the latest population data from the world body may have under-estimated the problem facing this country. Each of the scenarios modeled in the latest survey data assume that the Philippines will follow the rest of the world in implementing population policies that will lead to a declining rate of birth – the only questions then being when will it occur and how fast will that decline be? According to the data published by the United Nations, at the end of 2000 the population of the Philippine stood at 75.7 million. The population growth rate stood at 1.79 percent (annual), fertility rate (children per woman on average) at 3.18 and the crude birth rate at 2.53 percent In absolute terms, the population number given by the United Nations certainly accords with the official figure published by the (Philippines) National Statistical Coordination Board, which gives the population as of mid 2000 at 76.498 million. However the rate of population growth as determined from the National Census over the past thirty years is at variance with the UN data and in recent years the disparity is quite marked population at 82.7 million. Indeed it would appear that by end 2003, the population had already reached the level predicted by the international survey for 2005. That is not an insignificant margin of error. The population increase expected over a fiveyear period – actually occurred within three years! Against this information, the projections cited above almost certainly underestimated the future growth trend of the Philippines. Without a significant – and long-term – reduction in the birth rate, the Philippines will face a population that by the middle of the century exceeds 210 million people. Unfortunately this is not an item that appears on the national agenda. A population that is increasing more rapidly than expected also impacts on the broader demographic data not least of which is the median age of the population. While under the more modest growth scenarios the Philippines population ages from a median of around 21 years at the present time to around 35 years, under the high growth scenario the median age of the population hardly moves – only to 25 years. This means the Philippines is not only stuck with a rapidly growing population but it will remain a young population. The implications in terms of education and the demand for other social services including water and sanitation are equally alarming. Yet with such a young population, the broader tax base that comes with a rising median age will not be there to finance these demands. The population density currently stands at around 275 persons per square kilometer but could rise to as many as 700 if the worst-case scenario is realized. This possibility has immediate implications for agricultural policy and the need for rational land use and higher value-added cropping. Without such policies the poverty level – and political unrest– will be far worse than it is at present. Already the Philippines is starting late in the day. Other Asian countries, including most of the Philippines’ Asean neighbors have already adopted prudent population and industry policies to control their populations and to implement growth strategies that will make a meaningful difference to the lives of their people. Thailand for one is now reaping the benefit of policies started back in the sixties. The Philippines stands out as the exception to the rule in this regard and it is a policy stance that the country’s present political and economic elite can only ignore at the risk of jeopardizing the future of the country. http://www.philippinesforum.com/resources/research/files/PBLSR040216_population.pdf As shown at the outset of Chapter 1, the population of the Philippines is growing at the very high rate of 2.36% per year. At this rate, more than 5,000 people are born every day in a country where the number of poor people has increased by more than four million since 1985 [M92]. The population is projected to reach 111 million by 2015. Population growth in and of itself is not a problem if resources are available to cope with the additional people requiring public services, employment, housing, and so on. But in a country where the budget is already stretched and where poverty is high to begin with, population growth becomes a major issue. The links between rapid population growth and persistent poverty have been well established. Rapid population growth hinders development for two 96 Poverty in the Philippines: Income, Assets and Access interrelated reasons. First, because it reduces growth in per capita incomes and thus savings, it reduces the funds available for investment in productive capacity. This underinvestment in turn reduces overall economic growth and prospects for poverty reduction. Second, as population growth outpaces the capacity of industry to absorb new labor, urban unemployment and rural underemployment are compounded. In 2003, the Philippine economy generated 566,000 new jobs, of which 60% were in the services sector. Despite this job creation, unemployment levels rose because the job market was inundated with 624,000 new entrants (ADB Asian Development Outlook 2004). The larger the family, the more likely it is to be poor. Table 34 shows poverty incidence by family size for 1997 and 2000, and the two are very strongly correlated. Orbeta (2002) reviews the empirical evidence to show that high fertility is associated with decreasing investments in human capital (health and education). Children in large families perform less well in school, have poorer health, lower survival probabilities, and are less developed physically. The problem is one of resource dilution, where each additional child means a smaller share of family resources including income, time, and maternal nutrition. Orbeta (2002) further shows that larger family sizes in the Philippines are not the result of rational choice among the poor. Surveys including the APIS66 have shown that the poor have more limited access to family planning services, lower contraceptive prevalence rates, higher unwanted fertility, and higher unmet needs for family planning. The author’s conclusion is that subsidized family planning services for the poor must be an integral component of any poverty reduction strategy. Balisacan and Tubianosa (2004) undertook cross-country research to quantify the direct effects of population on economic growth, social services, and labor force participation in the Philippines. The Philippines and Thailand were similar in terms of both population and GDP per capita in 1975, but by 2000, there were 13 million more Filipinos than Thais. Total fertility rate (TFR) in Thailand had dropped to 1.9, while it remained at 3.6 in the Philippines. At the same time, by 2000 GDP per capita in Thailand had grown to 8 times its 1975 rate, while the Philippines’ GDP per capita was only 2.6 times higher. The empirical analysis shows that population is not the only cause of the poor performance of the economy, but it is the most significant one, ahead of corruption, for example. In an interesting exercise, the authors assess what the monetary savings in education and health would have been, had the Philippine population growth pattern followed that of Thailand. The authors find that P128 billion would have been saved in the education sector from 1991 to 2000, while P52 billion could have been saved in the health sector from 1996 to 2000. The Government’s new MTPDP 2004–2010 has been criticized for not articulating a clear population policy. Instead, it presents only a target: that population growth will slow to 1.98% per year by 2010. The NEDA response to this critique states that the population policy of the plan is based on responsible parenthood, respect for life, informed choice, and birth spacing (NEDA, 2004). This is insufficient. The Government, with strong donor support, should scale up family planning education and services. Innovative mechanisms and clear messages promoting contraceptive use are needed, because access does not automatically result in use, as reported in the 1999 APIS. The data shows that nearly 90% of married women aged 15–49 had access but less than 40% were actually practicing family planning. Population policy should not concentrate too narrowly on contraception alone: women’s rights, reproductive health, and education are also critical elements of the population-development equation. Rather than a singular focus on married couples, heightened emphasis should be placed on informing, educating, and providing access to adolescents and youth. The 1998 and 1999 APIS questionnaires included a series of family planning and maternal care questions–but only for married women. These were removed from the 2002 APIS for an unknown reason. http://www.adb.org/documents/books/poverty-in-the-philippines/chap6.pdf

Comets Essay -- Astronomy Essays Space Outer

Comets   Ã‚  Ã‚  Ã‚  Ã‚  Have you ever looked up in the sky and seen a little ball creeping by? If so, did you wonder what it was? That little ball is called a comet. Comets are small, fragile, and irregularly shaped. Most are composed of frozen gas. However, some are composed of frozen gas and non-volatile grains. They usually follow very strict paths around the sun. Comets become most visible when they cross the sun. This also applies to people who view comets with telescopes. When a comet gets near the sun it becomes very visible because the sun's radiation starts to sublime its volatile gases, which, in turn, blow away small bits of the little solid material the comet has.   Ã‚  Ã‚  Ã‚  Ã‚  Another feature of a comet is a long tail. This is caused by materials breaking off and expanding. They expand into an enormous escaping atmosphere called the coma. This becomes at least the size of our planet. With the comet going so fast, these materials are forced behind the comet, forming a long tail of dust and gas.   Ã‚  Ã‚  Ã‚  Ã‚  Comets are cold bodies. We see them only because the gases they are composed of glow in the sunlight. All comets are regular family members of the solar system family. They are bound by gravity to a strict path around the solar system. Scientists believe that all comets were formed of material, originally in the outer part of the solar system, which did not become incorporated into planets. This material is from when the planets just started forming. This makes comets an extremely interesting topic to scientists who are studying the history of the solar system.   Ã‚  Ã‚  Ã‚  Ã‚  In comparison to planets, comets are very small. They can be anywhere from 750 meters (or less) to 20 kilometers in diameter. However, lately, scientists have been finding proof that there are comets 300 kilometers in diameter or greater.   Ã‚  Ã‚  Ã‚  Ã‚  Comets are still compared to the planets, though. Planets usually follow the shape of a sphere. Most planets are fat at the equator. Comets come in all different shapes and sizes. Most evidence that science has revealed says that comets are extremely fragile. A comet is so poorly structured that it is like a loose snowball--it can be pulled apart with one's own bare hands.   Ã‚  Ã‚  Ã‚  Ã‚  Comets have very awkward rotation periods. They are very oblong. When comets reach their aphelion they are usually near Jupiter or even sometimes Ne... ... is expected to reach its closed point to the sun. At this time it will also be most visible because the sun reflects off the tail of the comet.   Ã‚  Ã‚  Ã‚  Ã‚  It will come .914 astronomical units from the sun. This is not all that close to the sun considering the fact that some comets have run into the sun and others have skimmed the surface of it.   Ã‚  Ã‚  Ã‚  Ã‚  Although the comet will be closest to the sun on April 1, it will be closest to the earth on March 23, 1997. Some people have been saying that the comet will hit earth and cause human extinction, just like the dinosaurs. The fact is, however, THE COMET WILL NOT HIT EARTH. The closest it will come is 120 million miles away from the earth.   Ã‚  Ã‚  Ã‚  Ã‚  Some people are saying that the comet is going to Be huge, and others say it will be small. We will never know though because we can not see the nucleus of a comet. The part of the comet we see is the tail. The tail of a comet can be over 10,000 kilometers long.   Ã‚  Ã‚  Ã‚  Ã‚  In all, comets, the history of comets, and comets waiting to be discovered is very interesting. I think that one day we will get to see the nucleus of a comet, and be able to watch comets form in the Oort Cloud.

Thomas Jefferson report card

The Barbara Pirates are a great example as to how Jefferson dealt with problems with foreign people. The pirates would take crew members from ships and demand payment on behalf of America, after making the decision to put an end to the payments to the pirates Jefferson sent a naval to punish them; although semi contradicting his devotion to peace and economy. Later on after in 181 5 Stephen Decatur was sent to the Mediterranean to where a treaty renouncing both raids and tribute were signed.Although It wasn't something totally eliminating the racketeers from being wicked it still was a success on behalf of Jefferson; he was able to lead the world toward a path of free seas and peace for all nations. Jefferson so far was able to fulfill his promises to keep peace and friendship with other nations. The relations between the new United States and European nations were pleasant and the Barbara Pirates had compelled admiration for the American flag. Intense admiration should be given to J efferson for he was able to handle the impressments of American seaman In an appropriate manner.He was able to keep calm and not go to war with Britain even though there was a vast amount of anger In the United States towards the situation. Instead of going Into something more drastic such as war, Jefferson simply demanded the British to stay out of the U. G's waters and for an apology. Lastly In relation to foreign relations, In 1803 war between France and Britain was renewed. As a war tactic each nation attempted to affect their opponent's trade using neutral nations such as the United States.Jefferson saw this and In an attempt to keep peace between the United States and other nations, there was the Embargo Act which cut off the United States trade In hopes of getting Britain and Napoleon Into terms. (Embargo Act of 1802) Jefferson was unsuccessful when It came to the Embargo act; neither the French nor Britain needed the American trade as much as American trade needed them there fore not making a difference when It came to scaring the nations. What this would have done Instead of scaring Napoleon and Britain out of their conflict was, demolish theAmerican commerce which was what It was trying to protect. Jefferson as a president managed to fulfill a lot of his promises made In his Inaugural address regarding keeping peace and honest friendships with other nations. He was very successful and although he had a failure with the Embargo Act he still attempted to make a change therefore his grade of a B Is accurate due to his successful attempts and failure of the Embargo Act. Thomas Jefferson report card By watermelon United States at peace with nations in Europe during his first term, as wealth and tooth raids and tribute were signed.Although it wasn't something totally eliminating impressments of American seaman in an appropriate manner. He was able to keep calm and not go to war with Britain even though there was a vast amount of anger in the United States t owards the situation. Instead of going into something more waters and for an apology. Lastly in relation to foreign relations, in 1803 war Jefferson saw this and in an attempt to keep peace between the United States and other nations, there was the Embargo Act which cut off the United States trade in popes of getting Britain and Napoleon into terms. Embargo Act of 1802).

Balanced Scorecard for Hospital Performance Productivity - Free Essay Example

Sample details Pages: 15 Words: 4432 Downloads: 3 Date added: 2017/09/20 Category Management Essay Type Argumentative essay Tags: Hospital Essay Did you like this example? The Balanced Scorecard for Hospital Performance and Productivity ABSTRACT The purpose of this paper is to provide an overview of the usefulness of the Balanced Scorecard in improving a hospitals management and delivery of health care at reduced cost without loss of quality. This paper describes an approach to designing and implementing a balanced scorecard system for measuring performance and productivity in a hospital setting. Specific measures of performance criteria are suggested as well as interpreted. Guidelines for measuring productivity are also suggested and interpreted. How these measures may be used by a hospital to improve its administration of health care while reducing costs and maintaining quality are described. This paper is a useful resource for hospital managers looking to improve their performance and productivity. The balanced scorecard is a management tool that is widely used in the manufacturing industry. This paper fulfills a need by healthcare provid ers to obtain information on implementing a balanced scorecard system that specifically addresses issues unique to hospitals. This paper also addresses how to measure productivity within a balanced scorecard system. Keywords:Hospital Performance, Balanced Scorecard, Hospital Productivity 1. INTRODUCTION Performance measurement and productivity in health care are important issues to individuals and at a national level. Medical costs continue to rise and consume an increasing proportion of GNP worldwide. Cost pressures are producing dramatic changes in the health care environment. The government continues to search for ways to control spiraling costs, principally through caps on reimbursement rates, and at the same time the public seeks coverage for more services. Competition among health care providers is intense as alternative delivery systems grow and compete with public health facilities forcing all health care organizations to lower their costs, downsize, or close facilitie s (Gumbus et al. 2003). Increasingly health care providers are cutting services to, or refusing to treat, Medicare and Medicaid patients because of inadequate reimbursement rates. One result of cost pressures faced by individuals, employers, insurance companies, and the government is to shift health care provider performance priorities in several areas. Previously, a primary objective of health care provider organizations was to attract more patients (a revenue focused strategy). Now, they are concerned with reducing costs to meet patient demand. In the past, hospitals wanted simply to attract leading doctors trained in the latest procedures and technologies (a high-cost strategy). Now, the emphasis is on improved service quality to meet the demands of payers and regulators. Historically, hospitals wished to bill more care to more patients (another revenue enhancing strategy). Now, they seek to balance cost versus patient outcomes resulting in shorter stays, less expensive tre atments, and fewer tests. Traditionally, hospitals allowed doctors free reign in treatment plans, which increased demand for hospital services (and costs). Now, hospitals seek to attract patients from managed-care plans and balance the goal of maintaining physician loyalty with limits (i. e. , lower costs) on the use of the latest, and more expensive, medical technologies. Finally, hospitals encouraged only limited innovation in delivery of core services and administration. Now, high rates of innovation in both areas are necessary to achieve cost effective and efficient health care. Key to achieving cost controls in health care is adopting new approaches to performance and performance measurement (Adler et al. 2003). Hospitals have been slow to develop and implement formal performance and productivity measurement systems (Voelker et al. 2001). The primary problems that have inhibited hospitals from making greater progress in this area are culture, organization, and managerial pra ctices that are inconsistent with competitive business, including operating practices that are not cost driven. Some specific reasons why hospitals have not been active in this area include the following: many hospital boards are composed of members lacking experience in competitive environments, lack of employee participation, particularly among doctors, and because many individuals regard hospital services as intangible and impossible to measure. Medical staff relations and quality of care are important attributes of hospital performance that can be difficult to measure, interpret, and compare with other health care organizations (Zelman et al. 2003). The balanced scorecard (BSC) is fundamentally a customized performance measurement system that looks beyond traditional financial measures and is based on organization strategy. This paper discusses fundamental concepts in developing performance metrics, provides an overview of issues in developing balanced scorecard measures, and gives numerous illustrations of performance measures. As shown later, the BSC is an active area of research within the medical community. However, previous research does not report on the fundamental linkages between hospital inputs, outputs, and the creation of performance metrics. In addition, these articles provide few specific examples of balanced scorecard measures and illustrations of how the balanced scorecard translates action into improved performance. 2. PERFORMANCE MEASUREMENT AND THE BALANCED SCORECARD IN HEALTHCARE Emphasis on financial measures of performance in response to cost pressures may be a dangerous impediment to creating future economic value (Weber 2001). Hospitals can benefit by using a balanced scorecard (BSC) to measure performance and productivity. The BSC consists of an integrated set of performance measures that are derived from the hospitals management strategy. The BSC is designed to translate managements strategy into performance measures t hat employees can understand and implement. Using a balanced scorecard can provide a hospital with the following benefits: * It aligns the hospital around a more patient-focused strategy, * It facilitates, monitors, and assesses the implementation of the overall strategy, * It provides a communication and collaboration mechanism, It assigns accountability for performance at all levels of the hospital, and * It provides continual feedback on the strategy and promotes adjustments to changing market and regulatory factors. The BSC was originally developed by Kaplan and Norton (1992; 1993) from the notion that reliance on financial measures of performance alone is insufficient for managing complex organizations, especially as those organizations become more customer focused and want to benefit from their knowledge-based human capital. The BSC has evolved into a strategic management system that uses a framework and core principles to translate an organizations mission and strategy int o a comprehensive set of performance measures (Kaplan 1996). Kaplan and Norton suggest measuring an organizations performance around four perspectives: (1) financial, (2) customer, (3) internal processes, and (4) learning and growth. This framework provides a balance between short- and long-term objectives, financial and non-financial measures, and external and internal performance indicators. The scorecard also balances the results the organization wants to achieve (typically the financial and customer perspectives) with the drivers of those results (typically the internal processes and the learning and growth perspectives) (Inamdar and Kaplan 2002). Zelman et al. (2003) establish the relevance of the balanced scorecard to health care, but with modifications to recognize unique characteristics of the industry and organizational characteristics. Numerous articles exist concerning the balanced scorecard and healthcare. One area of research on this topic is concerned with the in ternal process of developing the balanced scorecard in a generic sense (see Voelker et al. 2001; Pink et al. 2001; Inamdar and Kaplan 2002; Sioncke 2005). Another group is concerned with developing measures at specific organizations or within defined patient populations (see Kershaw and Kershaw 2001; Gumbus et al. 2002; Gumbus et al. 2003; Sugarman and Watkins 2004; Woodward et al. 2004; Wells and Weiner 2005). Fundamentally, measuring performance gives health care providers more control over their services. Performance measures are designed to answer the following questions; * Are the service objectives appropriate? * Are the services meeting their objectives? * Are the services meeting the desired standards in terms of quality, effectiveness, access, and efficiency? Measures are based on inputs (e. g. , staff, services, supplies, equipment, facilities), outputs (services rendered, e. g. , acute and elective services, professional advice, training), and outcomes (results of inpu ts and outputs, e. g. , health status, disability, continuing care). Examples of hospital services, outputs, and outcomes are shown in Table I. Efficiency measures are ratios of inputs to outputs and it relates to achievement of specific objectives. The effectiveness of a department is a measure of how well the outcomes are achieving desired outcomes. The cost effectiveness of a service is the resources required to achieve the outcome, for example the total cost of achieving mobility and/or pain relief. Table I: Examples of Hospital Services, Outputs, and Outcomes Service Output Outcome Obstetrics Live birth Healthy child and mother Pathology Diagnostic test results Correct diagnosis, effective treatment Engineering Preventive maintenance Decreased machine downtime, reduced operating costs Financial services Financial reports Effective financial management Faced with increasing cost pressures, extensive government regulation, high expectations by the public, and increasing criticism health service providers must be able to not only do many things well but communicate their achievements in a clear and concise manner. Hospitals can benefit by applying the BSC approach to answer the following questions about performance: * Has financial performance improved? * Do patients recognize that we are delivering more value? * Have we improved key services and processes so that we can deliver more value to patients? * Are we maintaining our ability to learn and improve? . ESTABLISHING AND INTERPRETING PERFORMANCE CRITERIA There are some simple principles to follow when using a BSC approach to establishing performance indices and monitoring performance in hospitals. First, major health goals for the hospital must be established. Second, these goals will serve as a roadmap for service managers of major segments of the organization to establish related goals and supporting objectives. Third, a series of indicator measures should be developed to assess service delive ry and effectiveness, operational performance, and the organizations response to the environment. All measures of performance/productivity are interpreted in light of the hospitals goals. Table II provides a high-level view of indicator measures, how they should link with hospital goals, objectives, and environmental concerns. Indicators are consistent with the perspectives outlined for application of the balanced scorecard, i. e. , they may be financial, patient focused, operational, and/or learning/growth oriented. Table II: Role of Indicator Measures in a Hospital Relate To Monitored By Timescale Service Goals Departmental Probably Effectiveness managers annually Indicators Service Objectives Departmental/ Monthly or Delivery cost center weekly Indicators managers Operational/ Detailed Cost center Monthly Organizational objectives/ managers Indicators action plans Environmental Assumptions, Corporate and Ad hoc, but Indicators goals, and departmental preferably objectives m anagers annually Following are brief descriptions and examples of performance measures for a public hospital using the perspectives of the BSC. 3. 1. FINANCIAL PERSPECTIVE The financial perspective garners the greatest amount of attention when cost control is paramount. However, it is difficult for most hospital managers to follow direct costs through to the general ledger and then relate them to the activities they manage. Health care organizations need to be able to accumulate this information in a concise and understandable way. Categories of financial measures might include financial health, capital, human resources, and efficiency. Financial Health. Measures such as the percent by which revenues exceed expenses, return on assets, liquidity measures (e. g. , current ratio, working capital ratio) will certainly be used. Capital. In an era of ever expensive medical technology, the percentage of total expenses accounted for by capital equipment is important to monitor. Human Resources. The costs of direct care staff are another important, and rising, health care cost component. Nurses, for example, are in short supply and hospitals regularly bid up the costs for their services. Measures such as nursing care hours as a percentage of total inpatient/outpatient nursing hours indicate the percentage of all inpatient/outpatient nursing hours for staff who are available to carry out the activities that contribute directly to care of in/outpatients. Efficiency. A measure of unit cost performance is the percent by which planned cost per weighted case differs from actual. Hospitals should monitor the cost of administrative services as a percentage of total expenses. Day in inventory is a useful measure of the efficiency of inventory usage. 3. 2. CUSTOMER PERSPECTIVE Patient service must include developing a positive perception of care delivery and an ability by the organization to quickly correct patient service problems (Kershaw and Kershaw 2001; Gumbus e t al. 2003). Several categories of customer/patient measures may be important. These include measures of patient satisfaction, patient involvement, and waiting time. Patient satisfaction. The number of complaints provides an indication of satisfaction. The results should be interpreted in light of the number of patient advocates, how well their presence is publicized, and if a centralized complaints system exists. The pattern of complaints should be monitored. Patient surveys should be conducted. Patient involvement. Indicators for patient involvement in treatment choices includes the number of sources from which treatment information is available, the proportion of treatment services for which protocols exist, and the proportion of consumers offered treatment choices. Monitoring of consumer involvement in the broader decision making process is difficult, with a possible measure being the number of consumers on service development groups. Waiting lists. Waiting lists for servi ces should be monitored separately. If the notional days required to clear either of these waiting lists is high, the percent change in patients on the list should be examined. In addition, the average length of time that patients have to wait for specialists should be surveyed because this may impact on the demand for public hospital services. 3. 3. INTERNAL PROCESSES PERSPECTIVE Hospitals need to identify the internal processes (service development, service delivery, service evaluation) that have the greatest impact on what patients (customers) value. Excellence in these areas is determined by measures that capture time to market, delivery time, cost, and process quality (Kershaw and Kershaw 2001). Ultimately, balanced scorecard measures such as patient satisfaction (from surveys), retention, and safety, establishment of minimally invasive surgery programs, accreditation, and patient referral rates will determine the outcome of internal process initiatives. Patient flow (timely discharge of patients) suggests another important area to measure. Following are some areas of concern for internal processes that may lead to well-functioning processes. Staffing. The ratio of staff to the area population and the staff workload should be monitored in aggregate and for specific work groups such as medical practitioners and nurses. An indication of the hospitals commitment to equal employment opportunity (EEO) could be gauged by examining the workforce by ethnicity and gender mix. Efficiency. If the average cost per inpatient or outpatient case by treatment is high, then the key determinants of cost, namely average length-of-stay and staff costs should be examined. Staff costs should be analyzed to identify whether costs are high because of the base cost of staff, the workload per staff member, or because of high overtime costs. Additionally, utilization rates such as occupancy rates, throughput rates, and outpatient clinic time utilized should be examined in assessing how efficiently services are provided. Facility utilization. The overall proportion of specialized treatment facilities or equipment time allocated to a medical service should be monitored as well as this time in relation to specialty treatment beds and patient population in the hospital. It is also important to analyze how facilities or equipment time is used. Equity of access. The balance between use of inpatient, outpatient, and community services should be monitored as well as the balance between provision of services in the public and private facilities. Other factors affecting access that should be monitored include staffing levels, average travel time, and the availability of facilities to accommodate families. Activity rates should be monitored in aggregate and by age, sex, ethnicity, and domicile. Mortality rates. Overall mortality rates for procedures should be examined and related back to the morbidity rates included in equity of access. 3. 4. Learning and Growth Perspective Measures from the learning and growth perspective attempt to identify the skills and tools needed to improve important internal processes. Key areas of concern include the skill levels of employees, availability of training, and employee satisfaction. Patient loads and training hours per caregiver are important BSC measures. Other concerns and measures in this area include. 4. CONTINUING PROFESSIONAL EDUCATION, TRAINING, AND EMPLOYEE SATISFACTION. Most medical practitioners are subject to continuing professional education requirements. Measures that encourage employees to remain current in their fields and enhance their credentials should be part of a balanced scorecard system. In addition, learning and growth measures should be present to encourage innovation in delivering medical services. Examples of measures include budgets and expenditures to support cutting edge procedures, number of experimental treatments attempted, and the number of test projects fund ed to improve service delivery. A service department must establish its own performance standards. It is not particularly helpful to monitor the activity levels, incident rates, etc. if there is no standard or budget for comparison. For example, expected throughput for surgical services should be specified on a month-by-month basis, and a standard should be set for post-operative infection rates (it may be appropriate to set a target level together with an acceptable or minimum standard). The deviation from these standards is the key management information that should be monitored. Comparative information should be used carefully. In addition to measuring the difference in actual performance from planned, it is often useful to compare current performance with historical and similar departments in other organizations. When comparing performance with outside departments or standards, differences in objectives and standards, measurement practices, information systems, environment al factors, and resource constraints should be considered. Careful study and comparisons of other organizations criteria and standards should be undertaken (e. . , admission rates, length of stay, environmental standards). Despite these difficulties, there are many examples where careful use of simple comparative information has helped improve the quality and productivity of service delivery. 5. PRODUCTIVITY: A PARTICULARLY USEFUL TYPE OF OPERATIONAL AND ORGANIZATIONAL MEASURE Increasingly, techniques borrowed from production organizations are being utilized to measure productivity and performance and to balance staff resources for greater flexibility in meeting patient demand. Productivity measures are very useful in hospitals if they are constructed with a clear purpose in mind and have the support of employees. Productivity measures are used for two purposes. First, they report information not previously known by asking the questions; * Is an activity on schedule? * What is th e cost of an activity or service? * How productive is a department? Second, they are used to control activities that need to be monitored or limited in some fashion. To be successful, productivity measures must affect employee behavior through a change in the relationship between performance nd rewards and generate commitment by employees to productivity improvement. Hospital department staffs are being asked to do more with less. Where hospital departments historically staffed according to peak loads, they now staff to meet the average load. This demands much greater flexibility in staffing, the greatest productivity challenge to hospitals because of the tremendous fluctuations in demand for hospital services. However, staffing flexibility impacts on service quality in periods when staffing is low and service demand is high. As a result, efforts to improve productivity need to be balanced with quality of care, effectiveness, and social equity. Productivity is easier to measure t han these other factors so there is a tendency to focus on productivity measures to the detriment of other important factors in health care, although improvements in productivity may help improve throughput, accessibility to services, and quality of services. A few simple guidelines are useful for building and sustaining a good productivity measurement system. The measures should be developed participatively. A participative approach lessens resistance to measurement and has motivational benefits. The measures should reflect where the hospital wants to be. If the strategic direction changes, then so should the measures. Productivity is a long-term process. Patience is required concerning expected results. Regarding the specific measures used, choose a mix of individual and group performance measures. Clearly, the performance of a hospital depends on a combination of individual and team efforts. Clinical employees often view their work as a set of technical activities that they perform independently. They fail to connect their work to that of individuals and departments preceding and following them. Develop measures that consider the customers point of view. Frequently productivity measures neglect to consider that a hospital exits to satisfy patient needs. Develop a family of measures for each department that encompasses productivity, performance, quality, and other relevant measures. Rarely does a single measure adequately describe performance. Broad indices such as nursing hours paid per admission are unlikely to be helpful in identifying the factors behind the performance index or helping managers decide what action needs to be taken. Specific measures may be developed by analyzing the chain of factors between the initial decision to treat a patient and the actual expenses incurred. By looking at each link in the chain, it is possible to identify the factors that generate nursing costs. It is also possible to consider the interrelationship between these measures. For example, a relatively high index for admissions/population may be linked with low average patient activity. 6. COMMUNICATING PERFORMANCE INFORMATION Performance should be communicated to three groups; * Staff * Management * External groups contributing to your objectives. Health managers can only change service delivery through changing the behavior of their staff employees. Therefore, it is necessary to communicate performance information that is credible and meaningful to those personnel. A brief outline of a process for constructing performance measures, feeding back the information, and facilitating staff involvement in performance and productivity improvement may include; * Identifying the key issues relating to both quality and productivity, * Developing a few selected indicators that are useful for that particular work setting, * Establishing the monitoring system and baseline standards/targets, * Facilitating employee involvement in interpreting inf ormation, solving problems, and changing behavior, and * Rewarding performance. This degree of participation may not be appropriate to all units but it is imperative that this process start top-down to demonstrate managements commitment and ensure consistency in application. Regardless of the degree of staff participation, the performance indices must be credible, the performance information must be communicated simply and frequently, and the information must be used for action to identify and solve problems, encourage improvements, and reward good behavior. Traditionally, management reporting has been on the basis of inputs, primarily deviations from budget (e. g. , bed and staff numbers), outputs and activity levels (e. g. , numbers of admissions, operations, tests conducted, inspections, etc. ), and progress in implementing plans. Communication with external groups requires information that is simple and credible. The objective of the communication should be very clear. If behavioral change is desired, then the communication will need to be reinforced with discussions and develop mutually acceptable action plans. . LEVELS OF MONITORING AND REPORTING Individuals throughout the organization will be interested in different performance levels of throughput. For example, the manager of surgical services for a multi-location facility might be concerned with total throughput in each surgical specialty (broken into acute and elective), quality as measured by post-operative morbidity, cost as measured by variance from budget, and accessibility as measured by average waiting time. The manager of surgical services at one location might be concerned with far greater detail. Finally, the manager of operating rooms might monitor; * availability of time for elective work (against an agreed upon standard), * availability of workers for acute work (against an agreed upon standard), * quality as measured by anesthetic related complications, * costs broken down into nursing, senior medical, junior medical, technical, etc. , * staff costs associated with scheduled and unscheduled sessions, * costs of OR and anesthetic supplies, * average cost per hour, and * unproductive time due to non-availability of staff. The managers of the surgical departments might also monitor a number of factors relating to their own specialties such as quality as measured by surgical related complications, use of allocated time, unproductive time due to non-availability of surgeons, delays in access to operating rooms for acute operations, and surgeon productivity. 8. CONCLUSION Concern by hospital management for performance and productivity measurement has grown in proportion to cutbacks in government funding for health services, pressure from businesses and insurance companies, and public concerns about the rising costs of health care. These factors have produced heightened competition in the health services industry. Many hospitals are responding by adopting t he performance/productivity measurement techniques more commonly found in manufacturing businesses, such as the balanced scorecard. Although scorecards may appear as a fad in the healthcare field, they have in fact earned a permanent place in strategic planning (Pieper 2005). A successful performance/productivity measurement system should follow a few important principles and take account of the unique characteristics of health care. 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ICES (Institute for Clinical Evaluation Sciences), Toronto. Zelman, W. N. , G. H. Pink C. B. Matthias (2003). Use of the balanced scorecard in health care. Journal of Health Care Finance 29(4), 1-16. Don’t waste time! Our writers will create an original "Balanced Scorecard for Hospital Performance Productivity" essay for you Create order