text:
Town Square
Know the facts, no matter how you vote on Measure E
Original post made by Steven on Apr 6, 2011
Please spend the time to view this investigative report by 20/20, and decide for yourself before you vote on Measure E.
It is well worth the time, and it is NOT political. Please click on the link to view.
<iframe title="YouTube video player" width="480" height="390" src="Web Link" frameborder="0" allowfullscreen></iframe>
Comments (84)
on Apr 6, 2011 at 4:22 pm
I'll save everyone the trouble of looking at Steven's video. It's an investigative piece into the state of US public schools by John Stossel, the well-known libertarian investigative journalist and columnist. Yes, there are a lot of dysfunctional public school systems in many inner cities and other places!
So what does this have to do with Pleasanton, Steve? Are you saying that our public schools are dysfunctional? No, it couldn't be that because our schools are top-ranked. Are you saying that Pleasanton school teachers are horrible? No? Then what? What is it that you want to say? Please just spell it out for us.
on Apr 6, 2011 at 4:35 pm
To Sam:
S c h o o l s d o n' t n e e d m o r e m o n e y.
I just spelled it for you.
Please look at the facts, and make up your own opinion.
on Apr 6, 2011 at 4:53 pm
Pleasanton has an excellent school system, with excellent test scores and high college placement numbers. Pleasanton schools have very little in common with broken, low performing schools. PUSD needs the money from Measure E because funding from state has been affected by the economic downturn. Money from Measure stays in the Pleasanton schools. It does not go to the state.
I'm voting yes on Measure E.
on Apr 6, 2011 at 4:55 pm
Settle down there Sam. Don't pop a vessel! I don't think anyone has every said that our teachers are bad, horrible or anything like that. Our schools are top notch. But it is not solely because of the teachers or administration. It has more to do with the education level participation of the parents of MOST students. The PUSD school board is a dysfunctional as any level of government. Mistakes are made on every level. Money is and has been squandered for the 12 years my children have been involved with PUSD. If you truly analyze the amount of time most teachers spend with students, it aint all that encompassing nor difficult. Its a great job for most people. When you factor in science labs, speech specialist, PE yada, yada, ya. It was never designed to be full time career that afforded you the income to live in an upscale community such as Pleasanton. Map out where the retired administrators live and that will give you an idea how whacked the system is. Our teachers are great! As a mater of fact, I cant recall any of my children's teachers that I didnt think did a great job. But the bottom line is it only requires 180 days a year. Everyone else works about 230 to 250. Now I will let you do the math from here as to what a teacher SHOULD be getting paid. And help me with this one...why does someone that teaches kindergarten make as much as someone that teaches 6th grade or high school calculus? That would be a good question for your union!
on Apr 6, 2011 at 5:15 pm
PUSD is not going to be operating on more money. The state is cutting back on how much money it will send PUSD -- and now that talks have broken down in Sacramento, those cuts will be significant.
Measure E will help to prevent some of those cuts.
I have yet to see anyone make a cogent argument that less funding for schools will improve students' education.
on Apr 6, 2011 at 5:24 pm
Sandy - it is not certain that 'those cuts will be significant'. In fact, Gov Brown has not said what his 'all cuts' budget plan is. He and his administration have said that weeks could be cut from the school year, and more. But the most cogent plan has come from the LAO who recommends that busing and K-3 CSR be eliminated. That will be the majority of the $5 Billion that might be eliminated from education. Since PUSD has already eliminated CSR and has no busing, then the impact will be quite small. Don't panic.
Let's see what Gov Brown's budget plan is, and let's see what PUSD and the unions have negotiated.
on Apr 6, 2011 at 5:32 pm
"Since PUSD has already eliminated CSR "
PUSD has not eliminated CSR. Class sizes in K-3 and 9 went from 20 to 25. They are in danger of going to 30.
on Apr 6, 2011 at 6:56 pm
That's not what EdSource or California School Services are projecting:
Web Link
"Dramatic cuts to K12 public schools and community colleges increasingly seem inevitable. Those cuts would total at least $2.1 billion or about 5% of Proposition 98 funding, but many expertsincluding the legislative analyst and the governorhave mentioned cuts of $4 billion to $5 billion as more realistic. School Services of California projects that even the 5% cut could push hundreds of school districts into financial trouble and make dozens of districts candidates for emergency loans from the state due to insolvency.
A cut of $5 billion represents about $800 per California K12 student. In a school of 1,000 students that totals $800,000 or the approximate cost of 10 teachers."
PUSD enrolls over 14,000 students. The low end estimate of state cuts of $2.1 billion is equivalent to $320 per student, or $4.48 million for Pleasanton. The high end estimate of $5 billion is equivalent to $11.2 million.
Class size reduction at its current level costs the district $1.7 million per year, so these cuts will have additional negative effects on students. The list of budget reductions that the board of trustees approved on February 22 is available at this link:
Web Link
on Apr 6, 2011 at 7:38 pm
Repleasanacrat:"If you truly analyze the amount of time most teachers spend with students, it aint all that encompassing nor difficult. Its a great job for most people.... It was never designed to be full time career that afforded you the income to live in an upscale community such as Pleasanton."
Repleasnacrat, you know I really don't think that I have to work very hard to counter your post because you are so good at torpedoing yourself. You do a wonderful job of undermining your own position with your not-so-veiled lack of respect for the teaching profession. To be sure, you're not alone in this on these forums but at least most of your comrades are bright enough to do a better job of disguising their lack of respect.
on Apr 6, 2011 at 7:41 pm
repleasnacrat from mission park states,
"And help me with this one...why does someone that teaches kindergarten make as much as someone that teaches 6th grade or high school calculus? That would be a good question for your union!"
So, repleasnacrat claims to have children in PUSD for 12 years and he's raising THAT question? It strikes me that repleasnacrat doesn't know very much about the education of our young people, perhaps including his own. I hope his children learned more than apparently he has.
I think the answer to repleasnacrat's question is pretty obvious to any caring parent who has had kids: the formative years, including kindergarten, are among the most important. It is in kindergarten that a child is inculcated with what it means to be a good learner in the classroom. A bad kindergarten experience could be a near disaster for the child's subsequent learning abilities and attitudes. Because my wife and I were conscientious about ensuring our child received a good education, we interviewed no less than 6 of his potential kindergarten teachers at private and public schools.
(We were most impressed with the public school teacher.)
When repleasnacrat states that he is unable to grasp the value of a kindergarten teacher, my heart goes out to repleasnacrat's children. Reading repleasnacrat's words, for me, is akin to observing a parent slap his child in the grocery store. The level of ignorance behind his words is, to say the least, utterly astonishing. And that he would pretend to know something about education, and convey it with words on these posts, leaves me shaking my head in sadness.
Repleasnacrat's post speaks to the enormous challenges faced by teachers at every level. With the level of ignorance reigning in repleasnacrat's household, it brings to light what a monumental task our teachers are faced with, day in and day out.
on Apr 6, 2011 at 7:51 pm
I agree with Former Educator! I read repleasnatic and want to reach out to help his kids! What an absolute shame!
on Apr 6, 2011 at 11:13 pm
Steve, can you please re post the link since it did not come through? Thank you.
on Apr 6, 2011 at 11:30 pm
The thing that really made me reconsider was the Michelle Rhee fraud scandal.
Web Link
Web Link
It turned out that all this evidence of improved performance due to "school reform" was actually due to fraud. Michelle Rhee, who was admired by John Stossel and interviewed on his show, appears to have been more interested in putting money in her own pocket than she was in helping children.
Pleasanton has fantastic schools and excellent teachers.
Three Yes on Measure E votes in this household. It is very encouraging to see that my neighbors are supporting it too.
on Apr 7, 2011 at 12:28 am
To Kelley:
Sure, here is the link again
Web Link
If you have not seen the video, please do. It is lengthy, but eye opening!! Even if you have already made up your mind, do see it.
Not bashing Pleasanton teachers, or Pleasanton schools.
As the report says, let schools compete for students, and let's reward teachers on results. Schools CANNOT be a monopoly. Let competition thrive!
Many foreign countries out-test our children. It is not even a close race, and they spend far, far less than we do in this country!
See the video!!! Then comment.
on Apr 7, 2011 at 7:25 am
@Steven:"As the report says, let schools compete for students, and let's reward teachers on results. Schools CANNOT be a monopoly. Let competition thrive! Many foreign countries out-test our children. It is not even a close race, and they spend far, far less than we do in this country! "
Steven, as the old saying goes, "If it ain't broke don't fix it." What relevance does any of this have to our top-ranked Pleasanton school system? You want to tinker and experiment with some completely different system? Fine, then take your ideas to some sections of Oakland where the schools are really broken and show us what you and your comrades can do. But you want to try tinkering with the already excellent Pleasanton school system? No thanks.
Yes on Measure E.
on Apr 7, 2011 at 8:06 am
I agree with you. I can't see any relevance to Pleasanton in that video. People move here for the schools. These are the schools that parents want their children to attend by choice. People leave private schools to go to the excellent public schools in Pleasanton.
Everyone in my household will be voting yes on Measure E.
on Apr 7, 2011 at 9:51 am
To follow-up on "former educator", all teachers receive the same pay, depending on the number of years they have been teaching. Does not matter the grade or the subject. So a PE teacher is paid the same as a teacher of AP English. Although I am sure the AP English teacher spends much more time with lesson plans and grading (and reading essays) than a PE Teacher. Does not matter the grade level or the subject matter.
on Apr 7, 2011 at 10:09 am
Sandy - here's the LAO's analysis. Web Link See page 5 for the details. Over half of the $4 billion will not affect PUSD (K-3 CSR, busing, basic aid district funding, and more).
So, you can use budget gross numbers, or you can use the LAO's recommendations and stop panicking.
on Apr 7, 2011 at 10:12 am
Arthur - Sandy's link to PUSD's budget cuts shows line item 10 which eliminated K-3 Class Size Reduction. These reductions were approved by the school board. This is PUSD's current plan for the next school year. Teachers affected have received their layoff notices.
on Apr 7, 2011 at 10:13 am
PUSD's link here Web Link
on Apr 7, 2011 at 10:35 am
Yes, Let's know the facts about our successful district before you vote:
Seven Pleasanton Schools Honored
California business group names schools that have excelled in academic achievementWeb Link
on Apr 7, 2011 at 10:54 am
Looking at the list of cuts posted by StartAfresh, I agree with some of the cuts, like the health liason position - nice to have but definitely not needed and the other health staff can take over the duties.
I also did not realize that reading specialists were paid so much - doing the math for the amt to be cut and the number of specialists. For what they do and the number of students they serve, they get paid a bit much. Barton is mostly run by volunteers (the ones who do the actual tutoring), so I am not sure why we need two paid positions for that program, one would be enough.
I do not agree with elimination of CSR in k-3 although I think we will be fine if we eliminate CSR in 9th grade (given that our students have been without CSR in 4th - 8th grades)
Now a question:
which cuts will not be made if measure E passes?
I am a bit confused about how to vote now. At first I was against E, then I figured I would vote for E since the root problems must be addressed at the state level and we should not punish our kids. I have not received the ballot yet but would like to make up my mind already.
Which of the potential cuts listed would be saved by measure E? And what about 7 period in HS? I hear they are re-instating it - would that money come from measure E or what would be cut in order to bring back the 7 period? Anyone knows?
on Apr 7, 2011 at 10:59 am
Resident - don't hold your breath about HS 7th period. It is likely not coming back. Sure, PUSD can stagger the schedule to get 7 periods at Foothill, like they do today at Amador, but PUSD will likely NOT spend any money to bring back sections at the high schools.
on Apr 7, 2011 at 11:04 am
Start Afresh,
Where does it say "This is PUSD's current plan for the next school year"? What it says is "List of Possible Budget Solutions for 2011]2012". Measure E would help prevent some of those things from happening. That is one reason why my family and my neighbors will be voting yes on Measure E.
on Apr 7, 2011 at 11:05 am
"Adult Education ‐ Reduce program offerings to contribute an additional $100K of
prior year carryover and current year funding to the General Fund for a total
contribution of $579K."
I also agree with cutting this. Why do we need adult education? If any of us needs an enrichment class or something, we can go to the rec center or one of the many community colleges. Last time, I saw adult ed classes offering things like chinese and stuff, very nice but again, we can take those at the community college if we really are interested in them.
Overall, I am OK with the cuts proposed, except for CSR in k-3.
What is the plan for measure E funds? What are they planning to cut to fund step and column and will then re-instate with measure E? What about the 7 period and the plans to bring it back? (the no cost option does not quite work because it does not accomodate all students who want to participate, so the question is how the selection of students will be, or how are they planning to fund it so that all who want can participate)
on Apr 7, 2011 at 11:10 am
"Measure E would help prevent some of those things from happening. "
What things? Can you be more specific? If I vote yes on E and it passes, what will be funded with it? What is the plan for the 7 period in HS? (re-instate as they say and if so where is the money coming from). It would be nice to get a list of the items the district plans to fund with measure E before having to vote, and the ballots i am told, will be here anytime this week.
The sample ballot has a very vague statement of what they plan to do. For example, retaining teachers could mean saving CSR or reinstating the 7 period, or keeping PE specialists in elementary, etc. Anyone knows anything specific?
on Apr 7, 2011 at 11:51 am
"Resident - don't hold your breath about HS 7th period. It is likely not coming back. Sure, PUSD can stagger the schedule to get 7 periods at Foothill, like they do today at Amador, but PUSD will likely NOT spend any money to bring back sections at the high schools. "
But students have signed up for 7 periods, what's the deal? And if they do bring it back, is that what E is for? Or what would they cut?
on Apr 7, 2011 at 12:10 pm
If you haven't worked it out by now, Start Afresh is trying to confuse people. Or, at the very least, is dangerously under-informed.
The current agreement brings back 7th period in the fall, unless a new memorandum of understanding is negotiated. The 7th period/collaboration schedule is part of the 3-year contract, but suspended up to the end of this school year by mutual (and temporary) agreement.
So when s/he says "it's unlikely 7th period will be returning," Start Afresh probably means, "I want you to think this is so because I need to manipulate you into voting against Measure E." Either that, or "I imagine it is so, so it must be true!"
Keep reading and you'll see the pattern this poster, like Nomad and others, is engaged in.
on Apr 7, 2011 at 12:16 pm
"Resident", what do you expect us to all do here? Debate the merits of reinstating the 7th period versus keeping PE specialists versus saving CSR? Perhaps you would rank the importance of these three specific issues in one order, "Arthur" would rank them in another order, and I would rank them in yet another order. So where do we end up then? Are we any closer to coming to a consensus?
The way I look at it is either (A) you trust the Pleasanton school system to make the proper decisions or (B) you don't trust the Pleasanton school system to make the proper decisions. If you do trust them to make the proper decisions, then a "yes" vote on E is easy. If you don't trust them, then no amount of specificity in spending plans will ever satisfy you.
on Apr 7, 2011 at 3:00 pm
""Resident", what do you expect us to all do here? Debate the merits of reinstating the 7th period versus keeping PE specialists versus saving CSR? Perhaps you would rank the importance of these three specific issues in one order, "Arthur" would rank them in another order, and I would rank them in yet another order. So where do we end up then? Are we any closer to coming to a consensus?"
All I want is to know how measure E funds will be spent because that would influence my vote.
Too many programs are on the chopping block and some have already been cut and they are talking about re-instating them.
All I want to know is how exactly will PUSD use measure E funds. I have not gotten my ballot yet and will be contacting the registrar of voters, but hopefully I can get some answers before I vote.
on Apr 7, 2011 at 3:04 pm
"The current agreement brings back 7th period in the fall, unless a new memorandum of understanding is negotiated. The 7th period/collaboration schedule is part of the 3-year contract, but suspended up to the end of this school year by mutual (and temporary) agreement."
Thanks Rodant. But where will the 440K needed come from? Will PUSD use measure E funds or cut existing programs?
I would love to see period 7 re-instated but not at the expense of programs currently being funded. I would certainly prefer to keep k-3 CSR than take money from any elementary program to bring 7 period back (and I have HS kids)
If indeed 7 period is coming back, what is the plan? What is PUSD planning to cut in order to fund it? The sample ballot is vague but there is no room for funding the 7 period, or is there?
on Apr 7, 2011 at 4:16 pm
I'm sure there will be plenty of people coming along to tell your their own opinion dressed up as fact, but the truth is that a clear plan is not yet in place because it is still early in the budgeting scenario and there are many variables that have yet to work themselves out. First is ongoing negotiations with the teachers' union, and at this stage there's no public information to be had about how that is going or what is being discussed (as with any negotiation in progress). Second, it almost certainly looks like we will face further cuts from the state now that there will be no special election to extend CA's tax increases. Finally, of course, is Measure E, which won't be decided until May. In my opinion, the likely cuts from the state are going to place us in a worst-case situation this year. Who knows if Measure E will pass, either.
on Apr 7, 2011 at 4:32 pm
My wife and I are going to vote Yes on Measure E. Let's hope one bad scenario is followed by another!
on Apr 7, 2011 at 5:38 pm
Sorry Folks I don't do this often :)
Let's hope one bad scenario is not followed by another.
on Apr 7, 2011 at 10:12 pm
Less is more. The less the community spends on education, the better the education is for our children, or so the argument goes above.
on Apr 8, 2011 at 8:12 am
VOTE YES! The state is cutting and cutting. The money has to come from somewhere. We just moved here and I was shocked at the state of the schools. My freshman daughter had to take one less academic class here then she did in our previous district because of there is one less perdiod due to budgets. Furlough days? Is that a joke???? I hate to tell you....PUSD is a 'great district', but not any better than 'great districts' across the country. I've lived in two other such districts. But if the schools aren't funded, we won't be at the top.
on Apr 8, 2011 at 8:54 am
New Mom, the problem in our district is it is business as usual. Tax revenue is down (because people's income is down) but the district keeps giving out automatic raises. You cannot have the state cutting and cutting and still keep giving out raises. Simple economics. The parcel tax will not even cover the cost of the raises over four years.
Time for the district to make some fiscal changes, stop automatic raises and eliminate the outrageous pensions. We are not flush in money anymore. Can you believe we have 15 retired administrators making over $100,000 per year in their retirement pay, going up to $176,000 per year? We also give out free medical insurance to retirees, paid for by the taxpayers, not a penny is paid for by the retiree while working or while retired. This has to stop.
I am voting No on Measure E. After fiscal reforms are made I will probably be a supporter of more money but until the district gets a handle on things I do not want to give them more money. It is like giving money to an alcoholic that promises after you give them the money they will go to AA. Got to be the other way around.
on Apr 8, 2011 at 9:24 am
Where do you get this information? Is it public?
"15 retired administrators making over $100,000 per year in their retirement pay, going up to $176,000 per year?"
I would like to see the salary of each PUSD employees like this one:
Web Link
I am not sure if $2M (20k x 100) more would help anyway to PSUD.
on Apr 8, 2011 at 9:25 am
Comparing PUSD to an alcoholic just doesn't compute for me. Pleasanton has one of the best school districts in the state, and my family moved here for the schools. I did some research on these "automatic raises", and they are what is known as step and column increases. Only step raises are automatic, and many teachers are not even eligible for these. Column increases only come from the teacher achieving a higher level of training. This is the same method that all the other top performing districts use in the Bay Area. I'm completely in favor of this, because it allows our district to hire the best new teachers and retain them. If I were a teacher and had offers at Palo Alto and Pleasanton, and Pleasanton had frozen step and column salary increases, that would be a major factor in my decision of which offer to take. My message to PUSD is don't freeze step and column. Measure E won't solve all our problems, but it will help. PUSD didn't cause the recession. Measure E will help us maintain the high quality of education we have here in Pleasanton.
Yes on Measure E.
on Apr 8, 2011 at 9:28 am
I am planning to vote YES. $98/year is a small price to pay to maintain our good schools, keep our quality teachers, and keep our community a nice place to live.
All of the Tri-Valley cities have parcel taxes (except for ours) and by cutting off local funding for our schools, we are exposing our district to the state's budget ax.
By at least guaranteeing a source of funds through Measure E, we can protect our schools somewhat from periods of lower-than-expected funding.
Jill, comparing PUSD to an alcoholic is harsh. Good schools do nothing but HELP a community and society in general. Your posts are nothing but typical tea party rhetoric.
on Apr 8, 2011 at 9:41 am
Good post, Arthur. In their efforts to be penny-wise and pound-foolish, Jill and some others don't seem to realize that our city and community are in constant competition with other cities and communities. As you pointed out, we have to compete with other communities to get the best teachers. We also 'compete' for for new homebuyers who 'vote' with their dollars for various cities, pushing property prices up or down in those cities as a result. If we fail to effectively compete with our neighboring cities, then we will end up with the worst teachers and the lowest property values in the area. If we fail to support our schools, both teachers and prospective homebuyers will walk away from Pleasanton and look elsewhere for better, more supportive communities.
on Apr 8, 2011 at 10:08 am
To Former Educator.
Thank you for your words. My sister is a kindergarden teacher and works just as hard (if not harder) as my sister-in-law who teaches high school math.
And to repleasnacrat; I'm concerned about your children who only completed 12 years of schooling, K-12 is 13 years of schooling.
on Apr 8, 2011 at 10:12 am
The reason the schools are top ranked is the students not the teachers. The parents who live in Pleasanton are generally very educated and start teaching their children before they ever get to the PUSD.
Cal Grad
on Apr 8, 2011 at 10:29 am
"Cal Grad", yes demographics are one important reason that our schools are top ranked. But all the factors are linked together. If the quality of our teachers goes down and we make more cuts to student programs and our student-to-teacher ratio becomes worse, then what effect do you think that will have on the decision-making process of well-educated prospective homebuyers? Do you think that Pleasanton becomes more or less attractive to them? If there is even the perception that our schools are not on par with those of our surrounding cities, all those well-educated professional homebuyers will decide to buy elsewhere in other cities with top-ranked schools (e.g., Danville, San Ramon) and avoid Pleasanton. Say "goodbye" to Pleasanton's demographic advantage.
on Apr 8, 2011 at 10:43 am
"If the quality of our teachers goes down and we make more cuts to student programs and our student-to-teacher ratio becomes worse, then what effect do you think that will have on the decision-making process of well-educated prospective homebuyers?"
So why isn't keeping our student-to-teacher ratio something we are focusing on? This is the key to property values. Why isn't this guaranteed for four years as part of the parcel tax? Why are we guaranteeing raises, but not class sizes? I think the priorities are confused or deliberately not being made clear, which is why people are struggling with this vote. I'm voting yes, but can see the no side too.
on Apr 8, 2011 at 11:01 am
"So why isn't keeping our student-to-teacher ratio something we are focusing on? This is the key to property values. Why isn't this guaranteed for four years as part of the parcel tax? Why are we guaranteeing raises, but not class sizes?"
Well, I don't think that there is a single "key" or factor. Student-to-teacher ratio is important, but so is attracting and retaining good teachers. Note that we don't give raises to teachers simply out of the goodness of our hearts. Giving raises is not a form of charity. We give raises to teachers for the same reason that companies give raises to their employees: To recruit and retain good talent.
Speaking as a recent Pleasanton homebuyer (moved into the Oak Hill area just last July) I can't overemphasize how important schools are to the buying decisions of homebuyers. Homebuyers talk about school quality all the time. If you go to Redfin, for example, you'll see the forums filled with posts from house hunters asking each other about the best schools in various areas. School quality has an overwhelming effect on your property value.
on Apr 8, 2011 at 11:15 am
Just a clarification. You said "Why are we guaranteeing raises, but not class sizes". I don't see anywhere that we are "guaranteeing raises". There is no language in the parcel tax that guarantees that step and column will be cut, and the same is true about class sizes.
on Apr 8, 2011 at 11:35 am
@Sam: as the old saying goes, "If it ain't broke don't fix it."
If that is the philosophy, then we would still be driving Model T's or perhaps the horse and buggy.
Competition brings improvements, otherwise we would still listen to music on a gramophone, instead of a multichannel stereo system.
We need to be flexible and realize that the answer is not spending more money. Where is it going to stop?
The school system the way it is now needs fixing. They waste too much money. I hear commercials on the radio from the Teacher's Union!!! Commercials!!!! Really? Really? They could spend that money to reduce class sizes, or preserve programs from being cut. And don't get me started with how much money they spend on electing politicians. Really???
But no, they want more money!! I do not hear commercials on the radio for the electrician or retail worker, or even the software engineer that lost their jobs, or want to preserve their job. What about those people?
But no, the teachers want their raises, or perhaps their union want their raises so that they can have money to spend on more commercials and their nice salaries and pensions! Talk about a systen that really needs fixing.
As Rick said, "The reason the schools are top ranked is the students not the teachers. The parents who live in Pleasanton are generally very educated and start teaching their children before they ever get to the PUSD"
It is no wonder that the union resists competition, they are scared to lose their money.
No more money. PUSD needs to learn to live within its means.
NO on E
on Apr 8, 2011 at 11:42 am
"Just a clarification. You said "Why are we guaranteeing raises, but not class sizes". I don't see anywhere that we are "guaranteeing raises". There is no language in the parcel tax that guarantees that step and column will be cut, and the same is true about class sizes."
No, it's different. Teachers have a contractual right to step and column raises, so they are guaranteed.
Class sizes are on the cut list with many other things and no one is saying what the parcel tax would fund. They could easily move class sizes to 30-1 and use the parcel tax money for other things on the list.
I for one would like class sizes to have similar contractual rights as the S&C raises (via the parcel tax ringfence and the committee looking after it) if the parcel tax passes. Class sizes are essential to property values, teacher retention and student development. I think this is more important for all the stakeholders - community, teachers and children - than raises to be perfectly honest.
on Apr 8, 2011 at 11:47 am
"Student-to-teacher ratio is important, but so is attracting and retaining good teachers"
By the way, retaining teachers mostly about class sizes. The reason we have sent pink slips to so many teachers is all about increasing class sizes. Not a great attraction and retention technique to put people's jobs on the line year after year after spending whatever it takes to "attract" them.
on Apr 8, 2011 at 11:48 am
Steve, I'll tell you exactly what I've told others here before: If you want to try tinkering with some "innovative" new ideas for public education, then take your ideas over to some of the truly broken and dysfunctional schools in Oakland and show all of us what you can do. Try out your ideas on some school which ranks as a low "1" or "2" on GreatSchools 1-to-10 scale and show us how you can turn it into a school which ranks "9" or "10".
But you want to take your scalpel an operate on Pleasanton schools already operating in the loft "10" range? Thanks but no thanks. Go find another patient to operate on.
on Apr 8, 2011 at 12:17 pm
" software engineer that lost their jobs"
Put our your resume. It hasn't been this good since the dotcom days.
on Apr 8, 2011 at 12:28 pm
Before I vote on this can someone answer my question what about the kids that come from other cities and attend PUSD? There parents are not paying this extra amount but they are getting the benefit of our schools. How do you make this equitable?
on Apr 8, 2011 at 12:36 pm
Anne, I'm not exactly sure what you're referring to. When preregistering my daughter for kindergarten a month ago, I had to show two proofs of residency (e.g., utility bills, close-of-escrow documents, etc.). If you know of any particular cases, report them to the PUSD.
on Apr 8, 2011 at 12:37 pm
Sam: No tinkering needed. Plain and simple, competition brings results. This country was built on competition, free markets.
Schools should not be a monopoly.
NO on E
on Apr 8, 2011 at 12:40 pm
I don't see how your question is relevant. If they come from any of the cities neighboring Pleasanton, they are paying parcel taxes in those school districts.
on Apr 8, 2011 at 12:46 pm
"If they come from any of the cities neighboring Pleasanton, they are paying parcel taxes in those school districts."
?? That may be true, but those parcel taxes are going to those other school districts, not PUSD.
on Apr 8, 2011 at 12:47 pm
Steve has a point, Sam. We should have something where if a parent wanted to, they could send their student to a "private school" of some sort. This competition would end the monopoly currently in place.
It's like Steve said, our current strong economy was built on free markets. Look at how well corporations are serving Americans in areas such as banking, real estate, energy, automobiles, health insurance, air travel, and communications--wouldn't it be wonderful if we could fix our broken Pleasanton schools by bringing this successful model to the classroom?
on Apr 8, 2011 at 12:47 pm
There is nothing "plain" or "simple" about it. To institute some kind of "competition" at PUSD would require setting up an entirely new system for evaluating teacher performance (I assume you are talking about competition between teachers). It is easy to get such a system wrong and make matters worse. We've all seen the results of what happened in the Michelle Rhee case, which has been held up as an example of a successful application of merit pay. It was not successful, far from it.
Web Link
We already have a top performing school district. Parents move here for the excellent schools.
Yes on Measure E.
on Apr 8, 2011 at 12:49 pm
Sam, If you work in Pleasanton you can send your child to a PUSD school. I know of this with many kids, kids who use grandparents address to go to our schools, it goes on all the time.
Arthur, Are you sure that every city has a parcel tax?
on Apr 8, 2011 at 12:52 pm
So what? Go turn them in, then. Unless...YOU'RE ONE OF THEM!!
on Apr 8, 2011 at 12:58 pm
Rodant, I disagree with your characterization of Pleasanton schools as "broken". You want to see "broken", go look at some schools in parts of Oakland or Hayward. Do you think that a community with "broken" schools could make this list?: Web Link
I'm not necessarily opposed to experimenting with new ideas. But if, for example, you're going to let your teenage son tinker with some radical new fuel-injection idea that he claims will boost engine performance 200%, are you going to let him do his tinkering with the broken down Datsun in the back, or with your brand-new Lexus?
on Apr 8, 2011 at 12:59 pm
Rodant, The schools know they are from another city, if you work in P-town you can attend a P-town school. As for my children they are grown, so I am not one of them. I just want to know if there is any way to get the funds transferred from another district for these children. It would sure help the budget situation.
on Apr 8, 2011 at 1:03 pm
Anne. "Rodant" and I are in agreement on this one - and I don't think that happens often. Stop complaining to us and report the cases to the PUSD. Unless the grandparents are legal custodians of the kids, I don't believe that the kids are allowed to go to PUSD schools.
on Apr 8, 2011 at 1:05 pm
@Anne: "I just want to know if there is any way to get the funds transferred from another district for these children. It would sure help the budget situation."
Probably not, but it's not your problem. Just report the cases to the PUSD and let them handle it.
on Apr 8, 2011 at 1:06 pm
I suggest you set your sarcasm sense on "tingling" and re-read my earlier post.
on Apr 8, 2011 at 1:10 pm
Sorry, my sarcasm sensor works just fine in verbal conversations, but for some reason I often have difficulty picking it up in posts.
on Apr 8, 2011 at 2:04 pm
pRes, You can get a list of the Pleasanton Unified School District Retirees that are collecting over $100,000 at: Web Link
As for salaries of the employees, The Bay Area News Group did a public records request to the District in February to get that info. I heard that the New Group finally received the information and is working on posting to their database. Their database is at: Web Link . They have the Pleasanton City Employees listed but not the school district yet (different agency). You should look at some of the salaries for the City and especially look at how much they receive in "other" income, typically used to spike pensions. For The City, you can see a bunch of people who retired the year of the salary survey (two stars by their name). Some of their "other" income was way above their annual salary.
As I have heard from somebody (or maybe read), Public Employees seem to think the pension system is to build wealth, although it was intended to give a reasonable retirement income. Many of the retirees come back and "consult" for even more money while they are collecting the pensions.
The CalSTRS pension system is different than CalPERS. STRS is for teachers and the contribution rates are set by legislation and not by actuarial computed numbers. Here is an article: Web Link that shows that if CalSTRS does not raise their rates, they will run out of money by 2040. They have an underfunded pensions plan. In the private sector, the feds would be all over them. Since this is paid for by tax money, those in the pension plan are not worrying as they know the taxpayer is on the hook to pay their pensions should the system run out of money. When are we going to do something about these outrageous pensions in a system that is underfunded?
I am voting No on Measure E until I see some reforms in our District. I have little influence over the State problems but as a community we have more control over our District and we need to tell them they need to run this fiscally better. We have been doing well because we received lots of money from the state previously plus we have been borrowing against our capital funds to pay for operations, like pensions. The gravy train days are over and the district needs to show some responsibility.
on Apr 8, 2011 at 4:04 pm
The state pension problems need to be solved at the state level. Our school district is one of the best in California. It isn't some kind of "gravy train". It is producing excellent results. The great recession is what caused the shortfall in revenue from state. Voting no on Measure E will not affect that in any way. PUSD did not cause the recession. We need Measure to help mitigate the effects of the recession.
Yes on Measure E.
on Apr 8, 2011 at 4:07 pm
Sam- it is becoming very clear why you want to keep the status quo. Your teacher wife can make a lot of money in Pleasanton while you sit on the p-town weekly boards all day. Everything you've said in your posts (at least the ones I have seen) is just reiteration of union talking points.
And speaking to your "Datsun and Lexus," argument, that actually reminds me of how many luxury cars are parked in the faculty parking lot at our school. Guess the Pleasanton teachers aren't doing so bad after all. It looks like we are doing a good job, "attracting and retaining talent."
on Apr 8, 2011 at 4:29 pm
To "Wow",
Do you think taking the discussion personal really helps your argument? Could it be that Sam, like me, moved his family to Pleasanton and paid a premium price for his house because of Pleasanton's reputation for good schools? Maybe he doesn't want to want to see things get worse, as they did in the Michelle Rhee case? We can have a difference of opinion and still have a civil discussion.
on Apr 8, 2011 at 4:34 pm
Nice argument. Oh, wait. You have no argument. This raises the question: Do you have a brain? I'd love to hear what was the cause behind you failing high school. Please share. It would be more interesting than reading the limp points you attempt to raise. Please tell us more about yourself.
on Apr 8, 2011 at 4:37 pm
Well, "Wow", if your memory and reading comprehension were better, you would recall that my "teacher wife" works just part-time as a language teacher at a private school. I'm sure her pay is quite a bit better than at a public school (which, come to think of it, kind of defeats your argument about how public school teachers are raking in the dough), but even so she doesn't make all that much money.
As for the implications of nice cars in parking lots, your logic is faulty. My wife actually drives a fairly nice car even though, as I already stated, she doesn't make all that much money. How did that happen? Pretty tricky puzzle isn't it? But I think that a Pleasanton school 2nd-grader can figure it out, so I'm sure that you can, too.
on Apr 8, 2011 at 4:49 pm
The Pleasanton teachers and administrators all deserve a 20% raise, just for having to deal with all the greedy tax cutters constantly attacking them. I can't imagine why anyone would want that job. Plenty of better-paying professional jobs that come without the grief.
on Apr 8, 2011 at 5:01 pm
I took my boys out for breakfast today- a treat for spring break, one spent at home since my voluntary $4000 pay cut and no movement on S&C for the past 4 yrs ensured no vacations this year.
As we sat there, a table of ladies were speaking so loudly about "the teachers making all this money, and demanding more, working part time, ruining our whole economy...." Lie after lie, we had to sit and listen. Actually they sounded just like Jill et al
My sons, old enough to know better, were shocked at the disrespect they had for educators- they are the first to feel the affects of me working all vacation grading, lesson planning etc, missing games for meetings, not doing homework with them because I have school work to do....etc. They were so upset by these women, we had to move tables.
Funny, the ladies left, climbed into their Mercedes and didn't think twice about how they behaved in public. THANK YOU ladies for teaching my children a valuable lesson today- my boys showed more character and were better behaved than you. You left quite an impression on them, how ignorant and mean adults can be. They said this would never be allowed in their class- especially since what they were saying wasn't even true!
Somehow, this town is not so Pleasant anymore and I really question why I work so hard for so many years to educate this town's children. I really question why I value their children'e education more than they do. I also wonder why after years of praise and requests for kids to be in my class- I am now the villian, one not to be trusted.
This is a sad day for sure. I believe it is time to look for a new job, a new community, one that values education and listens to the professionals working for them.
on Apr 8, 2011 at 5:19 pm
arthur, while many of the pension problems need to be solved at the state level, locally we should do work to not allow spiking of pensions and we should not being giving out free medical insurance to the district retirees. We simply cannot afford to do this.
It is not the great recession by itself causing all of this. It is actually the great economic boom followed by the great recession. With the great economic boom we had a big influx of tax dollars. The tax dollars were all spent on operations which need to continue. Then we had the great recession. Well we are paying more for operations because of the economic boom and now we are caught. The state, and the district, should have been putting money aside when we had the boom (which we all knew could not continue at that rate).. We spent every dollar on programs (including salaries and raises) when we had the boom. Now that we are not in a boom, we cannot afford everything we did during the boom era. It is time to evaluate our spending policies and make adjustments. The main thing is we have to save money when times are good to pay for step and column raises when the economy is not expanding, or we have to halt step and column raises when the economy is not expanding.
on Apr 8, 2011 at 5:46 pm
What bothers me about 'Wow', is just what he was doing in the school parking lot? Counting faculty cars? Taking down license numbers? How does he seem to think he knows so much about some of the posters here? He's clearly weak-minded, and I wouldn't trust him on any school premisses without authorization. I'll tell you what. If a guy knocked on my door and started saying the kinds of things he says on these posts, I'd call the authorities.
on Apr 9, 2011 at 11:44 am
Thank you for what you do, "Be Positive." There are some (many, really) who appreciate your hard work and sacrifices.
on Apr 9, 2011 at 11:59 am
Be Positive,
At $98,000 a year for nine 180 days of work, you can likely buy your own Mercedes if you want one.
on Apr 9, 2011 at 12:01 pm
That should have read ...for 180 (really 176) days of work ...
on Apr 9, 2011 at 12:57 pm
It is ignorant to believe that teachers work only 180 days a year. They are paid for only 180 days and we'd better hope that they don't start working on only the paid days! Our kids will be in a world of hurt if that happens.
on Apr 10, 2011 at 9:04 am
Still no compelling reason to vote yes on Measure E. Not enough has been done by the school district (trustees, administrators, and teachers) to reign-in costs during this difficult economy. I'm voting NO on E.
on Apr 10, 2011 at 9:32 am
We support our excellent schools and our excellent teachers. We have some of the best in the entire state of California. Both of our kids have done extremely well in school. It is because of the great teachers they've had, without exception. The parcel tax will help maintain the excellence. The measure will help Pleasanton through this difficult economic period. We do not want to see the quality of our schools go down. Our kids' future is at stake. We sent in our vote in support of Measure E.
on Apr 11, 2011 at 7:07 pm
Ok, lets review here! The consensus is that we have great schools, great teachers, great kids. The cost of operating these schools far out weighs tax revenues! How do you reign said cost of operations! Review the overall cost and make necessary adjustments. So who can handle a task of this nature. Someone from Sacramento? The school board? Independent review parties that consist of union members and or tea party members. How about the Administration. Come on folks, stop drinking the kool-aid. This not a big deal. Lets see how they perform with less dollars. Everyone else seems to be doing it. Just for fun it would be interesting to fire the lot of them and have a rehiring fair. That alone would cut 20% from the budget!
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text:
Town Square
Holiday DUI arrests top 100 in Palo Alto
Original post made on Jan 2, 2008
Read the full story here Web Link posted Wednesday, January 2, 2008, 9:54 AM
on Jan 2, 2008 at 4:08 pm
What are the names of these 100 drivers? we need to know, publish them
Also what is the status of the double homicide DUI case that killed 2 Palo Alto girls in Santa Barbara recently. the driver, Beau Robertson is also from Palo Alto, what is the status of his case?
on Jan 2, 2008 at 4:15 pm
I would actually like to know the demographics of these 100 people.
I am not interested in race, but age would be very interesting. Also, I would like to know if these were Palo Alto residents, or PA workers who are resident elsewhere. If they were people who were resident elsewhere and also worked elsewhere, were they here socializing with PA residents who encouraged them to drink and drive. This sort of information is much more useful than just the plain number 100.
on Jan 2, 2008 at 4:16 pm
Please publish these names; better yet, bring back pillories in the public square (two hour time limit) for those who unnecessarily endanger others by drinking when they drive.

subset: commoncrawl


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Skills for Care understands the importance of recognising workforce quality and development. All too often our sector doesn't draw the nation's attention to our sector's successes but the Accolades provide an opportunity to do just that. They are not awarded to individual care workers but rather to organisations and employers who are committed to delivering high quality care and developing their workforce.
You can enter the Accolades by clicking on the category below and downloading the form, the closing date for this year's entries is Thursday 4 September 2014. For more information on the Accolades 2014/15, including the judging process, rules of entry and sponsors click here.
Before entering the Accolades read our top tips.
This will give you an idea of how to make your entry stand out from the crowd and how to select the right category for you.
Here's what some of our winners have to say about entering the Accolades:
"This is a fantastic achievement and to have been awarded this prestigious award is a great honour…The recognition by an organisation such as Skills for Care has endorsed the work we have been doing and gave us an opportunity to thank our staff and members. In addition we have been able to share our experiences with other organisations and commissioners with the Accolades as a validation of our work as an example of best practice." Gabby Machell CEO and Mandy Crowford Director of Adult Services at The Westminster Society for people with learning disabilities, Accolades 2013/14 Winner of Winners
"We were thrilled to win such a prestigious award and recognised nationally for our achievements, we would recommend any employer to enter!" Carina Monnelly-Owen, Friendship Care and Housing, Accolades Winner 2011/12 "Securing the award [an Accolade] raised the profile and validated the work we do at the Pod. I would recommend any employer applies - best practice needs to be recognised and celebrated" Christine Eade, The Pod, Coventry City Council, Accolades Winner 2011/12 "Winning a national award has really helped raise the profile of our business... I would recommend any employer to enter as it has had a hugely positive impact across our organisation." Andrew Azzopardi Managing Director at Sunnyside House, Accolades 2011/12 Winner of Winners
In challenging times it is critical that employers invest in developing the skills and knowledge of theirworkforce to provide high quality social care.
This category invites entries from employers who can demonstrate a planned and effective approachto developing a capable, confident and skilled workforce.They should champion a personalised approach to social care services.
Who should enter this category: organisations that employ 250 staff or less.
Who should enter this category: organisations that employ 250 staff or more.
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This category invites entries from individual employers who can demonstratean effective approach to developing capable, confident and skilled staff.This can include demonstrating good methods of recruiting the right people, training and developing them so they can provide excellent care andsupport to you.
An individual employer is someone who buys their own care and support, usually by employing one or more personal assistants. They are sometimes called direct employers. Often, an individual employer will have been assessed by social care as eligible to receive funding (often by means ofa 'direct payment'), but sometimes they will pay for their own care (knownas self-funding) or through Personal Health Budgets. Either way, they havechoice and control about how they are supported.
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It aims to improve confidenceand readiness to practice, building on the skills and knowledge developed through qualifyingprogrammes.
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Adult social care is evolving rapidly. The movement towards personalised services has led to theworkforce, employers, commissioners, carers and people in need of care and support, interacting inmany creative ways.Skills for Care's 'Most effective new approach to integration and innovation' Accolade, recognisesexamples of excellence, in which organisations or individuals have found new and creative ways towork in partnership, which deliver learning that changes how people are supported.
Nominations are encouraged from all parts of the adult social care sector including: local authorities, organisationsfrom the independent sector (such as user-led organisations (ULOs)) or individual employers (someone who buys their own care and support, usually by employing one or more personalassistants).Skills for Care recognises that effective approaches to integration and innovation do not just existbetween one social care organisation and another; applicants may have worked with partners fromother sectors including - but not limited to - housing, the arts, spots, health and public health.
Who should enter this category: organisations, individual employers, ULOs, local authorities and partnerships.
Workforce planning using detailed workforce intelligence from the National Minimum Data Set for Social Care (NMDS-SC) is now being increasingly undertaken by social care providers to improve services.
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Who should enter this category: care providers.
Skills for Care has recognised the importance of developing the workforce to support carers. Skills for Care's common core principles (CCPs) for working with carers, as well as the suite of resources available, promote the need to work with carers as expert partners in care.
This Accolade is given as a recognition of where employers are making sustained improvements or changes in the way learning and development is delivered so that workers at all levels are skilled to specifically support the CCPs for working with carers. Skills for Care recognises that approaches to learning can often be developed in partnership, between organisations that have complementary skills. In the case of this Accolade, this may be partnerships between carers organisations and others. Therefore, it is possible to enter the Accolades jointly, where this has been the case.
Who should enter this category: organisations and individual employers.
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text:
RICHLAND, Wash.-- A Richland middle school is devastated by the sudden death of a student.
Students, teachers and administrators are coming together to cope with the loss Monday.
Students at Carmichael arrived at school this morning to hear the tragic news that an 8th grade boy took his own life.
Students and teachers are overwhelmed by the loss.
The Richland School District sent 10 additional counselors from other schools to Carmichael to support the students and staff.
Counselors spoke with students individually and in groups in the library.
At times, there were as many as 50 students using the counselor services and a steady stream of students continued throughout the day.
"If you have a lot of students wanting to talk about this, they might've known the student, all of a sudden they see an empty desk in their classroom and the emotions can run high. So we provide that service so students can talk about it," said Steve Aagaard, Richland School District spokesperson.
The school's 950 students were formally told about the death and a letter will be sent home to parents.
The school district encourages parents to talk with their children about the loss to help them through the grieving process.
Many of the students were too upset to stay at school and went home after hearing about their classmate's death.


text:
FRANKLIN — A Capitol Police officer with Indiana State Police faces a charge of child molest after an alleged incident in Johnson County.
Scott Litten, 43, of Anderson, is accused of inappropriately touching an 11-year-old girl at a pool party Saturday, according to a press release from Johnson County Sheriff Doug Cox. Litten was arrested on an initial charge of sexual battery, and the charge was upgraded after the girl admitted she was touched by Litten, Cox said in the release.
Johnson County deputies were dispatched to the 5600 block of South County Road 550 East in Franklin after a child molest was reported at about 8 p.m. Sunday. Two adults told deputies they saw Litten fondle the girl in a swimming pool at the address, according to the press release.
Child molest is a Class A felony in Indiana.
According to Indiana State Police, Litten has been with ISP since July 2002 and he is currently on paid administrative leave pending his court hearing. Attempts to reach Litten on Tuesday were unsuccessful.
Capitol Police patrol the Statehouse and state office buildings.
Like Jack Molitor on Facebook and follow him @aggiejack4 on Twitter, or call 640-4883.


text:
i've pulled some of those self-drives before, they were surprisingly solid, though the hangers are shockingly thin.
Hey Scott, I must agree that self drives are pretty darn solid for how shallow the hole is. I figured I'd swap them while I was there due to their leeper hangers and their age. One of those was the only protection for a long section of slab at the top of pitch 4, where a bolt failure would be disasterous. :)
Thanks for replacing these! Did you use "The Device"?
You are welcome! Yeah, the device works really well ... I am psyched about it!


text:
K/DOQITM Disclaimer
These guidelines are based on the best information available at the time of publication. They are designed to provide information and assist in decision making. They are not intended to define a standard of care, and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.
K/DOQI is a trademark of the National Kidney Foundation.
From its rudimentary beginnings in the 1960s, renal replacement therapy has become a lifesaving treatment that can provide end-stage renal disease (ESRD) patients with a good quality of life. As a result, the number of ESRD patients who receive renal replacement therapy has risen, and their survival has increased, but considerable geographic variability exists in practice patterns and patient outcomes. It was this realization, and the belief that substantial improvements in the quality and outcomes of renal replacement therapy were achievable with current technology, that prompted several organizations to seek to reduce variations in ESRD treatment with the goal of a more uniform delivery of the highest possible quality of care to dialysis patients. Notable among these efforts were the report on "Measuring, Managing and Improving Quality in the ESRD Treatment Setting" issued by the Institute of Medicine in September 1993; the "Morbidity and Mortality of Dialysis" report issued by the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) in November 1993; the Core Indicator Project initiated by the ESRD Networks and the Health Care Financing Administration (HCFA) in 1993; the "Clinical Practice Guidelines on the Adequacy of Hemodialysis" issued by the Renal Physicians Association in December 1993; and the Dialysis Outcomes Quality Initiative (DOQI) initiated by the National Kidney Foundation (NKF) in 1995.
In keeping with its longstanding commitment to the quality of care delivered to all patients with kidney and urologic diseases, the NKF convened a Consensus Conference on Controversies in the Quality of Dialysis Care in March 1994. Following a series of nationwide town hall meetings held to obtain input into the recommendations made at the Consensus Conference, the NKF issued an "Evolving Plan for the Continued Improvement of the Quality of Dialysis Care" in November 1994. A central tenet of the plan was recognition of an essential need for rigorously developed clinical practice guidelines for the care of ESRD patients that would be viewed as an accurate and authoritative reflection of current scientific evidence. It was to this end that the NKF launched the "Dialysis Outcomes Quality Initiative" (DOQI) in March 1995, supported by an unrestricted grant from Amgen, Inc.
The objectives of DOQI were ambitious: to improve patient survival, reduce patient morbidity, improve the quality of life of dialysis patients, and increase efficiency of care. To achieve these objectives, it was decided to adhere to several guiding principles that were considered to be critical to that initiative's success. The first of these principles was that the process used to develop the DOQI guidelines should be scientifically rigorous and based on a critical appraisal of all available evidence. Such an approach was felt to be essential to the credibility of the guidelines. Second, it was decided that participants involved in the development of the DOQI guidelines should be multidisciplinary. A multidisciplinary guideline development process was considered to be crucial, not only to the clinical and scientific validity of the guidelines, but also to the need for multidisciplinary adoption of the guidelines following their dissemination, in order for them to have maximum effectiveness. Third, a decision was made to give the DOQI guideline development Work Groups final authority over the content of the guidelines, subject to the requirement that guidelines be evidence-based whenever possible. By vesting decision-making authority in a group of individuals, from multiple disciplines and with diverse viewpoints, all of whom are experts with highly regarded professional reputations, the likelihood of developing sound guidelines was increased. Moreover, by insisting that the rationale and evidentiary basis of each DOQI guideline be made explicit, Work Group participants were forced to be clear and rigorous in formulating their recommendations. The final principle was that the guideline development process would be open to general review. Thus, the chain of reasoning underlying each guideline was subject to peer review and available for debate.
Based on the "NKF Evolving Plan for the Continued Improvement of the Quality of Dialysis Care" and criteria recommended by the Agency for Health Care Research and Quality (AHCRQ; formerly known as the Agency for Health Care Policy and Research [AHCPR]), four areas were selected for the initial set of clinical practice guidelines: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access, and anemia. Each Work Group selected which topics were considered for guideline creation. During the DOQI guideline development process, nearly 11,000 potentially relevant published articles were subjected to evaluation, and both the content and methods of approximately 1,500 articles underwent formal, structured review. Although labor-intensive and costly, the process resulted in an intensive, disciplined, and credible analysis of all available peer-reviewed information. When no evidence existed, or the evidence was inadequate, guidelines were based on the considered opinion of the Work Group experts. In all cases the rationale and the evidentiary basis of each recommendation was stated explicitly.
Draft guidelines were then subjected to a three-stage review process. In the first stage, an Advisory Council, consisting of 25 experts and leaders in the field, provided comments on the initial draft of the guidelines. In the second stage, a variety of organizations (ESRD Networks, professional and patient associations, dialysis providers, government agencies, product manufacturers, and managed care groups) were invited to review and comment on a revised draft of the guidelines. After considering these comments and suggestions, the Work Groups produced a third draft of the Guidelines. In the final stage, this draft was made available for public review and comment by all interested individuals or parties. Following consideration of the comments submitted during this open review period, the guidelines were revised again and then published as supplements to the September and October 1997 issues of the American Journal of Kidney Diseases was made available on the Internet and widely distributed.
The four sets of DOQI guidelines published in 1997 addressed only part of the "Evolving Plan for the Continued Improvement of the Quality of Dialysis Care" adopted by the NKF in 1994. In that plan, as well as in the early DOQI prioritization process, nutrition was considered to be an important determinant of ESRD patient outcome. Consequently, a Nutrition Work Group was convened in 1997 to review the key clinical nutrition literature and to define topics for which guidelines related to the nutritional management of patients should be developed. Supported primarily by a grant from Sigma Tau Pharmaceuticals, Inc, the Nutrition Work Group began to work intensively on those topics in January 1998, and the Nutrition Guidelines that they have developed constitute this fifth set of the original DOQI guidelines.
NKF-DOQI achieved many, but not all of its goals. The guidelines have been well received and are considered by many to reflect the "state of the art" of medical practice in their fields. The frequency with which the DOQI guidelines have been cited in the literature and have served as the focus of local, national, and international scientific and educational symposia is one measure of their influence. The guidelines also have been translated into more than 10 languages and have been adopted in countries across the globe. In addition, DOQI has spawned numerous educational and quality improvement projects in virtually all relevant disciplines, as well as in dialysis treatment corporations and individual dialysis centers. Furthermore, the Health Care Financing Administration has responded to a Congressional mandate to develop a system for evaluation of the quality of care delivered in dialysis centers by developing a series of Clinical Performance Measures (CPMs) based on selected DOQI guidelines.
It is encouraging that two of the ESRD Networks have developed a guideline prioritization tool and embarked on a Prioritization and Implementation Project that would link selected DOQI guidelines into the Health Care Quality Improvement Project proposed by HCFA in the ESRD Networks' most recent Scope of Work. This project would involve a collaborative effort of professional organizations, local practitioners, and patients. In fact, it is this collaborative spirit and total commitment to patient care that accounts for the success that DOQI has achieved heretofore.
As we begin the new millennium, the DOQI clinical practice guideline initiative will move forward into a completely new phase, in which its scope will be enlarged to encompass the spectrum of chronic kidney disease well before the need for dialysis, when early intervention and prevention measures can delay or prevent the need for dialysis and improve its outcomes. This enlarged scope increases the potential impact of improving outcomes of care from hundreds of thousands to millions of individuals with kidney disease. To reflect this expansion, the reference to "Dialysis" in DOQI will be changed to "Disease" and the new initiative will become known as Kidney Disease Outcomes Quality Initiative (K/DOQI).
The dissemination and implementation strategies that have proven so effective for NKF-DOQI have been adapted and expanded to reflect the new mission of K/DOQI and its multidisciplinary focus. Relevant material from the Nutrition Guidelines and future K/DOQI Guidelines will be developed into implementation tools appropriate not just for nephrology, but also the specialties most likely to encounter those at risk for chronic kidney disease early in the course of their illness, including cardiology, hypertension, diabetes, family practice, pediatrics, and internal medicine.
On behalf of the National Kidney Foundation, we would like to acknowledge the tremendous contributions of all the volunteers who gave so much of their time and effort to the success of DOQI in order to improve the quality of life and outcomes of dialysis patients. The Nutrition Guidelines extend the DOQI objectives even further into the new and broader K/DOQI goals. Since the effort that went into preparing the Nutrition Guidelines was under the aegis of the original DOQI Advisory Council and Steering Committee, these two bodies are acknowledged. The new K/DOQI Advisory Board now will assume the charge of disseminating and implementing the Nutrition Guidelines.
Garabed Eknoyan, MD
Nathan W. Levin, MD
K/DOQI Advisory Board Members
Protein-energy malnutrition (PEM) is very common among patients with advanced chronic renal failure (CRF) and those undergoing maintenance dialysis (MD) therapy worldwide. Different reports suggest that the prevalence of this condition varies from roughly 18% to 70% of adult MD patients. In adults, the presence of PEM is one of the strongest predictors of morbidity and mortality. However, in the poorly nourished pediatric patient, mortality is less common, and growth retardation is an additional and greater concern. Impaired linear growth persists despite ongoing renal replacement therapy with either hemodialysis (HD) or peritoneal dialysis, and improvements in linear growth after successful renal transplantation usually fail to fully correct pre-existing growth retardation unless growth hormone (GH) is administered. Although several factors contribute to the impaired skeletal growth in pediatric patients with chronic renal disease, protein and energy malnutrition play a critical role, particularly during the first few years of life. Additional factors that contribute to impaired growth in pediatric patients include anemia, acidemia, calcitriol deficiency, renal osteodystrophy, and tissue resistance to the actions of GH and insulin-like growth factor-I (IGF-I).
There are many causes of PEM in patients with advanced CRF. These include:
Notwithstanding the many causes of PEM in patients with CRF, provision of adequate nutrition is a key component of the prevention and treatment of PEM in adults and children receiving MD. These K/DOQI Nutrition Clinical Practice Guidelines provide recommendations regarding the nutritional assessment of protein-energy nutritional status and the desirable dietary energy and protein intake for adults and children undergoing MD. Guidelines were developed for children treated with MD concerning their nutritional needs for vitamins, zinc, and copper and for their treatment with recombinant human GH. Guidelines are also provided regarding the nutritional intake of L-carnitine for adult MD patients, the nutritional management of the nondialyzed adult patient with advanced CRF, and the management of the acutely ill pediatric and adult patient. For logistical reasons, recommendations for the nutritional management of nondialyzed pediatric patients with advanced CRF were not developed. The decision was made to not address vitamin and mineral needs or the use of anabolic agents in the adult MD patient, because the scope of the subject matter and the volume of scientific literature was considered to be too large for inclusion in this set of guidelines.
The guidelines are based on a structured review of the medical literature and, where insufficient evidence exists, on the expert opinion of the Work Group members. In each case, the guidelines are intended to serve as starting points for clinical decision making, and it is emphasized that the clinical judgment of the health care practitioner must always be included in the decision making process and the application of these guidelines. The guidelines are not to be considered as rules or standards of clinical practice. At the end of each guideline, recommendations are made for research studies that may enhance the scientific evidence base concerning the subject matter of that guideline. In keeping with the K/DOQI objectives, it is hoped that the information provided in these guidelines and the research recommendations will improve the quality of care provided to children and adults who have chronic kidney disease or are receiving chronic dialysis therapy and will stimulate additional research that will augment and refine these guidelines in the future.
The K/DOQI Nutrition Work Group expresses its indebtedness and appreciation to Thomas Golper, MD, and John Burkhart, MD, for their contributions to Guideline 27; to Tom Greene, PhD, and Thomas Depner, MD, for their assistance with the development of Appendix V; to Paul Shekelle, MD, and Erin Stone, MD, for the structured review and guidance in the guideline development process; and to Donna Fingerhut, MSEd, for the innumerable hours she devoted to the overall administration of the project. The efforts and expertise of these individuals were invaluable.
© 2000 by the National Kidney Foundation, Inc.
The Guideline Development Process
The Institute of Medicine has defined practice guidelines as "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." The American Medical Association endorsed this definition by describing practice guidelines as "systematically developed statements, based on current professional knowledge, that assist practitioners and patients to make decisions about appropriate health care for specific clinical circumstances." Put simply, practice guidelines constitute an effort to advise health-care providers and patients as to what constitutes optimal clinical practice, based on the best information available. As a result, practice guidelines can not only improve both quality and cost-effectiveness of care, but can also facilitate continuous improvement in clinical practice as new information becomes available.
Four principles guided decision-making in the conduct of the NKF-DOQI and will be retained for the K/DOQI guidelines:
The guidelines were developed using an evidence-based approach similar to the one used by The Federal Agency for Health Care Research and Quality (AHCRQ). That is, before formulating recommendations, the Work Groups reviewed all published evidence pertinent to the topics being considered and critically appraised the quality and strength of that evidence. For many issues that the Work Groups chose to address, there either was no pertinent literature available or available evidence was flawed or weak. As a result, in many instances the Work Groups formulated their recommendations based on the opinions of the Work Group members and comments received from the peer reviewers. In all instances, the Work Groups have documented the rationale for their recommendations. That is, they have articulated each link in the chain of logic they used as the evidentiary or opinion-related basis for their recommendation. This approach helps readers of the guidelines determine the quantity and quality of evidence underlying each recommendation.
Although some of the DOQI guidelines are clearly based entirely on evidence or entirely on opinion, many are based in part on evidence and in part on opinion. Such "hybrid" guidelines arise when some (or even most) of the links in the chain of logic underlying a guideline are based on empirical evidence, but some (ie, at least one) are based on opinion. The opinion of the Work Group members can enter the chain of logic that supports a guideline either to fill in a gap in available evidence on some scientific or clinical issue, or in the form of a value judgment regarding what they feel is appropriate clinical practice based on available evidence. Thus, many opinion-based guidelines may have substantial empirical evidence underlying them. These guidelines were developed using a seven-stage process.
Phase I: Work Group Member Selection
The DOQI Steering Committee selected a Chair to lead the Adult and Pediatric Nutrition Work Group and suggested names of individuals with particular expertise to serve on the Work Group. Final decisions on the membership of the Work Group were made by the Work Group Chair. In recognition of the different bodies of literature and expertise for nutrition issues in adult and pediatric ESRD and MD patients, the Work Group Chairs appointed separate nutrition Work Groups for adult and pediatric patients. Two Vice Chairs, for protein-energy nutrition and for carnitine, were appointed for the Adult Work Group, and one Vice Chair was appointed for the Pediatric Work Group.
Support for the Work Groups in coordinating and performing the systematic literature review, synthesizing data abstracted from the literature into evidence tables, facilitation of the guideline development process, conducting meetings of the Work Groups, and analyzing results of the guideline development meetings was provided by personnel from the RAND Corporation and Cedars-Sinai Medical Center. Both of these institutions are associated with the Southern California Evidence-Based Practice Center.
Phase II: Targeting
The Work Groups defined the specific topics on which guidelines would focus and the specific questions on which the systematic literature would focus. The following clinical questions were formulated:
Question 1. Which of the following measures of nutritional status best predicts patient morbidity/mortality (and growth rate in children) in MD patients?
Serum albumin, serum prealbumin, anthropometric measures (height, weight, skinfold thickness, body mass index [BMI], percent of normal body weight, percent of desirable body weight, postdialysis body weight), bioelectrical impedance (BIA), urea nitrogen appearance, serum creatinine and creatinine index, subjective global nutritional assessment (SGA), dietary diaries and interviews, serum cholesterol, serum transferrin, serum IGF in pediatric patients, protein equivalent of total nitrogen appearance (PNA/PCR), prognostic nutrition index, serum acute-phase proteins (C-reactive protein), serum alpha-1 glycoprotein, dual energy x-ray absorptiometry (DXA), a combination of more than one of these measures.
Question 2. Which of the following measures is the best diagnostic test for protein/energy nutritional status in MD patients?
Serum albumin, serum prealbumin, anthropometric measures (height, weight, skinfold thickness, BMI, percent of normal body weight, percent of ideal body weight, postdialysis body weight), BIA, urea nitrogen appearance, serum creatinine and creatinine index, SGA, dietary diaries and interviews, serum cholesterol, serum transferrin, serum IGF, PNA, prognostic nutrition index, serum acute phase proteins (C-reactive protein), serum alpha-1 glycoprotein, DXA, a combination of more than one of these measures.
Question 3. What is the effect of acid/base status on nutritional measures in MD patients?
Question 4. Which levels of intake of protein and energy in MD patients produce the following:
The lowest morbidity/mortality, the most optimum changes in nutritional status using measures from Question 1 above, positive nitrogen balance, the most optimal growth in children?
Question 5. Which levels of protein and energy intake in predialysis patients produce the lowest morbidity at the initiation of dialysis? (This question was included because of evidence that nutritional status at the onset of MD therapy is a strong predictor of nutritional status and mortality during the course of MD therapy.)
Question 6. What is the energy expenditure of MD patients during resting and other activities, and how does it compare with energy expenditure in normal individuals?
Question 7. Is interdialytic weight gain a good measure for dietary compliance or a good prognostic indicator?
Question 8. Does carnitine supplementation in adult MD patients improve morbidity or mortality?
Question 9. What are the toxic/adverse effects of L-carnitine, if any, in adult MD patients?
Question 10. Which nutritional interventions produce the lowest morbidity/mortality (and best growth in children) or the most optimum changes in nutritional status in MD patients using measures from Question 1 above?
Question 11. Does GH therapy improve growth or morbidity/mortality in pediatric MD patients?
Question 12. Does vitamin or mineral supplementation (exclusive of calcium, magnesium, and vitamin D) improve morbidity/mortality in pediatric MD patients?
Phase III: Literature Review, Selection, and Abstraction
A structured database search of two computerized bibliographic databases (MEDLINE and EMBASE) was performed with the following specifications: language: English and non-English articles; dates: 1966 through 1997; subjects: human; article types: letters, editorials, reviews, case reports, and abstracts of meeting proceedings were excluded. The literature search was performed in collaboration with a librarian experienced in searching computerized bibliographic databases and performing "evidence-based" systematic reviews. The Journal of Renal Nutrition was hand-searched, because, at the time, it was not indexed in the bibliographic databases listed above. Additionally, referrals from DOQI Work Group members through August 1999 were reviewed.
After loading articles from MEDLINE, EMBASE, Work Group referrals, and the Sigma Tau bibliography into an electronic database, one reviewer performed an initial title review of these articles. Two independent reviewers then reviewed the abstracts of articles whose titles were selected. Selection disagreements were resolved by consensus. English language articles for which the abstracts were selected were then obtained and categorized based on the clinical question the article addressed. Two independent reviewers then reviewed these articles. Information was abstracted from the articles (see below) by one abstracter and verified by a second. Disagreements were resolved by consensus. Articles that were rejected at this stage were coded using the following codes:
In order to increase precision and reduce systematic errors, the language of manuscripts was not limited to English.1,2 The English titles and English abstracts of foreign language articles, when available, were sent to all Work Group members for review. The abstracts of foreign language manuscripts were translated into English if any Work Group member thought that the paper might contribute positively to the evidence base. Selections were further based on study design. For prognostic articles, only those with prospective cohort or historical prospective cohort designs were included for further analysis. For assessment of nutritional status, only manuscripts in which a nutritional parameter was compared to a recognized standard nutritional measure or to a clinical outcome were included for further analysis. For manuscripts examining nutritional treatment, only those with a prospective design with concurrent controls were analyzed further. Because there were smaller numbers of these types of studies for carnitine treatment or pediatric renal nutrition, these requirements were not as rigidly applied for this literature.
After article abstraction (see below), evidence tables were produced from a subset of abstracted data elements and evaluated by the Work Group during meetings in Los Angeles in August 1998 (Adult Work Group), in October 1998 (Pediatric Work Group), and during a series of subsequent conference calls. The Work Group accepted or rejected articles based on the study design and methods and the adequacy with which it addressed the clinical questions. The final selected articles are indicated by an asterisk in the reference section. Other citations, that are not asterisked, were not used for guideline development, but were used to more fully explain the background or rationale for a guideline.
Critical Appraisal Method for Articles Concerning Prognosis. For each prognostic article, the following characteristics were ascertained3: (1) the study type; (2) the three main co-morbid conditions; (3) whether there was a representative and well-defined sample of patients at a similar phase in the course of disease; (4) the characteristics of the study population and dialysis procedures that might have affected the study results; (5) the duration of the follow-up period; (6) whether the outcomes were objective and the interpretation of the outcomes was unbiased; (7) whether adjustment was made for important known prognostic factors; and (8) the results of the study.
Critical Appraisal Methods for Articles Concerning Nutritional Assessment. For each article concerning nutritional assessment, the following information was obtained4,5: (1) the type of study; (2) the three main co-morbid conditions; (3) whether there was an independent blinded comparison with a reference (gold) standard; (4) the characteristics of the study population and the dialysis procedures that might have affected the study results; (5) whether the results of the nutritional measure that was studied influenced the decision to measure the reference standard; (6) whether characteristics and variety of the patients' standard is similar to those found in dialysis centers; (7) whether the test methodology are described well enough to be reproducible; and (8) the results of the study.
Critical Appraisal Methods for Articles Concerning Nutritional Treatment. For each treatment article, the following information was obtained6,7: (1) the type of study; (2) the three main co-morbid conditions; (3) the Jadad quality scores8; (4) the randomization score; (5) the double blind score; (6) the score for whether all patients were accounted for; (7) an intention-to-treat score; (8) whether the treatment groups were similar at baseline; (9) the characteristics of the study population, dialysis procedure, and other ancillary treatment that might have affected the study results; (10) whether the treatment groups were treated similarly except for the study intervention; and (11) the results of the study.
The Jadad quality scores address issues most important in demonstrating the validity of randomized clinical trials and have been demonstrated to reflect methodological quality. Empirical evidence demonstrates that when these quality features are not met in clinical trials, bias and an exaggeration of the effect sizes often result.8-12
Results of the Systematic Review. The initial literature search identified 19,272 MEDLINE and 4,943 EMBASE articles. In addition, the Work Groups referred 134 articles for review, and the Sigma Tau Pharmaceutical Corporation submitted a bibliography that contained 138 additional references that were included in the analysis. Of these 24,487 references, 22,362 titles were rejected as not meeting the inclusion criteria, leaving 2,125 titles. Abstracts of these articles were reviewed and 1,021 were rejected as not meeting the inclusion criteria, thus leaving 1,104 articles. One hundred and seventy of these were foreign language articles whose titles and abstracts were sent to the Adult or Pediatric Work Groups. Of these, 102 were not selected for further evaluation. Two were selected but could not be translated, and 66 were further evaluated. Of the remaining 1,000 manuscripts (including the 66 mentioned above), 29 were unobtainable, leaving 971 to be abstracted. Of these, 640 were rejected because they were classified as an editorial, letter, review, case report, or abstract, did not answer a clinical question of relevance, did not have a valid study design, or did not involve humans. The remaining 331 articles were sent to the Adult or Pediatric Work Groups along with evidence tables for these articles created from the abstraction forms. The Work Groups rejected 81 additional articles for one or more of the same reasons indicated above, leaving 250 accepted articles.
Phase IV: Formulation of Guidelines
The group process used to develop the guidelines is a modification of the RAND/UCLA Appropriateness Method. This group process method has the following essential features: multidisciplinary, iterative, quantitative, and each panelist has equal weight in determining the final result.13
In conjunction with the Work Groups, RAND and Cedars-Sinai staff developed draft guidelines based on the results of the systematic review. The draft guidelines corresponded to the key questions developed by each Work Group. The draft guidelines included all possible topics articulated by the Work Groups during the targeting phase and at the Work Group meetings to discuss the evidence. These draft guidelines were then transmitted to the Work Group members, who used the evidence tables and their expert judgment to rate each guideline statement for validity on a 1-to-9 scale. The RAND staff then compiled summaries for the face-to-face meetings of the Work Groups. At these meetings, Work Group members were provided with the summaries of these first round ratings of validity. These summary ratings were used to key a point-by-point discussion of the evidence and opinion surrounding each potential guideline statement. After each discussion, the Work Group members privately re-rated each guideline statement for validity. These votes form the basis for the final guidelines. Statements were accepted as valid if the median panel rating on validity was 7 or greater on the 1-to-9 scale. "Complete agreement" was defined as occurring when all Work Group members rated a guideline statement within the same three-point range of the scale (for example, all members' ratings were in the range of 7, 8, or 9). After determining the final guideline statements, Work Group members went through a similar two-step rating process to assess the level of evidence. A rating of "Evidence" was defined as "mainly convincing scientific evidence, limited added opinion"; "Opinion" was defined as "mainly opinion, limited scientific evidence"; and "Evidence plus Opinion" was defined as "about equal mixtures of scientific evidence and opinion."
Phase V: Draft Report With Supporting Rationale
Following the development of the guidelines, the Work Group drafted a report that included the supporting rationale for each guideline. While writing the rationale for each guideline, Work Group members cited additional references that had either not been identified previously in the literature search efforts, or had been identified but rejected. These citations contained information that was felt to be important either as background material, or to further explain the rationales. However, these additional references were not part of the evidence base that was used to either formulate the guideline statements or the votes on the validity or the rating of evidence versus opinion for each guideline.
Phase VI: Peer Review
The purpose of the peer review process was to identify:
The nutrition guidelines were subjected to a three-stage peer review process:
Stage One: Primary Review. NKF-DOQI's multidisciplinary Steering Committee was assigned to review the draft report. Drafts were distributed to the committee in August 1999 and members had the opportunity to offer oral comments at a face-to-face meeting in mid-September. The draft report was also sent to the NKF-DOQI Advisory Council, the NKF Scientific Advisory Board, and selected experts in the field. Many substantive comments were received, and this resulted in substantive changes in the organization and content of some of the guidelines and rationales. Given the large volume of comments received, the Work Group vice-chairs reviewed the comments first and entered them into a computer database separating these according to whether they had a potential minor or substantive impact. Comments were sorted by guideline topic and then provided to the Work Groups for analysis and response.
Stage Two: Organizational Review. Close to 200 individuals representing nearly 50 end-stage renal disease (ESRD)-related organizations reviewed the second draft of the guidelines in December 1999. Organizations that were invited to participate in the second round of peer review were selected by the Steering Committee based on suggestions from the Advisory Council and the Work Groups. Organizations included various nephrology professional societies (eg, Renal Physicians Association, American Society of Nephrology, American Nephrology Nurses Association, and American Renal Administrators Association), the American Association of Kidney Patients, the ESRD Networks, NKF Councils, dialysis chains, managed care organizations, and private industry organizations selected their own reviewers.
Stage Three: Open Review. In the final round of review, in December 1999, approximately 400 individuals received copies of the revised draft guidelines. Within 3 weeks, 30% of these reviewers provided comments. The Work Group vice-chairs sorted and organized these comments and the Work Group analyzed the responses.
Phase VII: Issue Final Guidelines
The Work Group and staff performed several tasks to complete the guidelines. The guidelines were edited to ensure clarity and consistency. The Work Group carefully reviewed the final draft and made the indicated changes. Accuracy of the literature citations for each guideline document were also verified.
The NKF plans to undertake three types of activities to promote implementation of these recommendations.
The development of the K/DOQI practice guidelines is a cooperative, rewarding, and unifying effort for the participants and the community of health care workers who are involved in the care of the individual with kidney disease. We hope this spirit of cooperation and commitment to improvement of dialysis patient outcomes will help the K/DOQI in efforts to put its quality improvements into practice.
© 2000 by the National Kidney Foundation, Inc.
© 2000 National Kidney Foundation, Inc
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