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February 10, 2010
1 STATEMENT OF ERIC A. HILLEMAN, DIRECTOR NATIONAL LEGISLATIVE SERVICE VETERANS OF FOREIGN WARS OF THE UNITED STATES BEFORE THE COMMITTEE ON VETERANS' AFFAIRS SUBCOMMITTEE ON HEALTH UNITED STATES HOUSE OF REPRESENTATIVES WITH RESPECT TO VA'S BUDGET REQUEST FOR FISCAL YEAR 2011 WASHINGTON, D.C. February 10, 2010 MR. CHAIRMAN AND MEMBERS OF THE COMMITTEE: On behalf of the 2.1 million men and women of the Veterans of Foreign Wars of the U.S. (VFW) and our Auxiliaries, I would like to thank you for the opportunity to testify today. The VFW works alongside the other members of the Independent Budget (IB) – AMVETS, Disabled American Veterans and Paralyzed Veterans of America – to produce a set of policy and budget recommendations that reflect what we believe would meet the needs of America's veterans. The VFW is responsible for the construction portion of the IB, so I will limit my remarks to that portion of the budget. VA's infrastructure—particularly within its health-care system—is at a crossroads. The system is facing many challenges, including the average age of buildings (60 years) and significant funding needs for routine maintenance, upgrades, modernization and construction. VA is beginning a patient-centered reformation and transformation of the way it delivers care and new ways of managing its infrastructure plan based on needs of sick and disabled veterans in the 21st Century. Regardless of what the VA health care system of the future looks like, our focus must remain on a lasting and accessible VA health-care system that is dedicated to their unique needs and one that can provide high quality, timely care when and where they need it. VA manages a wide portfolio of capital assets throughout the nation. According to its latest Capital Asset Plan, VA is responsible for 5,500 buildings and almost 34,000 acres of land. It is a vast network of facilities that requires significant time and attention from VA's capital asset managers. 2 CARES – VA's data-drive assessment of their current and future construction needs – gave VA a long-term roadmap and has helped guide its capital planning process over the past few fiscal years. CARES showed a large number of significant construction priorities that would be necessary for VA to fulfill its obligation to this nation's veterans and over the last several fiscal years, the administration and Congress have made significant inroads in funding these priorities. Since FY 2004, $4.9 billion has been allocated for these projects. Of these CARES-identified projects, VA has completely five and another 27 are currently under construction. It has been a huge, but necessary undertaking and VA has made slow, but steady progress on these critical projects. The challenge for VA in the post-CARES era is that there are still numerous projects that need to be carried out, and the current backlog of partially funded projects that CARES has identified is large, too. This means that VA is going to continue to require significant appropriations for the major and minor construction accounts to live up to the promise of CARES. VA's most recent Asset Management Plan provides an update of the state of CARES projects – including those only in the planning of acquisition process. Table 4-5: (page 7.4-49) shows a need of future appropriations to complete these projects of $3.25 billion. Project Future Funding Needed ($ In Thousands) Denver 492,700 San Juan 122,920 New Orleans 370,000 St. Louis 364,700 Palo Alto 478,023 Bay Pines 80,170 Seattle 38,700 Seattle 193,830 Dallas 80,100 *Louisville 1,100,000 TOTAL 3,246,143 This amount represents just the backlog of current construction projects. It does reflect the administration's FY 2011 proposed appropriation toward Denver, New Orleans, and Palo Alto. (*Louisville's cost estimate is found on table 5-6, on Page 7.5-93). Meanwhile, VA continues to identify and reprioritize potential major construction projects. These priorities, which are assessed using the rigorous methodology that guided the CARES decisions, are released in the Department's annual Five Year Capital Asset Plan, which is included in the Department's budget submission. The most recent one was included in Volume IV and is available on VA's website: http://www4.va.gov/budget/docs/summary/Fy2011_Volume_4-Construction_and_5_Year_Cap_Plan.pdf. Table 4-5 shows a long list of partially funded major construction projects. These 82 ongoing projects demonstrate the continued need for VA to upgrade and repair its aging infrastructure, 3 and that continuous funding is necessary for not just the backlog of projects, but to keep VA viable for today's and future veterans. In a November 17, 2008 letter to the Senate Veterans Affairs Committee, Secretary Peake said that ―the Department estimates that the total funding requirement for major medical facility projects over the next 5 years would be in excess of $6.5 billion.‖ It is clear that VA needs a significant infusion of cash for its construction priorities. VA's own words and studies show this. Major Construction Account Recommendations Category Recommendation ($ in Thousands) VHA Facility Construction $1,000,000 NCA Construction $60,000 Advance Planning $40,000 Master Planning $15,000 Historic Preservation $20,000 Medical Research Infrastructure $100,000 Miscellaneous Accounts $58,000 TOTAL $1,295,000 VHA Facility Construction – this amount would allow VA to continue digging into the $3.25 billion backlog of partially funded construction projects. Depending on the stages and ability to complete portions of the projects, any additional money could be used to fund new projects identified by VA as part of its prioritization methodology in the Five-Year Capital Plan. NCA Construction's Five-Year Capital Plan details numerous potential major construction projects for the National Cemetery Association throughout the country. This level of funding would allow VA to begin construction on at least three of its scored priority projects. Advance Planning – helps develop the scope of the major construction projects as well as identifying proper requirements for their construction. It allows VA to conduct necessary studies and research similar to planning processes in the private sector. Master Planning – a description of our request follows later in the text. Historic Preservation – a description of our request follows later in the text. Miscellaneous Accounts – these include the individual line items for accounts such as asbestos abatement, the judgment fund, and hazardous waste disposal. Our recommendation is based upon the historic level for each of these accounts. 4 Minor Construction Account Recommendations Category Funding ($ in Thousands) Veterans Health Administration $450,000 Medical Research Infrastructure $200,000 National Cemetery Administration $100,000 Veterans Benefits Administration $20,000 Staff Offices $15,000 TOTAL $785,000 Veterans Health Administration – Page 7.8-138 of VA's Capital Plan reveals hundreds of already identified minor construction projects. These projects update and modernize VA's aging physical plant, ensuring the health and safety of veterans and VA employees. Additionally, a great number of minor construction projects address FCA-identified maintenance deficiencies; the backlog of 216 projects in FY 2010 with over $1 billion that has yet to be funded. Medical Research Infrastructure – a description of our request follows later in the text. National Cemetery Administration of the Capital Plan identifies numerous minor construction projects throughout the country including the construction of several columbaria, installation of crypts and landscaping and maintenance improvements. Some of these projects could be combined with VA's new NCA nonrecurring maintenance efforts. Veterans Benefits Administration – Page 7.6-106 of the Capital Plan lists several minor construction projects in addition to the leasing requirements VBA needs. Staff Offices – Page 7.8-134 lists numerous potential minor construction projects related to staff offices. Increase Spending on Nonrecurring Maintenance The deterioration of many VA properties requires increased spending on nonrecurring maintenance For years, the Independent Budget Veteran Service Organizations (IBVSOs) have highlighted the need for increased funding for the nonrecurring maintenance (NRM) account. NRM consists of small projects that are essential to the proper maintenance and preservation of the lifespan of VA's facilities. NRM projects are one-time repairs such as maintenance to roofs, repair and replacement of windows, and flooring or minor upgrades to the mechanical or electrical systems. They are a necessary component of the care and stewardship of a facility. These projects are so essential because if left unrepaired, they can really take their toll on a facility, leading to more costly repairs in the future, and the potential of a need for a minor construction project. Beyond the fiscal aspects, facilities that fall into disrepair can create access difficulties and impair patient and staff health and safety. If things do develop into a larger 5 construction projection because early repairs were not done, it creates an even larger inconvenience for veterans and staff. The industry standard for medical facilities is for managers to spend from 2%-4% of plant replacement value (PRV) on upkeep and maintenance. The 1998 PriceWaterhouseCoopers study of VA's facilities management practices argued for this level of funding and previous versions of VA's own Asset Management Plan have agreed that this level of funding would be adequate. The most recent estimate of VA's PRV is from the FY 08 Asset Management Plan. Using the standards of the Federal government's Federal Real Property Council (FRPC), VA's PRV is just over $85 billion (page 26). Accordingly, to fully maintain its facilities, VA needs a NRM budget of at least $1.7 billion. This number would represent a doubling of VA's budget request from FY 2009, but is in line with the total NRM budget when factoring in the increases Congress gave in the appropriations bill and the targeted funding included in the supplemental appropriations bills. Increased funding is required not to just to fill current maintenance needs and levels, but also to dip into the extensive backlog of maintenance requirements VA has. VA monitors the condition of its structures and systems through the Facility Condition Assessment (FCA) reports. VA surveys each medical center periodically, giving each building a thorough assessment of all essential systems. Systems are assigned a letter grade based upon the age and condition of various systems, and VA gives each component a cost for repair or replacement. The bulk of these repairs and replacements are conducted through the NRM program, although the large increases in minor construction over the last few years have helped VA to address some of these deficiencies. VA's 5-Year Capital Plan discusses FCAs and acknowledges the significant backlog the number of high priority deficiencies – those with ratings of D or F – had replacement and repair costs of over $9.4 billion, found on page7.1-18. VA estimates that 52 percent of NRM dollars are obligated to toward this cost. VA uses the FCA reports as part of its Federal Real Property Council (FRPC) metrics. The department calculates a Facility Condition Index, which is the ratio of the cost of FCA repairs to the cost of replacement. According to the FY 08 Asset Management Plan, this metric has gone backwards from 82% in 2006 to just 68% in 2008. VA's strategic goal is 87%, and for it to meet that, it would require a sizeable investment in NRM and minor construction. Given the low level of funding the NRM account has historically received, the IBVSOs are not surprised at the metrics or the dollar cost of the FCA deficiencies. The 2007 ―National Roll Up of Environment of Care Report,‖ which was conducted in light of the shameful maintenance deficiencies at Walter Reed, further prove the need for increased spending on this account. Maintenance has been neglected for far too long, and for VA to provide safe, high-quality health care in its aging facilities, it is essential that more money be allocated for this account. We also have concerns with how NRM funding is actually apportioned. Since it falls under the Medical Care account, NRM funding has traditionally been apportioned using the Veterans Equitable Resource Allocation (VERA) formula. This model works when divvying up health-care dollars, targeting money to those areas with the greatest demand for health care. When dealing with maintenance needs, though, this same formula may actually intensify the problem. 6 By moving money away from older hospitals, such as in the northeast, to newer facilities where patient demand is greater, even if the maintenance needs are not as high. We were happy to see that the conference reports to the VA appropriations bills required NRM funding to be apportioned outside the VERA formula, and we would hope that this continues into the future. Another issue related to apportionment of funding came to light in a May 2007 Government Accountability Office (GAO) report. They found that the bulk of NRM funding is not actually apportioned until September, the final month of the fiscal year. In September 2006, GAO found that VA allocated 60% of that year's NRM funding. This is a shortsighted policy that impairs VA's ability to properly address its maintenance needs, and since NRM funding is year-to-year, it means that it could lead to wasteful or unnecessary spending as hospital managers rushed in a flurry to spend their apportionment before forfeiting it back. We cannot expect VA to perform a year's worth of maintenance in a month. It is clearly poor policy and not in the best interest of veterans. The IBVSOs believe that Congress should consider allowing some NRM money to be carried over from one fiscal year to another. While we would hope that this would not resort to hospital managers hording money, it could result in more efficient spending and better planning, rather than the current situation where hospital managers sometimes have to spend through a large portion of maintenance funding before losing it at the end of the fiscal year. Recommendations: VA must dramatically increase funding for nonrecurring maintenance in line with the 2%-4% total that is the industry standard so as to maintain clean, safe and efficient facilities. VA also requires additional maintenance funding to allow the department to begin addressing the substantial maintenance backlog of FCA-identified projects. Portions of the NRM account should be continued to be funded outside of the VERA formula so that funding is allocated to the facilities that actually have the greatest maintenance needs. Congress should consider the strengths of allowing VA to carry over some maintenance funding from one fiscal year to another so as to reduce the temptation some VA hospital managers have of inefficiently spending their NRM money at the end of a fiscal year for fear of losing it. Inadequate Funding and Declining Capital Asset Value VA must protect against deterioration of its infrastructure and a declining capital asset value The last decade of underfunded construction budgets has meant that VA has not adequately recapitalized its facilities. Recapitalization is necessary to protect the value of VA's capital assets through the renewal of the physical infrastructure. This ensures safe and fully functional facilities long into the future. VA's facilities have an average age approaching 60 years, and it is essential that funding be increased to renovate, repair, and replace these aging structures and physical systems. As in past years, the IBVSOs cite the Final Report of the President's Task Force to Improve Health Care Delivery for Our Nation's Veterans (PTF). It found that from 1996-2001, VA's recapitalization rate was just 0.64%. At this rate, VA's structures would have an assumed life of 155 years. 7 The PTF cited a PriceWaterhouseCoopers study of VA's facilities management programs that found that to keep up with industry standards in the private sector and to maintain patient and employee safety and optimal health care delivery, VA should spend a minimum of 5 to 8 percent of plant replacement value (PRV) on its total capital budget. The FY08 VA Asset Management Plan provides the most recent estimate of VA's PRV. Using the guidance of the Federal government's Federal Real Property Council (FRPC), VA's PRV is just over $85 billion (page 26). Accordingly, using that 5 to 8 percent standard, VA's capital budget should be between $4.25 and $6.8 billion per year in order to maintain its infrastructure. VA's capital budget request for FY 2009 – which includes major and minor construction, maintenance, leases and equipment – was just $3.6 billion. We greatly appreciate that Congress increased funding above that level with an increase over the administration request of $750 million in major and minor construction alone. That increased amount brought the total capital budget in line with industry standards, and we strongly urge that these targets continue to be met and we would hope that future VA requests use these guidelines as a starting point without requiring Congress to push them past the target. Recommendation: Congress and the Administration must ensure that there are adequate funds for VA's capital budget so that VA can properly invest in its physical assets to protect their value and to ensure that the Department can continue to provide health care in safe and functional facilities long into the future. Maintain VA's Critical Infrastructure The IBVSOs are concerned with VA's recent attempts to back away from the capital infrastructure blueprint laid out by CARES and we are worried that its plan to begin widespread leasing and contracting for inpatient services might not meet the needs of veterans. VA acknowledges three main challenges with its capital infrastructure projects. First, they are costly. According to a March 2008 briefing given to the VSO community, over the next five years, VA would need $2 billion per year for its capital budget. Second, there is a large backlog of partially funded construction projects. That same briefing claimed that the difference in major construction requests given to OMB was $8.6 billion from FY 03 through FY 09, and that they have received slightly less than half that total. Additionally, there is a $2 billion funding backlog for projects that are partially but not completely funded. Third, VA is concerned about the timeliness of construction projects, noting that it can take the better part of a decade from the time VA initially proposes a project until the doors actually open for veterans. Given these challenges, VA has floated the idea of a new model for health care delivery, the Health Care Center Facility (HCCF) leasing program. Under the HCCF, VA would begin leasing large outpatient clinics in lieu of major construction. These large clinics would provide a broad range of outpatient services including primary and specialty care as well as outpatient mental health services and ambulatory surgery. On the face of it, this sounds like a good initiative. Leasing has the advantage of being able to be completed quickly, as well as being adaptable, especially when compared to the major construction process. Leasing has been particularly valuable for VA as evidenced by the success of the Community Based Outpatient Clinics (CBOCs) and Vet Centers. 8 Our concern rests, however, with VA's plan for inpatient services. VA aims to contract for these essential services with affiliates or community hospitals. This program would privatize many services that the IBVSOs believe VA should continue to provide. We lay out our objections to privatization and widespread contracting for care elsewhere in the Independent Budget. Beyond those objections, though, is the example of Grand Island, Nebraska. In 1997, the Grand Island VA Medical Center closed its inpatient facilities, contracting out with a local hospital for those services. Recently, the contract between the local facility and VA was canceled, meaning veterans in that area can no longer receive inpatient services locally. They must travel great distances to other VA facilities such as the Omaha VA Medical Center. In some cases, when Omaha is unable to provide specialized care, VA is flying patients at its expense to faraway VA medical centers, including those in St. Louis and Minneapolis. Further, with the canceling of that contract, St. Francis no longer provides the same level of emergency services that a full VA Medical Center would provide. With VA's restrictions on paying for emergency services in non-VA facilities, especially for those who may have some form of private insurance, this amounts to a cut in essential services to veterans. Given the expenses of air travel and medevac services, the current arrangement in Grand Island has likely not resulted in any cost savings for VA. Ferrying sick and disabled veterans great distances for inpatient care also raises patient safety and quality concerns. The HCCF program raises many concerns for the IBVSOs that VA must address before we can support the program. Among these questions, we wonder how VA would handle governance, especially with respect to the large numbers of non-VA employees who would be treating veterans. How would the non-VA facility deal with VA directives and rule changes that govern health-care delivery and that ensure safety and uniformity of the quality of care? Will VA apply its space planning criteria and design guides to non-VA facilities? How will VA's critical research activities, most of which improve the lives of all Americans and not only veterans, be affected if they are being conducted in shared facilities, and not a traditional part of VA's first-class research programs? What would this change mean for VA's electronic health record, which many have rightly lauded as the standard that other health-care systems should aim to achieve? Without the electronic health record, how would VA maintain continuity of care for a veteran who moves to another area? But most importantly, CARES required years to complete and consumed thousands of hours of effort and millions of dollars of study. We believe it to be a comprehensive and fully justified roadmap for VA's infrastructure as well as a model that VA can apply periodically to assess and adjust those priorities. Given the strengths of the CARES process and the lessons VA learned and has applied from it, why is the HCCF model, which to our knowledge has not been based on any sort of model or study of the long-term needs of veterans, the superior one? We have yet to see evidence that it is and until we see more convincing evidence that it will truly serve the best needs of veterans, the IBVSOs will have a difficult time supporting it. Recommendation: VA must resist implementing the HCCF model without fully addressing the many questions the IBVSOs have and VA must explain how the program would meet the needs of veterans, particularly as compared to the roadmap CARES has laid out. Research Infrastructure Funding 9 The Department of Veterans Affairs must have increased funding for its research infrastructure to provide a state-of-the-art research and laboratory environment for its excellent programs, but also to ensure that VA hires and retains the top scientists and researchers. VA Research Is a National Asset Research conducted in the Department of Veterans Affairs has led to such innovations and advances as the cardiac pacemaker, nuclear scanning technologies, radioisotope diagnostic techniques, liver and other organ transplantation, the nicotine patch, and vast improvements in a variety of prosthetic and sensory aids. A state of-the-art physical environment for conducting VA research promotes excellence in health professions education and VA patient care as well as the advancement of biomedical science. Adequate and up-to-date research facilities also help VA recruit and retain the best and brightest clinician scientists to care for enrolled veterans. VA Research Infrastructure Funding Shortfalls In recent years, funding for the VA Medical and Prosthetics Research Program has failed to provide the resources needed to maintain, upgrade, and replace VA's aging research facilities. Many VA facilities have exhausted their available research space. Along with space reconfiguration, ventilation, electrical supply, and plumbing appear frequently on lists of needed upgrades in VA's academic health centers. In the 2003 Draft National Capital Asset Realignment for Enhanced Services (CARES) plan, VA included $142 million designated for renovation of existing research space and build-out costs for leased researched facilities. However, these capital improvement costs were omitted from the Secretary's final report. Over the past decade, only $50 million has been spent on VA research construction or renovation nationwide, and only 24 of the 97 major VA research sites across the nation have benefited. In House Report 109-95 accompanying the FY 2006 VA appropriations, the House Appropriations Committee directed VA to conduct ―a comprehensive review of its research facilities and report to the Congress on the deficiencies found and suggestions for correction of the identified deficiencies.‖ In FY 2008, the VA Office of Research and Development initiated a multiyear examination of all VA research infrastructures for physical condition and capacity for current research, as well as program growth and sustainability of the space needed to conduct research. Lack of a Mechanism to Ensure VA's Research Facilities Remain Competitive In House Report 109-95 accompanying the FY 2006 VA appropriations, the House Appropriations Committee expressed concern that ―equipment and facilities to support the research program may be lacking and that some mechanism is necessary to ensure the Department's research facilities remain competitive.‖ A significant cause of research infrastructure's neglect is that there is no direct funding line for research facilities. The VA Medical and Prosthetic Research appropriation does not include funding for construction, renovation, or maintenance of research facilities. VA researchers must rely on their local facility managements to repair, upgrade, and replace research facilities and capital equipment associated with VA's research laboratories. As a result, VA research competes with other medical facilities' direct patient care needs—such as medical services infrastructure, 10 capital equipment upgrades and replacements, and other maintenance needs—for funds provided under either the VA Medical Facilities appropriation account or the VA Major or Minor Medical Construction appropriations accounts. Recommendations: The Independent Budget veteran's service organizations anticipate VA's analysis will find a need for funding significantly greater than VA had identified in the 2004 Capital Asset Realignment for Enhanced Services report. As VA moves forward with its research facilities assessment, the IBVSOs urge Congress to require the VA to submit the resulting report to the House and Senate Committees on Veterans' Affairs no later than October 1, 2010. This report will ensure that the Administration and Congress are well informed of VA's funding needs for research infrastructure so they may be fully considered at each stage of the FY 2011 budget process. To address the current shortfalls, the IBVSOs recommend an appropriation in FY 2010 of $142 million, dedicated to renovating existing VA research facilities in line with the 2004 CARES findings. To address the VA research infrastructure's defective funding mechanism, the IBVSOs encourage the Administration and Congress to support a new appropriations account in FY 2010 and thereafter to independently define and separate VA research infrastructure funding needs from those related to direct VA medical care. This division of appropriations accounts will empower VA to address research facility needs without interfering with the renovation and construction of VA direct health-care infrastructure. Program for Architectural Master Plans: Each VA medical facility must develop a detailed master plan. The delivery models for quality healthcare are in a constant state of change. This is due to many factors including advances in research, changing patient demographics, and new technology. The VA must design their facilities with a high level of flexibility in order to accommodate these new methods of patient care. The department must be able to plan for change to accommodate new patient care strategies in a logical manner with as little effect as possible on other existing patient care programs. VA must also provide for growth in already existing programs. A facility master plan is a comprehensive tool to look at potential new patient care programs and how they might affect the existing healthcare facility. It also provides insight with respect to possible growth, current space deficiencies, and other facility needs for existing programs and how VA might accommodate these in the future. In some cases in the past, VA has planned construction in a reactive manner. After funding, VA would place projects in the facility in the most expedient manner – often not considering other projects and facility needs. This would result in shortsighted construction that restricts, rather than expands options for the future. 11 The IBVSOs believe that each VA medical Center should develop a comprehensive facility master plan to serve as a blueprint for development, construction, and future growth of the facility. Short and long-term CARES objectives should be the basis of the master plan. Four critical programs were not included in the CARES initiative. They are long-term care, severe mental illness, domiciliary care, and Polytrauma. VA must develop a comprehensive plan addressing these needs and its facility master plans must account for these services. VA has undertaken master planning for several VA facilities; most recently Tampa, Florida. This is a good start, but VA must ensure that all facilities develop a master plan strategy to validate strategic planning decisions, prepare accurate budgets, and implement efficient construction that minimizes wasted expenses and disruption to patient care. Recommendation: Congress must appropriate $20 million to provide funding for each medical facility to develop a master plan. Each facility master plan should include the areas left out of CARES; long-term care, severe mental illness, domiciliary care, and Polytrauma programs as it relates to the particular facility. VACO must develop a standard format for these master plans to ensure consistency throughout the VA healthcare system. Empty or Underutilized Space VA must not use empty space inappropriately and must continue disposing of unnecessary property where appropriate Studies have suggested that the VA medical system has extensive amounts of empty space that the Department can reuse for medical services. Others have suggested that unused space at one medical center may help address a deficiency that exists at another location. Although the space inventories are accurate, the assumption regarding the feasibility of using this space is not. Medical facility planning is complex. It requires intricate design relationships for function, but also because of the demanding requirements of certain types of medical equipment. Because of this, medical facility space is rarely interchangeable, and if it is, it is usually at a prohibitive cost. For example, VA cannot use unoccupied rooms on the eighth floor to offset a deficiency of space in the second floor surgery ward. Medical space has a very critical need for inter- and intra- departmental adjacencies that must be maintained for efficient and hygienic patient care. When a department expands or moves, these demands create a domino effect of everything around it. These secondary impacts greatly increase construction expense, and they can disrupt patient care. Some features of a medical facility are permanent. Floor-to-floor heights, column spacing, light, and structural floor loading cannot be altered. Different aspects of medical care have different requirements based upon these permanent characteristics. Laboratory or clinical spacing cannot be interchanged with ward space because of the needs of different column spacing and perimeter configuration. Patient wards require access to natural light and column grids that are compatible with room-style layouts. Labs should have long structural bays and function best without windows. When renovating empty space, if the area is not suited to its planned purpose, it will create unnecessary expenses and be much less efficient. Renovating old space rather than constructing new space creates only a marginal cost savings. Renovations of a specific space typically cost 85% of what a similar, new space would. When 12 you factor in the aforementioned domino or secondary costs, the renovation can end up costing more and produce a less satisfactory result. Renovations are sometimes appropriate to achieve those critical functional adjacencies, but it is rarely economical. Many older VA Medical Centers that were rapidly built in the 1940s and 1950s to treat a growing veteran population are simply unable to be renovated for modern needs. Most of these Bradley-style buildings were designed before the widespread use of air conditioning and the floor-to-floor heights are very low. Accordingly, it is impossible to retrofit them for modern mechanical systems. They also have long, narrow wings radiating from a small central core, which is an inefficient way of laying out rooms for modern use. This central core, too, has only a few small elevator shafts, complicating the vertical distribution of modern services. Another important problem with this unused space is its location. Much of it is not located in a prime location; otherwise, VA would have previously renovated or demolished this space for new construction. This space is typically located in outlying buildings or on upper floor levels, and is unsuitable for modern use. VA Space Planning Criteria / Design Guides: VA must continue to maintain and update the Space Planning Criteria and Design Guides to reflect state-of-the-art methods of healthcare delivery. VA has developed space-planning criteria it uses to allocate space for all VA healthcare projects. These criteria are organized into sixty chapters; one for each healthcare service provided by VA as well as their associated support services. VA updates these criteria to reflect current methods of healthcare delivery. In addition to updating these criteria, VA has utilized a computer program called VA SEPS (Space and Equipment Planning System) it uses as a tool to develop space and equipment allocation for all VA healthcare projects. This tool is operational and VA currently uses it on all VA healthcare projects. The third component used in the design of VA healthcare projects is the design guides. Each of the sixty space planning criteria chapters has an associated design guide. These design guides go beyond the allocation of physical space and outline how this space is organized within each individual department, as well as how the department relates to the entire medical facility. VA has updated several of the design guides to reflect current patient delivery models. These include those guides that cover Spinal Cord Injury / Disorders Center, Imaging, Polytrauma Centers, as well as several other services. Recommendation: The VA must continue to maintain and update the Space Planning Criteria and the VA SEPS space-planning tool. It also must continue the process of updating the Design Guides to reflect current delivery models for patient care. VA must regularly review and update all of these space-planning tools as needed, to reflect the highest level of patient care delivery. 13 Design-build Construction Delivery System The VA must evaluate use of the Design-build construction delivery system. For the past ten years, VA has embraced the design-build construction delivery system as a method of project delivery for many healthcare projects. Design-build attempts to combine the design and construction schedules in order to streamline the traditional design-bid-build method of project delivery. The goal is to minimize the risk to the owner and reduce the project delivery schedule. Design-build, as used by VA, places the contractor as the design builder. Under the contractor-led design build process, VA gives the contractor a great deal of control over how he or she designs and completes the project. In this method, the contractor hires the architect and design professionals. With the architect as a subordinate, a contractor may sacrifice the quality of material and systems in order to add to his own profits at the expense of the owner. Use of design-build has several inherent problems. A short-cut design process reduces the time available to provide a complete design. This provides those responsible for project oversight inadequate time to review completed plans and specifications. In addition, the construction documents may not provide adequate scope for the project, leaving out important details regarding the workmanship and / or other desired attributes of the project. This makes it difficult to hold the builder accountable for the desired level of quality. As a result, a project is often designed as it is being built, which often compromises VA's design standards. Design-build forces the owner to rely on the contractor to properly design a facility that meets the owner's needs. In the event that the finished project is not satisfactory to the owner, the owner may have no means to insist on correction of work done improperly unless the contractor agrees with the owner's assessment. This may force the owner to go to some form of formal dispute resolution such as litigation or arbitration. Recommendation: VA must evaluate the use of Design-build as a method of construction delivery to determine if design-build is an appropriate method of project delivery for VA healthcare projects. The VA must institute a program of ―lessons learned‖. This would involve revisiting past projects and determining what worked, what could be improved, and what did not work. VA should compile and use this information as a guide to future projects. VA must regularly update this document to include projects as they are completed. Preservation of VA's Historic Structures: The VA must further develop a comprehensive program to preserve and protect its inventory of historic properties. The VA has an extensive inventory of historic structures that highlight America's long tradition of providing care to veterans. These buildings and facilities enhance our understanding of the lives of those who have worn the uniform, and who helped to develop this great nation. Of the approximately 2,000 historic structures, many are neglected and deteriorate year after year because of a lack of funding. These structures should be stabilized, protected and preserved 14 because they are an integral part our nation's history. Most of these historic facilities are not suitable for modern patient care. As a result, a preservation strategy was not included in the CARES process. For the past six years, the IBVSOs have recommended that VA conduct an inventory of these properties; classifying their physical condition and their potential for adaptive reuse. VA has been moving in that direction and historic properties are identified on their website. VA has placed many of these buildings in an ―Oldest and Most Historic‖ list and these buildings require immediate attention. At least one project has received funding. The VA has invested over $100,000 in the last year to address structural issues at a unique round structure in Hampton, VA. Built in 1860, it was originally a latrine and the funding is allowing VA to convert it into office space. The cost for saving some of these buildings is not very high considering that they represent a part of history that enriches the texture of our landscape that once gone cannot be recaptured. For example, VA can restore the Greek Revival Mansion in Perry Point, MD, which was built in the 1750's, to use as a training space for about $1.2 million. VA could restore the 1881 Milwaukee Ward Memorial Theater for use as a multi-purpose facility at a cost of $6 million. This is much less than the cost of a new facility. As part of its adaptive reuse program, VA must ensure that the facilities that it leases or sells are maintained properly. VA's legal responsibilities could, for example, be addressed through easements on property elements, such as building exteriors or grounds. We encourage the use of P.L. 108-422, the Veterans Health Programs Improvement Act, which authorized historic preservation as one of the uses of a new capital assets fund that receives funding from the sale or lease of VA property. Recommendation: VA must further develop a comprehensive program to preserve and protect its inventory of historic properties. Mr. Chairman, this concludes my statement. I would be happy to answer any questions that you or the members of the Committee may have.
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A middle class pimp. He makes as much as George W. Bush ,a corperate exectutive, or airline pilot(i.e. $50,000 to $200,000 a year) He also has 5 to 10 hookers working for him.
My nextdoor neighbour is a player pimp and he make 200 grand a year.
מאת Le Mans 8 ביולי, 2005
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SPRINGFIELD, Mo. – The Missouri Department of Conservation (MDC) will host a public meeting at 6:30 p.m. on Wednesday, Oct. 9, at its Springfield Conservation Nature Center. The purpose of the meeting is to provide information on Missouri deer and Chronic Wasting Disease (CWD), and to get comments about limiting the spread of CWD among captive and free-ranging deer.
Based on current scientific research and Conservation Department management priorities, MDC has identified several areas of concern related to disease transmission and captive cervids. Those items include the separation of captive and free-ranging wildlife populations, movement of captive wildlife, disease testing and herd certification.
"CWD has been found in captive deer and free-ranging deer in north-central Missouri," said MDC State Wildlife Veterinarian Kelly Straka. "This neurological disease is currently limited to deer and other members of the deer family, called cervids. It has no vaccine or cure and is 100-percent fatal. Once it is well-established in an area, CWD is impossible to eradicate."
The Department of Conservation has been working with hunters, landowners, conservation partners and businesses to detect cases of this infectious disease and limit its spread in free-ranging deer. MDC has also made regulation changes affecting free-ranging deer in the area where CWD has been found.
MDC is also working with the captive cervid industry, landowners, hunters, and others to address areas of concern related to captive deer and other captive cervids. There are 47 big-game hunting preserves and 253 wildlife breeders in the state that have captive deer and other captive cervids.
Missouri's first cases of CWD were detected in 2010 and 2011 in captive deer at private big-game hunting preserves in Linn and Macon counties. A total of 11 cases of CWD have been confirmed in captive deer at these facilities. CWD has since been found in 10 free-ranging deer within two miles of the captive facility in Macon County.
Missouri offers some of the best deer hunting in America. Deer hunting is an important part of many Missourians' lives and family traditions, including almost 520,000 deer hunters and almost two million wildlife watchers. Deer hunting also gives Missouri an important economic boost. Deer hunting supports 12,000 Missouri jobs and gives a $1 billion annual boost to state and local economies.
The Springfield Conservation Nature Center is located at 4601 S. Nature Center Way in Springfield. Call MDC's Southwest Regional Office at 417-895-6880, or the Nature Center at 417-888-4237, for more information about this meeting. Information can also be found by searching for "chronic wasting disease" at mdc.mo.gov.


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'I maintain my position that all of the details should remain a private matter between us," he said in the statement to MTV. "I do appreciate her support and wish her the best."
In a 20/20 interview Friday, Rihanna offers a graphic account of the Feb. 7 fight with her then-boyfriend Brown, describing what she calls the terrifying blankness that seemed to come over him as he assaulted her. "He was clearly blacked-out," she says. "There was no person when I looked at him."
Although Brown declined to respond to her specific comments, he again took responsibility.
"I am extremely sorry for what I did, and I accept accountability for my actions," he tells MTV. "At this point, I am taking the proper steps to learn about me and grow from my mistakes. I only hope that others in similar situations can learn from our experience as well. Abuse of any kind is always wrong. The rest I leave it to God."
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Larynx Cancer Center - Amarillo, TX
- WebMD Physician Directory of Amarillo Oncologist Doctors
- Related Larynx Cancer Articles
- Amarillo Emergency Contacts
- Nearby Amarillo Hospitals
- Find a Local Pharmacy on RxList - Amarillo
Amarillo Oncologist Doctors for Larynx Cancer
Type of Physician: Oncologist
What is a Oncologist? A subspecialty certification by the Board of Internal Medicine; the oncologist specializes in the diagnosis and treatment of all types of cancer and other benign and malignant tumors. These subspecialists decide on and administer chemotherapy as well as consult with surgeons and radiotherapists on other treatment for cancer.
Specialty: Oncology (Medical)
Common Name: Cancer Doctor
Oncologist Doctors in Amarillo * results
- 2
Suhasini R. Nadesan
Harrington Cancer Center
1500 Wallace Blvd
Amarillo, TX 79106
(806) 359-4673
- 46 years experience
- 1 office location(s)
- 3
Anita Ravipati
Harrington Cancer Center
1500 Wallace Blvd
Amarillo, TX 79106
(806) 359-4673
- 15 years experience
- 1 office location(s)
- 4
Brian T. Pruitt
Harrington Cancer Center
1500 Wallace Blvd
Amarillo, TX 79106
(806) 359-4673
- 43 years experience
- 1 office location(s)
- 5
Leonardo Forero
Texas Oncology PA
1000 S Coulter St Ste 100
Amarillo, TX 79106
(806) 358-8654
- 23 years experience
- 1 office location(s)
- 6
Srini B. Reddy
Texas Oncology PA
1000 S Coulter St Ste 100
Amarillo, TX 79106
(806) 358-8654
- 21 years experience
- 1 office location(s)
- 7
Subhasis Misra
Texas Tech University Physicians Surgery
1400 S Coulter St FL 2
Amarillo, TX 79106
(806) 354-5696
- 16 years experience
- 1 office location(s)
Don't see your city? Use the WebMD Physician Directory to expand your search.
Larynx Cancer
Throat cancer (larynx cancer) facts*
*Throat cancer (larynx cancer) facts Medically Edited by: Melissa Conrad Stöppler, MD
- The larynx is the voice box located at the top of the windpipe (trachea).
- Cancer of ...
Other Related Larynx Cancer Articles
Emergency Contact for Amarillo
- In case of Emergency, call 911
Nearby Amarillo Hospitals results
- 1Plum Creek Specialty Hospital
5601 Plum Creek Dr
Amarillo, Texas 79124
(806) 351-100
- 2VA Medical Center
6010 W Amarillo Blvd
Amarillo, Texas 79106
(806) 355-970
- 3Quail Creek Surgical Hospital
6819 Plum Creek Dr
Amarillo, Texas 79124
(806) 212-200
- 4The Pavilion At NW Texas Hosp
7201 Evans St
Amarillo, Texas 79106
(806) 354-181
- 5Kindred Rehabilitation Hospital
7200 SW 9th Ave
Amarillo, Texas 79106
(806) 468-290
- 6Baptist St Anthonys Health Sys
1600 Wallace Blvd
Amarillo, Texas 79106
(806) 212-200
- 7Northwest Texas Healthcare Sys
1501 S Coulter St
Amarillo, Texas 79106
(806) 354-100
- 8Panhandle Surgical Hospital
7100 SW 9th Ave
Amarillo, Texas 79106
(806) 212-024
- 9Kindred Hospital
7501 Wallace Blvd
Amarillo, Texas 79124
(806) 351-160
- 10Northwest Texas Surgery Center
3501 S Soncy Rd Ste 118
Amarillo, Texas 79119
(806) 359-799
* Provider Directory Terms of Use:
The WebMD 'Provider Directory' is provided by WebMD for use by the general public as a quick reference of information about Providers. The Provider Directory is not intended as a tool for verifying the credentials, qualifications, or abilities of any Provider contained therein. Inclusion in the Provider Directory does not imply recommendation or endorsement nor does omission in the Provider Directory imply WebMD disapproval.
You are prohibited from using, downloading, republishing, selling, duplicating, or "scraping" for commercial or any other purpose whatsoever, the Provider Directory or any of the data listings or other information contained therein, in whole or in part, in any medium whatsoever.
The Provider Directory is provided on an "AS-IS" basis. WebMD disclaims all warranties, either express or implied, including but not limited to the implied warranties of merchantability and fitness for particular purpose. Without limiting the foregoing, WebMD does not warrant or represent that the Provider Directory or any part thereof is accurate or complete. You assume full responsibility for the communications with any Provider you contact through the Provider Directory. WebMD shall in no event be liable to you or to anyone for any decision made or action taken by you in the reliance on information provided in the Provider Directory.
The use of WebMD Provider Directory by any entity or individual to verify the credentials of Providers is prohibited. The database of Provider information which drives WebMD Provider Directory does not contain sufficient information with which to verify Provider credentials under the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), National Committee for Quality Assurance (NCQA) of the Utilization Review Accreditation Committee (URAC).
By using the WebMD Provider Directory, you agree to these Terms and Conditions.


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Happy 2010! After four months abroad in Spain, I am back in the United States, settling back into Chipotle burritos, big SUVs, free tap water at restaurants, and going to bed at midnight instead of 6am. And it's great. Although it's not great that I haven't written since December, but it's a new year! So here are 10 new thoughts on the emerging trends of 2010.
1. Twitter will remain unpopular among college age students.
2009 has been the year of twitter. Twitter traffic grew more than 1300% from Feb '08 to '09. However, one demographic remains dubious towards adopting another social media platform: college-age students.
Twitter should be used for developing professional networks and college age students are (usually) not thinking about their professional networks or careers (past their GPAs). For personal networks, twitter does not do anything that facebook doesn't also offer. Which leads me to my next prediction…
2. Twitter will be bought.
My brother will argue with me on this one, but I think that Twitter has to monetize next year or they will be bought by Facebook. And if they haven't made profits yet, I don't see them doing so in 2010.
3. LinkedIn profile expansion among college-age students.
More students will create LinkedIn profiles. However, they will miss the point completely, using it as an electronic copy of their resume rather than a networking tool because (see #1, they don't think about their professional networks until after college).
You've heard of the horror stories of students getting fired from their jobs for saying bad things about their bosses on Facebook.
In 2010, students will be more aware of their online reputation, increase their privacy settings across the board and cut back on the incriminating keg-stand photos.
Anyone seen Avatar? Heard of the Kindle? This one is kind of a given, with all the predicted CES hype around 3D TVs and E-book readers , you will be sure to see them crowding the shelves by Spring.
LinkedIn paired up with Twitter to offer cross-platform status updates. Maybe this is more of a desire than a prediction, but I want a multi-platform supported service that allows me to manage all of my social media identities from one single place. So, I predict it will happen.
The Facebook interface and user experience is sloppy. The site is difficult to navigate, privacy settings are confusing, and finding the features you want to use involves wading through pages of poorly designed interfaces (just ask my mom). The baby boomers are the largest growing demographic on Facebook. I've personally had to set up over ten accounts for family members who couldn't figure it out. If Facebook wants to retain the baby boomer demographic, they'll have to figure out a way to maintain the functionality they have while improving the user experience.
8. Google Wave will be an epic fail.
After playing with Google Wave for 3 months, I still don't understand its purpose. I rarely check it and I don't see many people adopting it into their internet toolbox in 2010.
9. Backlash towards telegraphic communication.
In my experience, Twitter's 140 character limit is not a positive. It hinders any real communication or connection and what you get is millions of users sharing a lot of links and talking mundanely about their personal lives.
10. Service that combines recommendations with personal networks.
I predict that some large retailer or rental company (maybe Netflix) will adopt users' social media profiles into their algorithms for making suggestions. This would work great on an E-Book reader: "Looking for a new book to read? Your X friends that you have interacted with the most on ______ (insert social media platform) liked: ______".
And there you have my predictions for 2010! Do you agree? Disagree? Have predictions of your own? Leave a comment and let me know.
Disclaimer: I am not responsible for any money lost due to gambling these claims. Unless you win.
January 7, 2010 | Filed Under Post, Uncategorized | 4 Comments


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Friday, April 10, 2009
Ministry KPIs: Start With Accountability and Transparency
Mahathir introduced his concept of "Bersih, Cekap, Amanah" to drive the performance of civil service. The civil service performance indicator is even more important than ministries' KPIs. It was an established fact that a number of policies faced implementation setbacks. Hence, the right thing for Najib and Koh Tsu Koon to measure is the government's implementation mechanism.
Abdullah introduced KPIs for the GLCs. The KPIs were created by Ethos Consulting. Unfortunately, not many of us are familiar with the performance measurement because it was never made transparent and open.
Second, I am beginning to doubt Koh's ability to come out with a comprehensive, fair and competent KPIs for all the ministries. He was super efficient. In less than a day, he has spoken to six ministries and gave the rest 30 days to come out with their respective KPIs. To come out with the right set of KPIs, a minister must be fully briefed on the important processes, objectives and works of his/her ministries. The KPIs must not only be able to measure the right activities and processes but can also be used to enhance performance, correct weaknesses and eradicate mediocrity.
I hope Koh does not forget about his own KPIs. Who is going to measure the KPIs of the minister in charge of unity and performance?
Najib has made a tactical mistake. Although it is a notable action to measure the performance of his ministers, he should have appointed an independent committee to look into the efficiency and performance measurements of his administration which should include the civil sector.
Third, does the performance measurement includes all BN chief ministers too? We can no longer tolerate chief ministers who spend public fund on flimsy 'technical visits' to amusement parks, Disneyland and others. If Mohd Khir Toyo was so intelligent that he can understand how an amusement park can be developed and run by mere social visits, there is no need for KPIs. Just appoint him to become the PM.
Fourth, can Koh handle these ministers? His other portfolio - unity - runs contrary to his main portfolio on performance. How can he help to promote 'unity' if he has to step on many shoes to ensure an optimal performance from the ministers? It is clear that Koh's appointment was made hastily. His own sets of KPIs run contrary against each other. Maybe, it was his mentor, Lim Keng Yaik, who helped him get the job.
If Najib is serious about KPIs, he should start with both accountability and transparency. An accountable government should not be afraid of public scrutiny. The first thing he should do is to free up the press and allow access to both MSM and online media to all important public information. His policies and implementation process must be subjected to constant public scrutiny and test.
Afterall, Najib is the one who said that the 'government knows best' era is over. The media, NGOs, academicians, analysts and stakeholders should be allowed to discuss, debate and provide feedback freely on public policies. Hence, previous actions of protecting details of privatisation concessions e.g. tolls, IPPs and other mega projects using the secretive OSA must be stopped immediately. A credible and efficient government is a transparent government.
Najib should have realised that the performance bar is high and expectations are many. Not many organisations and individuals are as generous as Hindraf which has given Najib a 100 days truce. The reception he received at the two by-elections, Bukit Selambau and Bukit Gantang, has shown that he is not going to enjoy a honeymoon period.
Najid should really get serious with promises and stop his 'instant noodle' reform.
16 comments:
Dream on!! It's all talk only la, sound nice to the ears, but nothing will ever change in BN, not with Jibby & Dotty plus Kutty on the helm!!
Good nite!
Najib will continue to reinvent. He will continue to recycle. KPI is his rhetoric and he did it at the defence ministry but what is the result - baggage and incompetency and mediocre everywhere in all departments.
The only thing is someone is going to gain out of this KPI - satu lagi projek BN!!! another instant noodles!!!
So you will find all ministries will be busy working on KPI just to please Najib and will not focus on their core business. There will be more seminars and people will get confuse and that will be Najib smoke screen. And stop fooling the rakyat.
- romerz said...
A KPI only really works if those who are required to prepare it are sincere in its preparation and those evaluating the KPIs are not bowled over by grandiose proclamations and insincere language which pleases the ears.
I know because every 6 months, I quarrel with my wife when its her KPI time. She wants me to write her KPI for her (saying that I write better English than her) and when I refuse, she would use her colleagues as examples, saying that their husbands write the KPIs for them. I have read some of her colleagues KPIs and all I can say is that the evaluator must not be doing his/her job when the KPIs contain objectives and accomplishments above their stations in the company (written from a managerial position when they are actually clerical).
So long as we have dishonest people, KPI is nothing more than a window dressing and the desire to follow western management techniques.
This is where we will fail because we still have a 3rd world mentality!
Sigh! Have to admit though that I did my wife's last 2 KPIs until the last one where she managed to persuade her MBA friend to do it for her.
I sincerely hope that KTK is not as afraid of the KPI respondents as I am of my wife.
Wishful thinking? I hope not but I'm not holding my breath after looking at I have fallen to threats!
Why don't they get some global HR consultants to come up with the KPI like Hewitt or Mercer ? That would surely be a "reform" initiated by Najib in the process of transparency and accountability.
Surely they can do a professional and objective job instead of KTK who may be blocked from doing his task by political wayang.
It is silly and wasting time to expect reforms from the new government, because history has shown us, non of the ruling regimes in this world was really able to reform from within ,as the interest parties would resist what ever changes that are causing problem to their vested interests, therefore if the people wants to have a change, the only way is to vote them out on the next general election.
Allow me to add to the KPIs:
1.Zero tolerance for corruption
2.Punctuality and timely work. No shirkers!
4.Stop the shows and sandiwaras. No wastage of public funds and resources.
Dear Khoo
Agreed with your assessment that it is more important to measure the civil service performance than ministerial KPIs. There are serious structural reforms that the Gov'n needs to undertake - and priority for that would be to restore public confidence in the MACC, the police and the Judiciary. And lately, with the Kugan case, that would include guardians of our Health Portfolio!
My honest evaluation at this juncture is that, this is yet another impotent gov'n that is bent on keeping as many people happy as possible - especially those with political bargaining power, and not so much address the critical structural issues plaguing Malaysia.
I have yet to hear what the new PM wants to do to improve M'sia's competetive and cutting edge; how does he intend to both attract & stop the best brains from leaving the country?
How does he intend to tackle corruption, and not just provide lip service?
What about the so-called proposed ISA review? What are his measurable plans and goals to attain that?
Of course, will he also be given a KPI by Koh Tsu Koon? And how will he be held accountable to the Rakyat?
Thus far - lip service seems to be the best service the new Cabinet is offering...
Najib must really be short of ideas.
KTK was a non-performer as CM in Penang. He has not even seen fit to account for the widely publicised land scams.
Ahmad Ismail and the Penang Umno boys treat him with total contempt and they are not alone. Many Penangites share their contempt as well.
For him to be included in the cabinet is a sick joke and an affront to the people of Penang who have already passed their judgement on him and Gerakan in the last GE.
How on earth is Tan Sri Koh going to handle KPI of other more important ministry like finance, home, defence and education. He himself is not an elected rep and a rejected one.
- donplaypuks® said...
This is an eyewssh because any low rating of any civil servant, GLC CEO's and Deputy Ministers & Ministers does not mean they will be:
1. Sacked.
2. Demoted.
3. Have their salary reduced.
The whole exercise is to prevent Gerakan from ditching Barisan National and joining Barisan Rakyat.
I mean where is the real logic in making a Minister out of someone the Rakyat has clearly said is redundant. But, Malaysia Bolih; screw the Rakyat!
- SL Chan said...
Honestly Khoo...
Sorry to say this,I have doubt that they will change....that idiotic motto they "glued" with .."dulu,kian dan selama-lamanya".. after 50 years of their ketuanan melayau rhetoric mindset and mentality , malaysia belong to them mentality which they possess all this years...Look at the demo at PWTC where they challenge the "cow" sprm action on the "politik wang" within their party and have the guts to say it is their right..What kind of moronic mentality is this??????This is arroganceeeeee!!!! The only thing can change them is when they become opposition in the federal level!!!!!!!!
All these monitoring process , brain storming , motivation plan ,
contingency plan,performance index,teamwork ,bla..bla..bla..
reminded me of my corporate days.
It can works only with sincere participants.But most of the guys
are addressing the issues FOR THE SAKE OF ADDRESSING.It's just some sort of commitment to say something when it's your turn to do so.(time to pass homework).
Still recalled on one MOTIVATION SESSION in the production lines.
Sounded positive but the production result is negative, nothing to look forward.MC is high
as usual if not more.
Finally , with just one simple implementation of MONEY INCENTIVE without any motivation or counselling session , even the MC king limped to work and the production graph escalating all the way.
Basically most of the guys are talking just for the sake of talking or commencing and it does not carry any weight and truth in it.
End of the day , it's PAY that matters to them.
KPI must be defined by the Executive team and cascaded down across the organization. It is not up to each Ministries to define their own KPI.
As such, 1st rule of KPI already broken. You can set up your own report cards and report everything to be meeting the objective.
"If you choose to critize the corrupted politician you'll definitely be send to Kamunting to eat curry rice."
Poor old Samy is gnashing,clenching, grinding his sets of false teeth to nail you in court on this piece. At some or other, u need to get your defence team ready. We all do.
One must know how to praise good job done and not to label everything done by the people you hate (or BN) as evil. Buat kerja kena kritik, tak buat pun kena. Di sebaliknya if PR do evil, you people can accept it as a benevolent act! be rational.
There will be try and error on KPI setting. KPI doesn't promise us a success, but at least the performance is being measured. Hopefully the accountability won't be an issue anymore.


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on December 6, 2012 - 8:00 PM
, updated December 7, 2012 at 1:21 AM
ALBANY – A day after declining to rule out a toll increase on passenger vehicles, Thruway officials Thursday night said that option is off the table.
The Buffalo News reported earlier Thursday that the agency's director, Thomas Madison, declined to say Wednesday if officials were examining a toll hike on all vehicles, including cars, as a way to lower a proposed 45 percent toll increase on trucks and certain-sized campers being hauled by cars or trucks.
But Thursday evening, after a couple of Albany-area Assembly Republicans called Thruway officials everything from the Grinch to "arrogant" in response to the story, the agency ended the uncertainty and said no toll hike on passenger cars is under review.
In May the Thruway Authority proposed a 45 percent increase on three-axle and larger vehicles as a way to raise $90 million a year in new revenues.
Business groups say the increase would be passed onto consumers in the form of higher prices on virtually every product transported along the Thruway.
Two recent Thruway Authority board meetings to approve the plan were scuttled at the last minute, and now Thruway officials say they are looking at "all options" to raise revenues or cut expenses after they had already assured investors in a $1 billion bond sale that the toll hike was coming to help the agency balance its books.
Thruway officials still won't say, though, if a Dec. 17 board meeting will take up the toll issue, but the board will decide at that session on a bid for a new Tappan Zee Bridge to be built over the Hudson River.
Wednesday, Madison was asked by a reporter if the agency was looking at smoothing out the planned 45 percent toll hike, which Thruway Chairman Howard Milstein had dubbed "modest," by applying any toll increase to all classes of vehicles that use the highway system, including cars.
"All options covers a lot of ground … We're covering a lot of ground in our analysis," Madison responded.
Thursday evening, Thruway officials said there is no plan afoot to hike tolls on passenger vehicles.
email: firstname.lastname@example.com


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Best of '12: Dairy farming parody goes viral
Submitted by admin on Mon, 12/24/2012 - 09:02
Hoard's Dairyman:
Best of '12: Dairy farming parody goes viral
Date:Mon, 12/24/2012
Over the holidays, we will be sharing some of our most-viewed blogs of 2012. If you missed them earlier, we've got them ready to close out 2012.
Nine-year-old dairy farm boy, "Little Fred," sings a "Call Me Maybe" parody while putting a cute face on dairy farming.
by Chelsey Johnson, Hoard's Dairyman Editorial Intern
Leave it to farm kids to come up with creative ideas. When gathered with family over the 4th of July, Clymer, N.Y. brothers, 18-year-old Justin and 9-year-old Fred White decided to respond to the recent YouTube video "I'm Farming and I Grow It" created by the Peterson Farm Brothers. However, this time the parody would be based on Carly Rae Jepsen's hit, "Call Me Maybe," and the star would be an animated, charismatic 9-year-old who sings about the life of growing up on a dairy farm.


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on May 4, 2013 - 12:53 AM
It's one thing for school districts to share some sports teams and academic programs these days, but sharing a leader is largely untested territory.
That is, until two eastern Niagara County school districts this week decided to give it a go, primarily as a cost-saving maneuver. Both the Royalton-Hartland and Barker school boards this week sealed a deal that will allow them to share a superintendent for at least a year.
With the departure of Roy-Hart Superintendent Kevin MacDonald at the end of this school year to head the Genesee Valley Educational Partnership, the superintendent for the Barker district, Roger J. Klatt, will take on the role for both beginning July 1.
"Each board felt that the conditions were favorable after having already entered into a number of shared initiatives for this coming year," Klatt said Friday.
In an effort to reduce expenses and increase student access to programs, both districts had earlier agreed to implement a shared wrestling program, as well as sharing a special-education program and the services of a certified business teacher for the 2013-2014 school year.
The districts started working together two years ago when they merged their football programs.
"That collaboration has proved to be a very successful venture between the two districts. The parents and community members have embraced the shared program, as well," Klatt said.
An educator for 28 years, Klatt has been employed with the Barker district for 13 years, six of them as superintendent.
He will remain an employee of Barker, but the agreement reached Wednesday by both the Roy-Hart and Barker school boards will require each district to cover 50 percent of his annual $149,652 base salary and benefits.
There is another example of shared sports programs in Erie County, where the East Aurora School Board approved a plan that would allow students from Holland Central High School, who have been without a football program, to try out for East Aurora's team, effectively merging programs.
Sharing superintendents is not unheard of in New York State, Klatt said.
"I believe there are already one or two [school districts] in the Adirondacks that share a superintendent, but they have a smaller combined population than what either Barker or Roy-Hart have," he said.
Barker has a districtwide enrollment of about 900 students, and Roy-Hart has about 1,400. Typically, districts that seek to share a superintendent are smaller, Klatt said.
"It's not rare, but it's new to our area, and because it's a unique concept, both districts decided that it would be best if we entered into this agreement for just one year. We're hopeful that it becomes a manageable situation and that I will be able to manage each district effectively," he said.
"Being separate districts, they each have their unique circumstances and goals that are unique to each district. The hope is that I will be effective in meeting the separate goals established by each district, as well as meeting the needs of the students of each district and the respective communities." he added.
email: email@example.com


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More than 758,000 registered voters in Pennsylvania do not have photo identification cards from the state Transportation Department, putting their voting rights at risk in the November election, according to data released Tuesday by state election officials.
The figures - representing 9.2 percent of the state's 8.2 million voters - are significantly higher than prior estimates by the Corbett administration. Secretary of the Commonwealth Carol Aichele has repeatedly said that 99 percent of Pennsylvania's voters already had the photo ID they will need at the polls in November.


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Fantasy football gamers spend the entire week anxiously waiting for Sunday's arrival, grinding through six humdrum days so they can savor the good part. Good news everyone: The best day of the week is finally here.
In Thursday night's prelude, stud running backs LeSean McCoy and Jamaal Charles each showed why they warranted first-round selections. Can C.J. Spiller match their stellar outings against the New York Jets? How about Arian Foster versus the Baltimore Ravens?
This week also marks the rare occasion of a fantasy first-rounder switching locations during the season. Trent Richardson will don an Indianapolis Colts uniform for the first time against a San Francisco 49ers squad hungry to avenge an ugly Week 2 loss.
Week 3 is a big one, as managers can start effectively separating flukes from trends. Is Eddie Royal's touchdown barrage for real? Will James Starks transform into a reliable fantasy back? Which Colin Kaepernick can owners expect moving forward?
Keep checking for essential updates that will keep you in the loop for all of Sunday's pertinent scoops. We'll share all the important injury news while highlighting the day's studs and duds on the gridiron.
Sit back and relax, but not before getting your lineup ready to roll. Another precious week of football Sunday is set to begin. Are you ready?


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on February 4, 2013 - 4:01 PM
The suspected kingpin of a multimillion-dollar heroin ring that funneled drugs from the Bronx to Buffalo was arrested late last week after eluding authorities for nearly two years, the State Police announced Monday.
The State Police special investigations unit in White Plains had been tracking leads on the suspect, Eury Rodriguez, 33, of Queens, and took him into custody Thursday.
Authorities say Rodriguez was involved in moving more than seven kilograms of heroin with an estimated street value of $3.5 million from New York City to Buffalo.
Rodriguez is scheduled to be arraigned today in Erie County Court on charges of criminal possession of a controlled substance in the first degree, criminal sale of a controlled substance in the first degree, conspiracy in the second degree and operating as a major trafficker, also known as the "drug kingpin law," officials said.
The case began to unfold about two years ago as authorities from Schneiderman's office, State Police and local police began making street-level purchases and conducting wiretaps and other forms of surveillance.
That led them to a stash house in an alley in the heart of Elmwood Village in February 2010. Later that year, two Buffalo men driving up from the Bronx on the Thruway were stopped in Onondaga County and arrested with 300 grams of heroin. A month later, authorities seized five kilograms in the Bronx.
In March 2011, 13 of 15 people named in a 51-count indictment were arrested. But among those who managed to avoid arrest was Rodriguez. State Police said he "went underground."
email: email@example.com


text:
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text: Deerstalking in the Val Trupchun, the national park valley richest in game, near S-chanf or on Stabelchod, by the Ofen Pass in Zernez. Wherever your hike takes you, it will be an unforgettable experience for people of all ages. Around 2000 deer dwell for a maximum of five months during the summer in the National Park. They have adapted perfectly to high altitudes and their alpine surroundings – dwelling during the summer months at altitudes of around 3000 meters.


text:
Friday, November 15, 2013
Class 8 - Part 1
Saturday morning is bright and sunny with a promise of high temperatures after a week of autumn coolness. I leave the house with a worm of excitement arguing with trepidation in my stomach. I look strange in a combination of socks pulled up over long pants, a short-sleeve shirt and high rubber Wellingtons. I don't care.
There had been an animated discussion during the last class about chiggers, what they do and where they can end up. They were not going to get me. Had I owned a haz-mat suit I would have worn that. The other concern was mosquitos. We are going to the outdoor range owned by MeadWestvaco, which generously allows law enforcement its use. I have been there before and the mosquitos are the size of my cat.
We meet at the police station and form a caravan following Lt. Thomas Peterson out to the range.
The first order of safety is to pull our cars completely out of the drive giving Peterson a straight shot out in case he has to make a hospital run. Not reassuring. He backs his car in.
Peterson gathers us and he goes through a checklist: Safety goggles, ear plugs, Kevlar vests, where we can stand, treat all weapons as if loaded, never point at anything you don't intend to shoot, know the foreground as well as what is behind the target, has anyone consumed alcohol or drugs?
He talks about the right side eject of the spent casing, that it is very hot and that although we are shooting alone here, if we were shooting with someone else, we would need to wear a hat with a bill, a high necked shirt, etc, to keep the casing from hitting us or going down our shirt.
Three at a time he takes us across the field toward the targets. Everyone else has to stay by the cars and tables.
He stops about 10 feet from the targets. I think, to myself, if I can't hit the target from here….
Two of us have never shot a handgun before. The third has, once, on New Year's Eve, into the air.
Peterson carefully shows us the ammunition - for us newbies it is .22 caliber. This will give us the least recoil or kick of the three ammunition sizes he has. The other two are .40 caliber and a 9mm competition pistol.
The .40 has the most recoil and the 9mm falls somewhere in between.
He switches out the barrel of the Glock to take the .22 caliber ammunition.
The younger of the two neophytes goes first.
Peterson has her stand, legs apart, holding the gun with both hands straight in front of her. Ahead is a target with the outline of a man. There is what they call a bottle shape outlined inside that defines the vital organ area. A hit there will stop the threat.
Law enforcement shoots to stop the threat. They do not aim to wound or incapacitate. They are not movie stars who shoot the gun out of the bad guy's hand. They are human beings, whose mandate is to protect the rest of us and, when under threat, if deadly force is necessary, they shoot to stop the threat.
Peterson stands to the left of the first shooter. He makes sure the rest of us are well behind the casing ejection path. He holds her arms steady with a hand gently around her wrists. I imagine this is so the shot doesn't go wild.
He tells her to place her finger on the trigger and to steadily and smoothly pull back. There is a trigger pull weight of 5.5 lbs., standard for SPD.
Competition pistols might have a pull weight of 2 lbs. However, most safety literature emphasizes to never have a carry gun with less than 4 lbs. of trigger pull. The lighter the pull the easier it is to shoot…accidentally.
She pulls the trigger and there is a moderate bang and a hole appears in the target almost simultaneously as a poof of dust rises from the berm behind the target.
She shoots a few more times, without Peterson's hand on her wrist.
The second of our group takes her turn and then it is my turn....
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text:
In Theaters
A Most Wanted Man Drama
- Summary
- Reviews / Ratings
- Photos
- Videos
- Events
Anton Corbijn's adaptation of John Le Carre's psychological novel follows German spy Gunther Bachmann as he tracks down Issa, a suspicious Chechen-Russian immigrant on the run in Hamburg. Pressured by his German and American colleagues to capture and interrogate his suspect as a Muslim terrorist, Bachmann instead asks for more time to carefully track Issa's movements and his relationship with his German immigration lawyer, Annabel Richter. Using his secret contacts and keen skill, Bachmann uncovers a connection between a world-renowned Muslim philanthropist and a terrorist group and devises a plan to use Issa and Annabel in a brilliant ploy to expose the scheme.
Oct 27, 2014
Jul 25, 2014
Jan 21, 2014
More Details
Released - Friday, July 25 , 2014
Official Website
Official Website
- Starring - Philip Seymour Hoffman, Rachel McAdams, Willem Dafoe, Robin Wright
- Directed by - Anton Corbijn
- Distributed by - Roadside Attractions
- MPAA Rating - R


text:
Witnesses told authorities that Sunday at around 12:35 p.m. the filmmaker left his parked Toyota Prius on the Vincent Thomas Bridge, scaled a fence and then leapt without hesitation. A note with contact information was left in the vehicle, says the newspaper.
Los Angeles Port police pulled his body from the water four hours later. A suicide note was recovered in his office, reports the Times. Its contents have not been disclosed.
The British-born Scott, the younger brother of director-producer Ridley Scott (Alien, Gladiator), lived in Beverly Hills. He had twin sons with his third wife, actress-model Donna Wilson.
Family spokesman Simon Halls confirmed Scott's death and said the family requests "that their privacy be respected at this time."
Ridley and Tony Scott ran Scott Free Productions, whose TV shows include The Good Wife. Tony Scott frequently worked with Denzel Washington, on Crimson Tide, Man on Fire, Deja Vu and The Taking of Pelham 123. Most recently they collaborated on Unstoppable.
Scott recently finished shooting the drama Out of the Furnace, starring Christian Bale.
In a Tweet Sunday, director Ron Howard wrote, "No more Tony Scott movies. Tragic day."


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This Web site is powered by Joomla! The software and default templates on which it runs are Copyright 2005-2008 Open Source Matters. The sample content distributed with Joomla! is licensed under the Joomla! Electronic Documentation License. All data entered into this Web site and templates added after installation, are copyrighted by their respective copyright owners.
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text:
Hunt & Schaub unofficially agree to fight
Sometimes fighters like to make Joe Silva's job easy and agree to fights in the media or even on Twitter. Tonight a big heavyweight fight between Mark Hunt and Brendan Schaub was agreed to, so we'll see if the UFC makes it happen:
Schaub's manager, Lex McMahon of Alchemist Management, told UFC Tonight that his client wants a big fight in his next outing and would like to face Hunt in a main event or co-main event bout. Schaub (10-3) last fought at UFC 165 on Sept. 21, 2013 where he defeated Matt Mitrione by first round submission.
Hunt, who is ranked eighth in the heavyweight division, said that he feels a fight with Schaub would be a step backwards but wasn't opposed to the match-up.
"If he wants to go to sleep first, sure, why not," Hunt told UFC Tonight.


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Wednesday, February 19, 2014
Jamez Rogers, Michele Boykin and Mary Harriet Moore highlight an outstanding group of athletes selected to this season's All-East Cooper basketball teams.
Wando's Rogers leads the boys team as East Cooper's Most Outstanding Player, while Bishop England's Boykin and Moore share co-MOP honors atop the girls team.
Players were selected from the area's four local high schools: Wando, Bishop England, Palmetto Christian and Coastal Christian. After receiving nominations from coaches, the sports staff at Moultrie News decided on eight boys and six girls to receive All-East Cooper honors. On-court performance weighed heavily on the decisions, but leadership, academics, consistency and impact on team success was factored in.
Rogers led the Warriors to a Class 4A Region VII championship as a sophomore this season, averaging 16 points, five rebounds and four steals per game. A long 6-foot-4 forward, he can rise and shoot above defenders, is quick enough to blow past them on his way to the rim, and doesn't mind fighting for rebounds in the post. He's shown a knack for hitting big shots in clutch situations and was named Most Valuable Player of November's Military Magnet Thanksgiving Classic.
In their senior season, Boykin and Moore have become an unstoppable one-two combo for the Lady Bishops on their march toward the playoffs. Boykin is a quick, physical guard who makes her living in opposing team's passing lanes. She leads the Lady Bishops with 18 points and 5.3 steals per game, in addition to four rebounds, four assists, and shoots 62 percent from the floor. Moore controls the post but is athletic enough to run the floor or step out for the jumper. She averages 15 points and eight rebounds per game, along with 2.4 blocks, three steals and two assists.
Wando boys head coach David Eaton and Bishop England girls head coach Paul Runey were selected as this season's Coaches of the Year. Eaton earned his 100th career win this season with a No. 1 upset of Goose Creek. The Warriors spent most of the season ranked in the top five of Class 4A and won 20 games, including seven region wins by an average margin of 26 points on the way toward their third region title in four years.
Runey has once again positioned the Lady Bishops at the top of Class AA basketball. Bishop England has been ranked No. 1 in AA since mid-January. The Lady Bishops won 22-0 games this season and dominated Region VI, winning 14 games by an average of 46 points. Runey is just 14 wins away from joining the exclusive 600-win club.
All-East Cooper Boys PPG RPG APG SPG Jamez Rogers* Wando Forward Soph. 16 5 4 -- Matthew Pegram Wando Center Junior 10 11 -- -- Andrew Glover Wando Guard Senior 9 6 -- -- 37 total threes B.J. Grevey BE Guard Junior 16 6 -- 2 Dillon Corbett BE Forward Senior 11 7 -- 2 J.T. Waters PCA Guard Senior 10 3 4 2 Chris DeMarco PCA Guard Junior 11 3.4 -- 1.2 Raequan Gregg Coastal Guard Senior 25 9 2 1 David Eaton Wando COY Girls Michele Boykin BE Guard Senior 18 4 4 5 62% FG Mary Harriet Moore BE Center Senior 15 8 2 3 2.4 blocks per Caroline McQueeney BE Forward Soph. 6 4 2 2 50% FG Corey Caulder PCA Guard Junior 21 8 3 4 Annie Pascutti PCA Forward Junior 9 7 2 1 Kimberly Smalls Wando Forward Junior 8 6 1 3 Paul Runey COY
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A funny movie that was meant to be scary.
The Exorcist: BLELREHGHEGH
Me: PFFFBABAHAHBHAH
Me: PFFFBABAHAHBHAH
от Brilliant Definer 02 април 2013
A sex act where the the female is on top of the male in cowgirl position. The male then pushes upwards with his pelvis until he is in the classic "The Exorcist" crab walk position. The girl then proceeds to grind upon the mans penis in the air. Often, she will be suspended completely in the air.
I totally performed an exorcism on my girlfriend last night.
You could say, I was The Exorcist. *wink wink, nudge nudge*
You could say, I was The Exorcist. *wink wink, nudge nudge*
от James "FireWire280" Young 24 октомври 2008
When you are about to cum during missionary, you pull out, sit on her stomach pinning her arms down with your legs, whip your dick up and down while yelling, "THE POWER OF CHRIST COMPELS YOU!"
This chick was so mad when I did The Exorcist, that she looked possessed.
от sambouka 05 април 2014
When engaged in doggy style classic sex, the active party unexpectedly sticks 3 fingers in the passive party's asshole, causing her/him to rotate her/his head 180° as in the exorcist movie.
Me: I did the exorcist to your mom yesterday
от AquilesBaeza 29 април 2015
The Exorcist: (v.) when one is being fucked while standing on their hands and feet in a crabwalk position....when the partner is finished he then blows his load n the females mouth and from this position it will drip out of her mouth such as in the Exorcist.
Hey! So my girlfriend pulled The Exorcist on me last night, it was the shit!
от thebootyholebruiser 19 октомври 2010


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In 2009 my family adopted a child from Russia. All of our friends wanted to know how a single income family was able to save for a debt-free adoption. We are now adopting twin girls from Uganda. This blog is how God has grown our family.
Monday, October 24, 2011
Paper Bead Necklaces For Sale
Since we will be hanging around a bit longer we will be having a few extra expenses. To help us with this I am going to offer paper bead necklaces. We purchased these necklaces from the girls baby home in Jinja. The ladies at the baby home make the necklaces by rolling recycled pieces of paper into beads. The beads are then dipped into a type of resin. Arise and Shine babies home sales these in order to fund the orphanage. By purchasing these necklaces you will be helping fund the orphanage and help us bring home our girls.
The necklaces are long enough to be wrapped around your neck up to 3 times. They are multicolor. We are selling them for $15 each. Chad will have them available when he returns home in a few days. You can also purchase them from our family in Memphis. We hope to be seeing most of you around the holidays. If you would like us to bring you home a necklace please send me an email to email@example.com or post a comment.
Posted by Holly S at Monday, October 24, 2011
3 comments:
- Mary Bea JohnsonOctober 24, 2011 at 9:49 AM
I would love one...ReplyDelete
I would like one as well. The more colors the better so it can go with anything! :-)ReplyDelete
- Susan BraceOctober 24, 2011 at 3:12 PM
Alex and I both want one!ReplyDelete
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Female Founders To Watch: Google Acquisitions
Celebrating Google's birthday – and the female founders acquired by Google over the last 14 years.
By Angie Chang (Co-Founder & Editor-in-Chief, Women 2.0)
This week, Google announced partnering with Women 2.0 with the launch of the new Google for Entrepreneurs program.
We celebrated Google's 14th birthday and reflected on the 118 mergers and acquisitions made by Google over the last 14 years.


text:
Top Definition
having anal sex with a female or male and the receiver turns and faces the giver and says nuh-uh nuh-uh sounding like a dolphin. kudos to sean!
Hunter so gave WOAH-livia the angry dolphin last night and he felt like he was in the ocean!
Por Hunter and Olivia 29 de agosto de 2006
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Can you define these popular missing words?


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Settle Inn to Exceptional Service
Unpack and unwind at Settle Inn Extended Stay. Convenience, service and cleanliness make Settle Inn the Midwest's premier collection of economic hotels. With neighborly, reliable service, you'll see why we're the easy, no-fuss choice for family and business travelers alike. Join us soon, and see why Settle Inn is the best in the Midwest.