text:
The post Examining Advertising and Body Image appeared first on Honors Program.
]]>With the advent of modern technology, the images used in advertising are almost without exception digitally modified. Models who are already extremely slender are further edited to the point that their body is completely unrealistic. Media images thus portray unattainable thin body ideals. Exposure such media images has a well-documented negative effect on vulnerable young women's body dissatisfaction. A now robust body of literature has revealed a relationship between thin-ideal image exposure and both body dissatisfaction and disordered eating behaviors and young women. These results have borne out cross-culturally, with similar findings reported in studies including participants from Taiwan, India, and France.
While the majority of research has been conducted on print media, some research methods have included television, music videos, and the Internet. Body dissatisfaction increased upon exposure to thin-ideal images, regardless of media type. Nowadays, young women are viewing images on a screen just as often, if not more often, than they are seeing print pictures, therefore it is important to conduct research evaluating the effect of images presented on screen so as to increase ecological validity as much as possible.
While it has been suggested that the use of non-modified images might mitigate the negative effects on body image resulting from media exposure, this has not been empirically studied and the effects of images known to be unaltered have not been compared to those of images known to have been digitally modified. It is possible that unmodified images might have a less deleterious effect on body image than retouched images. Research in this area could help inform public policy and evidence-based recommendations to industry.
Therefore, this past fall with the help of Drs. Debra Franko and Rachel Rodgers, I started to conduct research on this topic using advertising from Aerie, a lingerie clothing company targeting adolescent girls, that had decided that none of their advertising will be photoshopped as of January 2014. This provided a unique opportunity to investigate the potential using unmodified images in advertising in order to decrease the documented detrimental effects of advertising on body image.
The grant from the Honors program was used to help in the recruitment process for subjects. Participants in the study were given a $15 gift card as compensation for their time and effort towards the experiment.
The present study utilized an experimental manipulation presented as a market research study that exposed female undergraduates to advertisements that are either retouched or unmodified. The goal was to determine whether exposure to unmodified images is less deleterious to body image than exposure to photo-shopped images in an experimental design. The main hypothesis is that participants in the retouch condition would demonstrate lower implicit body esteem and endorse higher body dissatisfaction. Furthermore, appearance comparison would moderate the effect of the retouch condition on implicit and explicit body image.
As a senior at Northeastern, the Honors Research Grant has allowed me to develop and run my own research study as part of my Honors in the Discipline thesis project. I have every hope that this project will help me reach my goal of entrance into a clinical Ph.D. program.
Alexandra Convertino, Psychology
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]]>The post Bringing Peruvian Textiles to the World appeared first on Honors Program.
]]>Although each community that ToP partners with is unique, conducting our socio-economic operational evaluation involving about 80 weavers in total is to better understand the artisans individually, as associations, and as a whole group. Better understanding how ToP collaborates with each of the five communities will allow for future project adaptation to improve effectiveness. While our initial baseline study is the first research of its kind being implemented by ToP, resulting conclusions will assist in decision making and program direction for years to come.
The research strategy involves the exploration of social and economic topics through a basic three-part interview which has been conducted with almost all partnering weavers. The interviews have been structured into three parts, including (I) an ethnographic survey, (II) a "defined" economic survey, and (III) a "hypothetical" economic survey. The ethnographic survey is enabling the development of comprehensive artisan profiles to better understand who the artisans are, the "defined" economic survey is highlighting the specifics of weaver income and expenses, and the "hypothetical" economic survey is exploring weaver ambitions and how Threads of Peru is affecting their achievement. As Annie and I near the completion of two months of data collection, analysis will soon begin and ultimately result in a thorough research report before the year's end.
After interviewing so many artisans, we have learned a great deal, ranging from individual-specific insights to trends that apply across the entire data set. The baseline ethnographic component will help us better understand weaver ages, places of birth, civil statuses, levels of education, degrees of Spanish language and literacy, and families. The ¨defined¨ economic section has revealed important nuances and preferences relating to the weaving process along with breakdowns of family income and expenses. Lastly, the ¨hypothetical¨ economic section has highlighted weaver desired family incomes, opinions about leaving their communities, and weaver ambitions across a variety of topics.
As we shift our attention toward compiling and analyzing the expansive data set will be working to identify trends, outliers, and valuable case studies. Such information will be used to more acutely explain ToP's work and also form recommendations for future project adaptation. Results and conclusions drawn from this research will help ToP maintain complete transparency in its work and ensure that the organization is constantly adapting to meet the pressing needs of the communities supported.
Despite the destitution prevalent in so many isolated highland Andean regions, the weavers that ToP collaborates with are constantly at work to turn opportunity into future investment. ToP supports indigenous artisans in reaching their own family and community goals of education, nutrition, health, and a brighter future by connecting their coveted textiles to a broad global market. When offered the chance to use their traditional weaving skills for income generation, most weavers express solace in being able to maintain the proud cultural practice and apply the techniques that have generationally been passed down in the art. For a majority of the weavers, alternatively abandoning weaving in search of other economic activities would mean completely starting over, likely in an unfamiliar urban setting with little to no education or technical training. By working with existing weaving cooperatives on general capacitation initiatives, ensuring self-leadership, and establishing internal quality control processes, Threads of Peru seeks to prepare even the most remote partner weaving associations with the necessary knowledge for modern international business. From some of the Sacred Valley region's most marginalized communities come flawless handmade and naturally dyed textile products, not only rich in cultural background but defined by real examples of empowerment and self-advancement. A story lies behind every product Threads of Peru sells; there are names, faces, and lives changed almost every day by the power of conscious consumers worldwide.
Harrison Ackerman, Political Science & International Affair
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]]>The post Volunteering with BuildOn appeared first on Honors Program.
]]>After getting to know each other, we headed out in teams for a Northeastern-themed scavenger hunt. From the original home of the Boston Bruins to the lucky token of tests takers, we tweeted group selfies for points (those hints are for Matthews Arena and the Ell Hall husky statue – did you get it right?). The five students in my group were impressed by the campus, amused by the statue of Shillman Cat, and absolutely obsessed with the touchscreen walls at the visitors center. We might not have won – okay, we came in last – but the CASH students were able to get a great impression of Northeastern, and everyone had a lot of fun.
After some pizza and conversation time back at the Honors office, we all headed to the T for the service part of our day. Spontaneous Celebrations is an arts and community nonprofit in Jamaica Plains, and we were there offering our help on the little things, so they could concentrate all their energy on their mission. After a quick tour of their colorful building, including a stop by the RoxBallet dance class, we headed back out into the autumn chill and picked up our rakes. Then what began as eye rolls and frozen toes started to turn into something else. Flushed faces laughed and joked, people raced each other to collect leaves, and some students even began to sing and dance in their native Haitian Creole. The time passed quickly, and soon the large yard was clear and some inner rooms were cleaned and painted. We gathered to reflect on our experience, the Northeastern and CASH students alike thanking each other for such a rewarding time. We crowded together for on last group photo and then parted ways, excited for the work we had done and the future of the partnership yet to come.
Gail Batutis, Political Science/Business Administration
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]]>The post Honors Leadership Institute 2014 appeared first on Honors Program.
]]>The cookout-style salads and burgers were replaced with an endless supply of soups, salads, steak, fish, fresh fruit, and dessert, all cooked to perfection by the full-time chef staff at Warren. The first thing we saw when we arrived was this feast. More importantly, we got to learn about ourselves from the activities. I think we can all remember the first few weeks of freshman year, when everything was about trying to get to know your peers, walk around in packs of around 30 people (at least), and not be the one to get lost on the way to classes (thank goodness we could avoid the Lake-Holmes-Meserve-Nightingale maze until it came time for office hours). It's fair to say that we were in a much better place for personal development this time around. We did a "leadership compass" test on the first night, and got to see how hilariously accurate the "leadership directions" were for all of our friends, as well as to actually revisit the idea throughout the weekend, and apply it to how we interacted and approached each new activity.
Our pre-conceptions were challenged. Whether it's a puzzle that actually tells a story by zooming in on one part of each page, or a race to collect items that you actually win when you don't worry about hitting the obstacles, every single activity proved to me that I could not just jump to understanding the concept without going through the entire process first. If the giant's ladder was (somehow) too easy last time (it wasn't), you get to try it blindfolded this time – and someone actually made it to the top like this. If that's not the most extreme example of trust in a team that you've ever seen, I don't know what is.
You know most people there, or have seen them around, or had a class together, or lived on the same floor of IV. And if you haven't met someone before, it seems like you've been friends for a year within the first couple hours. I was incredibly impressed with how friendly and enthusiastic everyone was, especially after an 8:30 wake-up call, and I came home to countless friend requests on Facebook and new friendly faces to say hello to in the hall
The weekend ended in the thirty five of us begging for a Third Year Leadership Retreat next year. I am very excited to see what the Honors Program comes up with next, and you can bet that Shaan and I will be there for Friendship Weekend: Round II.
Jessica Lewis, Industrial Engineering
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]]>The post Volunteering As a Farmer Through WWOOF appeared first on Honors Program.
]]>The place where I spent most of my time in Spain was Quart de Les Valls, a small town on the eastern coast. I lived and worked with a family of four for a month. Their farm included vegetable patches, olive groves, and orange orchards. We began each day by feeding and milking the six goats and moving them from the barn to pasture. Then we mixed a blend of organic grains to feed the many free-range chickens, and collected eggs. The rest of the day usually included weeding and harvesting in the vegetable patches. One memorable afternoon, I drove a tractor along rows of orange trees to distribute fertilizer.
One of the best aspects of WWOOF is the immersion component. By living with local families, volunteers are allowed the experience of being welcomed into a home and treated like a family member. In addition to farm life, I improved my Spanish skills; living in an area without other foreigners inspires constant effort.
My time working on the farms was wonderful. I learned how to build structures that support tomatoes, which nutrients chickens need, and how to hatch chicks in an incubator. There's nothing like waking up at sunrise to hear not the roar of street traffic but the enthusiasm of songbirds.
Volunteering with WWOOF inspired me to join environmental health efforts at Northeastern and in Boston. Sustainable agriculture is attainable. There are so many ways to improve farm practices: diversity and rotate crops, and manage pests with methods other than pesticides. It's a great thing to choose local foods from local farms – the less distance food travels, the better for the environment and the community. Best of all, home gardening makes veggies and herbs available and perfectly fresh. I know the lessons learned while farming will stay with me throughout my time at Northeastern and beyond.
Rose Martersteck, Health Science
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]]>The post Glacier National Park appeared first on Honors Program.
]]>I traveled to the park with nine other honors students from across the country, under the supervision of two professors. As guests at the national park, we were grateful to be given ample time with park service employees to learn about the inner workings of the park. The central theme of our trip was to examine the goals and challenges of stewardship in the national parks. Through conversations with the superintendent of the park, a park ranger, the head of the natural resources department and the museum curator I gained valuable insight into how the national parks are run. A balance must be struck between meeting the goals of providing recreation opportunities to the American public as well as preserving the natural landscape for future generations. Such work is by no means an exact science. The park service is continuously learning from the past and adjusting strategies to meet the needs of the future.
Our main contribution to the National Park Service during our week at Glacier National Park, was participating in a program called Citizen Science. We were tasked with helping the park in an ongoing project of determining the number of Mountain Goats and Bighorn Sheep in the park; both of which are iconic to the area. We were trained to identify each animal and determine their age, sex, activity, and the landscape they are found in. During our three-day backpacking trip in the backcountry of Glacier National, we stopped at several specific locations to complete 360-degree hour-long observations. While we counted nearly 20 goats at one location, other locations yielded none. Such work made clear to us the tireless, tedious, and rewarding work that the park service employees undertake. Hopefully, our contribution to the project can help the park in counting and tracking the activities of the beautiful and mysterious mountain goats and bighorn sheep.
In addition to the broad perspective I gained about the role of the national parks, the adventure also provided a valuable introspective experience. Extended periods of silence during our 24 mile long backpacking journey allowed for much needed reflection time after a hectic year of classes and co-op. The sounds, sights, smells, and feel of the park spurred thoughts about the delicacy of life, the vastness of the wilderness, and the universal feeling of well being that humans experience in nature. The moments I will cherish most from the trip are the ordinary experiences in the extraordinary place: skipping rocks on the pristine waters of Ole Lake and picking wild huckleberries along the narrow backcountry trails.
Such experiences are helping to determine the goals I set for myself and opportunities I hope to take advantage of in the future. Primarily, I was struck by how dedicated and grateful all of the national park employees were, and have began pondering how an industrial engineering major could be of use to the national park service. I think many of the skills and values present in industrial engineering would be of use to resource management and planning initiatives in the parks. Furthermore, the trip has affirmed my desire to explore our beautiful country. In an increasingly globalized world, I think it is as important as ever to discover the wonders right here at home
Harris Berton, Industrial Engineering
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]]>The post Why Failure is Important in Research appeared first on Honors Program.
]]>One day in the lab, one of the graduate students and I were discussing why one of my experiments failed. It turned out that the third time wasn't the charm and I would have to continue repeating my transformations until they worked. Naturally, I was upset my three days of work had resulted in nothing useful. While talking about this, the graduate student brought up that it is incredibly vital that I learn that failure is acceptable and that I must learn from this failure, because the only other option is to stop trying. We discussed how first year graduate students sometimes get very upset after doing research for a while and not achieving immediate gratification or success because all they had experienced before were class labs. We both realized that the co-op setup is so useful because it has taught me (before going to graduate school) that some experiments I design or conduct will not work and others will; it is just a matter of taking the results in stride and moving forward. From the experiences I have had with the support of the Honors Early Research Grant, I have learned to accept failure or failed experiments and am even more inspired to further pursue my goal of going to graduate school.
Kevin Gozzi, Biochemistry
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]]>The post Presenting at the American Chemical Society appeared first on Honors Program.
]]>When I describe the ACS National Meeting to others, many surprisingly do not see the appeal of joining 13,000 chemists in a concentrated location for a week…recalling my experiences at the National Meeting, I can assure that the conference is not only intellectually and professionally stimulating, but also a time of unbelievable fun and personal growth. Entertaining activities included feasting on traditional Texas barbeque, square dancing, mechanical bull riding, cowboy boot and ten gallon hat shopping, and free nightly social hours featuring a DJ, food, and drinks (for those over 21). Soaking up the unique Texas culture with fellow chemists added to the conference's novelty, but of course as a chemistry nerd I was most excited to attend scientific talks and present my own research. Among the many distinguished speakers was this year's Kavli Foundation speaker, Professor Emily Weiss from Northwestern University. Her talk, titled "The Behavior of Electrons at Nanoscopic Organic/Inorganic Interfaces," addressed the challenges of manipulating the surfaces of and empty spaces in between nanoparticles to mitigate or eliminate undesirable energy barriers, and the doors that are being opened with this research. In a nutshell, her research is extremely cool because if we can physically alter the outsides of nanoparticles (materials whose building blocks are on the nanoscale), these materials have endless applications in renewable energy, electronics, and much more!
In addition to hearing several impressive talks like Professor Weiss' and chatting with the speakers afterwards, I got to give my own presentation addressing my research conducted in Northeastern University's Center for Renewable Energy Technology (NUCRET) under Professor Sanjeev Mukerjee. My research project concerned developing a new kind of electrocatalyst that is made of cheap and abundant materials like iron (essentially rust) combined with high surface area materials called metal-organic frameworks (MOFs) that could replace rare metal (e.g. platinum) catalysts in batteries and fuel cells. The promising results of the material I developed and its potential for making renewable energy sources cheaper and therefore realistically able to replace fossil fuel combustion were well received at the National Meeting. Being able to compile my research into a concise story and share that with others is an invaluable skill that I have been able to practice thanks to presenting at such meetings. Additionally, talking about my research with other scientists helped me determine next steps to my project as well as next steps in my career. My love of developing and sharing science with others, a love that was discovered through doing research and presenting at conferences, has motivated me to attend graduate school which I began in June at MIT to pursue my PhD in chemistry. Going forward in my graduate studies, I feel extremely fortunate to have gained extensive research experience as an undergraduate and developed my own perspective on the field of and professions related to chemistry. The support from Northeastern's Honors Program was key to the progress of my undergraduate research project as well as my experiential education as a Husky and a chemist!
Elise Miner, Chemistry
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]]>The post Sequoia National Park appeared first on Honors Program.
]]>We left Fresno early in the morning the first day to start the drive to Sequoia. The ride was beautiful, passing through various landscapes – some desert, some farm, some mountains, and ultimately, the forest. The first sequoia tree we came upon, at the entrance to the park, I thought was fake. There was no way trees could be that ginormous. We continued on to Grant Grove, where lies General Grant (in tree form), the third largest tree in the world. We walked around the cove getting to know the people we'd be spending the next week in the wilderness with. We then continued on to our campsite, went for a moonlight hike, and went to sleep.
The second day we took a tour of Crystal Cave, a cave discovered by a soldier, lost in the mountains, who got lost in the cave for three days and came out permanently insane. We then headed to Foothills Visitor Center, behind which was an awesome swimming hole with a nice 15-foot cliff to jump off of, and a river to explore. A few others and I swam upstream and found an underwater cave! It was about 20 feet long and it came out in another section of the river, separated from the main section by a huge rock.
Day Three started off with some trail maintenance where we helped the Mineral King trail crew widen a trail using loppers to "lop" away the brush on either side of the trail. The trail crew guys were awesome and one of them was from New Jersey, pretty close to where I grew up. We then started the backpacking portion of our trip, hiking 4.2 miles up to Monarch Lake. Starting off the backpacking trip right, it rained and hailed most of the way up.
We slept well that night and the next morning set out for Sawtooth Pass, which we would have to cross over to get to our next campsite, Columbine Lake. The hike was incredibly steep, gaining over 1,000 feet in the first mile. We got up to the pass, ate lunch, and some of us set out to conquer Sawtooth Peak, a 12,343 ft. peak with not an easy summit path.
The next day we hiked back down to Monarch Lake, where we all went for a swim and hung out on our last night together. We then hiked back down to the trailhead, packed up the vans, and drove over the ranger station, where the ranger that accompanied us on our backpacking trip was there waiting with junior ranger badges to award us all with. We drove back to Fresno, bid our goodbyes, and returned to our various corners of the country.
I'm so happy to be back in Boston with two other people on the trip, one student and one student leader, who I can hang out and reminisce with any time. The main theme of the trip, the question, "What is wilderness?" was analogous to so many other questions in life – the answer can be different for everyone and everything is about perspective. Wilderness to the trip leaders, from Southern Utah, is different than wilderness was to the girl on our trip from the Upper East Side of Manhattan. What wilderness is to me now, is a place free from invasive technology and free from human development. It is a place that I can't wait to go back to. When I miss Sequoia and the week I spent there, I think of how ranger Josh kept reminding us that all land is connected and that even out here in Boston, in the middle of a bustling city, the ground we stand on is connected to the beautiful Sawtooth Peak, the shiny lakes Monarch and Columbine, and the ground beneath the awe-inspiring Sequoias.
Elan Axelbank, Sociology
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]]>The post Debating Foreign Policy at NUMAL appeared first on Honors Program.
]]>The International Relations Council (IRC) is a student-run organization where students interested in foreign policy can debate in simulations of the North Atlantic Treaty Organization, the Arab League, and the United Nations. By remaining an active member of IRC, I have sharpened my debating skills and heightened my understanding of diplomacy and negotiation efforts. In addition to weekly meetings, the IRC travels to prestigious college-level organizations. In our most recent travel to Washington D.C., the IRC won first place at the National University Model Arab League (NUMAL) conference held in Georgetown University. Our intense preparation efforts and knowledge skills resulted in top-notch performance that earned us the highest title.
The Northeastern University delegation represented the Republic of Sudan. Tasked with representing a country with a less-than-stellar portfolio—corruption, a failing economic system, ethnic strife, and more, resulted in an anticipated challenge. Forming enemies in the room would have been effortless if we were not careful. We did not allow Sudan's reputation to deter us from exercising our diplomatic skills. In the Political Affairs committee, my co-delegate, Brianna Barbaro, and I formulated long-term contingency plans for the Middle East and a durable solution to the Syrian crisis. As it turns out, we were able to form strategic partnerships with countries like Egypt and Qatar because we had a thorough understanding of the nuances of Sudanese policy. Our hard work earned us the Outstanding Delegation award, the highest possible recognition a delegation can receive.
The IRC is truly a model of experiential learning. The knowledge I gain from debating in simulations of real-world regional and global organizations complements the courses I take every day of the week. Representing Sudan in NUMAL allowed me to understand the intimate diplomatic—and some not so diplomatic—relationships Sudan shares with its neighboring countries.
The dynamics of the Middle East are constantly changing. Debates in the IRC keep me updated on the ever-changing circumstances of the tumultuous region because I am pushed to revisit conventional notions of diplomacy. Overall, traveling with IRC to advance Sudanese policy in the face of regional conflict was a challenging and rewarding experience.
Rawan Alkhatib, International Affairs
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text:
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
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OCR for page 33
Definitions of Key Terms
"When I use a word," Humps Dumpy said, in rather a scornful tone,
"it means just what I choose it to mean- neither more nor less."
"~e question is," said Alice, "whether you can make words mean so
many different things."
"The question is," said Humpty Dumpy, "which is to be master
that's all."
Lewis Carroll, Through the looking Glass
If AHCPR and the Forum are to proceed confidently with their mis-
sion, they need clear, broadly acceptable definitions of four key terms,
which were used in the legislation establishing the agency: (1) practice
guidelines, (2) medical review criteria, (3) standards of quality, and (4)
performance measures. Neither the final legislation nor preceding House
or Senate bills offered definitions of these concepts.
The four key terms employed in HERA 89 have been defined and used
in quite disparate ways. Words like guidelines and standards may mean one
thing to clinicians, another to purchasers, and yet another to attorneys.
(The study directors for this project discovered early in their work that
they were using these terms differently.) Moreover, the same person may
use the same term differently in different contexts. Able 2-1 suggests how
context influences usage and terminology.
Further complicating the semantic and conceptual situation are other
frequently used terms that are not mentioned in the legislation terms
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TABLE 2-1 Influence of Context on Terminology
Context Influence
Users may be practitioners, payers, or consumers. Common practitioner
terms include Practice guidelines. and ~algorithms.. Consumer terms
include Patient information (such as Postoperative instructions. For
insurers, teens such as Medical necessity. and Standard practice. are used
in discussions of health plan coverage, and lawyers refer to Community
standards. in malpractice cases.
Purposes Purposes may include practice management, practitioner or patient
education] quality assessment, and payment determination. Purposes and
users overlap to some extent, but even a single user such as a clinician may
talk at one time about Protocols. or ~indications. for an intervention and at
another time about Clinical indicators. or Occurrence screens. to flag
potential problems for further review in quality assurance programs.
Timing Prospective, concurrent, or retrospective uses may require veer different
formulations. Practice management guidelines are intended to guide care
prospectively, and Recertification criteria are used to review proposed care
on a case-by~ase basis. Continued stay review has employed Length of stay
norms.W Retrospective review may use ~screens. and analyses of practice
Consensus A number of terminological distinctions have been based on the strength of
scientific evidence or expert consensus about what is effective or ineffective
medical care. One formulation uses ~standard,. Guideline, and adoptions to
indicate decreasing levels of information about the likely outcomes of an
intervention and decreasing levels of consensus about preferences for
different outcomes. Other frameworks use gradations such as class I, II, and
III to indicate conditions for which the application is justified, for which
there is divergent opinion, and for which it is unjustified. Still other
classifications use such teens as Approbate, "equivocal,. and
Complexity At one extreme are joules of thumbs and ~dicta,. which are often stated very
tersely. At the other extreme lie detailed algorithms, decision trees, and
Criteria maps
such as clinical indicators, pracizce parameters, norms, and practice policies
(Meyer, 1989~. Some people may treat certain of these terms as synony-
mous; others may make strong conceptual or practical distinctions. Given
this abundance of terminology and meaning, it is helpful to recall what
Donabedian (1981:409) said when discussing norms, criteria, and stan-
dards: '~we have used these words in so many different ways that we no
longer clearly understand each other when we say them. But we. . .do not
have the liberty of abandoning them.... Our more reasonable course...
OCR for page 33
is to see whether we can clarify the existing nomenclature, barnacled and
misshapen though it may be with the encrustation of careless past usage."
Guided by the spirit of this observation, the committee's objectives
are limited: to provide definitions that are clear, realistic, and practical for
use with expert panels, contractors, and others. These definitions are not
expected to serve all users for all purposes; however, they should permit
clear communication between the Forum and the many organizations and
interests with which it must work
The committee began its definitional exercise by consulting the litera-
ture on practice guidelines, quality of care, and related topics. This body of
work contains a number of thoughtful efforts by practitioners, researchers,
policy analysts, and others to define and explain key terms. In addition,
the committee used standard English and American dictionaries, which
provided common uses of the four terms. Congressional and agency staff
were also consulted.
In proposing definitions, the committee wanted to make its rationale
and purposes explicit. ~ that end, it identified six desirable, although not
fully compatible, characteristics of a definition.
1. Each definition should be parsimonious; that is, it should include
the minimum necessary distinguishing characteristics of the concept in
question. It should exclude elements that are not essential to make the
definition clear and useful (for example, priorities for action, contingencies,
or desired characteristics for "good" instances of the concept).
2. Each definition should be consistent with customary social and
professional usage, insofar as reasonable given other objectives.
3. Each definition should be consisterll with legislative language, inso-
far as reasonable.
4. Each definition should be practically and symbolically acceptable
to important interests, insofar as reasonable.
5. Each definition should not be easily misunderstood or misused,
insofar as reasonable.
6. A word or phrase should not be defined in teens of itself (for
example, a practice guideline should not be defined using words such as
"guiding medical practiced; the definition should not be tautolog~cal.
With these criteria in mind, the committee reviewed definitions in
common and professional use, developed draft definitions of terms, and
then revised the definitions based on committee discussion. The following
sections of the chapter describe the results of this process for each of the
four key terms.
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The committee began by defining the term guidelines because it appears
to be the term most commonly and comprehensively used in professional
and policy discussions. It is employed in this general way in the legislation
establishing AHCPR.
The Random House Dicizonary of the English Language (1987) dates the
American origin of guideline to 177~1785, presumably in its literal usage
as a "rope or cord that serves to guide one's steps especially over rocly
terrain, through underground passages, etc." Its more metaphorical use-
"any guide or indication of a future course of action" is a recent addition.
The verb "to guide" is given several meanings including "to supply with
advice or counsel." This dictionary notes that the term "implies continuous
presence or agency in showing or indicating a course" as distinct from pilot,
steer, escort, direct, or lead.
The Compact Edmon of the Oxford English Dictionary (OEDj (1971)
does not define guideline directly but includes it in a set of examples of
attributes of technical appliances and machinery parts (e.g., guideline for
a saw). It defines the verb "to guide" in much the same way as above: lo
direct the course of (a physical action, for instance) and to lead in a course
of action or the direction of events.
American Medical Association (AMA) (J. Kelly, director of the Office
of Quality Assurance, letter dated April 26, 1990): "Guideline: Recom-
mendation for patient management which identifies a particular manage-
ment strategy or a range of management strategies. Practice parameters:
Strategies for patient management developed to assist physicians in clinical
decision-making. "
The Foam (`S. King, Forum director, personal communication, January
1990~: "Aguideline is a description of the process of care which will permit
health to improve, and which has the potential of improving the quality of
medical decision-making" (provisional definition).
U.S. General Accounting Office (G. Silberman, assistant director, Pro-
gram Evaluation and Methodology Division, letter dated October 16, 1989,
to medical specialty societies): "[G]uidance by whatever name that aids
practicing physicians and others in the medical community (and consumers,
if included) in day-to-day decisions by describing the degree of appropri-
ateness and the relative effectiveness of alternate approaches to detecting,
OCR for page 33
diagnosing, and/or managing selected health conditions" (working defini-
IOM (1990:304~: "Appropriateness guidelines describe accepted indi-
cations for using particular medical interventions and technologies, ranging
from surgical procedures to diagnostic studies."
Joint Commission on Accred~tanon of Healthcare Organizations (1989a):
A guideline gives "indications or contraindications for appropriate patient
Physician Payment Review Commission: A) "Practice guidelines are
standardized specifications for care, either for the use of a particular service
[e.g., preventive screening] or procedure or for the management of a specific
clinical problem" (1988a:134. (2) "[Practice guidelines refer to] formally
developed guidelines based on the clinical research literature and the
collective judgments of experts" (1988b:223~. (3) ". . Essentially clinical
recommendations for patient care. They provide guidance to physicians
and others who must make decisions. . .'' (1988b:223~.
U.S. Preventive Services Task Force �1989:xx~rvii): "Recommendations
appearing in this report are intended as guidelines, providing clinicians
with information on the proven effectiveness of preventive services in
published clinical research. Recommendations for or against performing
these maneuvers should not be interpreted as standards of care but rather
as statements regarding the quaky of the supporting scientific evidence."
Mark Chassin (~1988~: "They "standards of care or practice guidelines]
are statements describing specific diagnostic or therapeutic maneuvers that
should or should not be performed in certain specific clinical circum-
David Eddy (forthcoming): "Pathway guidelines (protocols and algo-
rithms) are intended to direct a practitioner along a preferred management
path. Boundary guidelines (limits or criteria) are intended to define the
limits of proper practice." In distinguishing different types of practice poli-
cies (standards, guidelines, and options), Eddy states: "A practice policy is
considered a guideline if the outcomes of the intervention are well enough
understood to permit meaningful decisions about itS proper use, and if it iS
preferred (or not preferred) by an appreciable but not unanimous majority
of people." (Note in the section below that Eddy requires more stringent
agreement for a standard.)
Lucien Leape (1990:43~: Practice guidelines are "standardized specifi-
cations for care developed by a formal process that incorporates the best
scientific evidence of effectiveness with expert opinion."
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Practice guidelines are systematically developed statements to
assist practitioner and patient decisions about appropriate health
care for specific clinical circumstances.
Practice guidelines assist patients and practitioners in malting decisions
about health care. 1b that end, they describe clearly appropriate care,
clearly inappropriate care, or care about which the scientific evidence and
consensus are equivocal. Guidelines focus on specific clinical circumstances,
which may sometimes include clinically relevant organizational factors,
community characteristics, social variables, and similar influences on health
care derive. I-hey should be developed in a formal, systematic way that
is fully documented, as discussed in Chapter 3 of this report.
As defined here, practice guidelines include such varied means of as-
sisting clinical decisionmaking as pathway guidelines or practice algorithms,
boundary guidelines or appropriateness criteria, and practice parameters.
(Appendix B contains examples of different styles of guidelines.) The
choice of approach in developing guidelines will depend on their purpose,
the intended users and sites of care, and the clarity and quality of the
scientific evidence on which they are based.
Judged in terms of the principles the committee set forth for good
definitions, this definition is reasonably succinct, generally consistent with
common, professional, and legislative usage, and not mutological. The
element of advice or counsel in the committee definition differentiates
guideline from such terms as suggestion (which is weaker than advice or
counsel), information (which is less goal oriented), and cntenon (which,
as discussed below, adds the element of evaluation). The definition goes
beyond the dictionary by adding the requirement that the advice or counsel
be "systematically developed." This element is mentioned by many health
care researchers and medical organizations either explicitly or implicitly
through such phrases as "formal development" and "well understood" and
references to the scientific literature.
Based on its discussions in meetings and in other quarters, the com-
mittee believes its definition of practice guideline is, for the most part,
practically and symbolically acceptable lo varied groups. When combined
with the other definitions offered here and the specification of desirable
attributes of guidelines, the definition should be as little subject to misuse
and misunderstanding as is possible, given the semantic diversity described
1 Clinically relevant organizational factom include the equipment, facilities, personnel, and skill
levels available within a particular health care institution or local community. Clinically relevant
social factom include the patient's home and family circumstances.
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earlier. A few areas of potential controversy can be anticipated, however,
and they are discussed below.
Guidelines and the Strength of Evidence
In and of itself, the committee's definition of practice guidelines does
not explicitly require that guidelines describe the strength of the scientific
evidence or consensus associated with a set of guidelines. Rather than
being part of the definition, the committee views this proper as an
attribute that good guidelines must have (see Chapter 3~. Every set of
guidelines developed or adopted by the Forum should be accompanied by
clear statements about their strength, and the evidence for such statements
should be cited. When the evidence is extremely strong and professional
judgment is virtually unanimous, the guideline may be treated as a standard
of practice permitting few if any exceptions. When the evidence is equivocal,
the guideline may only identify currently acceptable practice options.2
This use of the phrases standard of practice and practice option is
consistent with Eddy's usage as described earlier. However, the committee's
use of the term guideline is equivalent to Eddy's umbrella use of the phrase
practice policy. The committee's primary reason for using guideline as the
general label was that the term is used this way in the legislation establishing
AHCPR and by other sources such as the Physician Payment Review
Commission. Admittedly, the committee risks creating some confusion by
using the phrase standard of practice, given the OBRA 89 reference to
"standards of quality," but it judges that the risk is acceptable because the
term is useful and, indeed, hard to avoid.
Relation of Guidelines to Review Criteria and Other Evaluation Tools
In the committee's reading, OBRA 89 does not use the terms standards
of quaky, performance measures, and medical review criteria as synonyms for
practice guidelines. Instead, it links these three terms to evaluating practice
rather than to assisting practitioners and patients.3 Although the Forum
is required to arrange for the development of these tools, other sponsors
of guidelines may do no more than offer general observations on how the
guidelines should or should not be used in evaluating practitioner decisions
and outcomes. For various practical or technical reasons, some elements
2 Some health care organizations or health benefit plans may rule out certain of these options
given their objectives, resource limits, or other constraints (Havighurst, forthcoming). Such deci-
sions, however, are distinct from scientifically and professionally based judgments about practices
that are acceptable options for clinicians.
3 See sections 912(a)~1) and (amp) of Title IX of the Public Health Service Act as amended by
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of a set of guidelines may have no corresponding review criteria or other
practice evaluation tools at all.
For example, one guideline of the U.S. Preventive Services Task Force
(1989:108) states that "screening for congenital hypothyroidism is recom-
mended for all neonates during the first week of life." This statement
and a subsequent one defining specific tests to be used could be directly
translated into a criterion for reviewing care for a specific neonatal case
or for reviewing the pattern of neonatal care provided by a practitioner or
an institution. In contrast, the further statement by the Disk Force that `'it
may be pnu den t to perform regular physical examinations of the thyroid in
persons with a history of upper-body irradiation" (emphasis added) would
be difficult to translate into a criterion for assessing either case-by-case or
aggregate performance. Of course, even though certain statements about
neonates could be used for medical review performance, determining that
they should be so used requires a decision that the benefits of such a review
in improving health or other desired outcomes warrant the administrative
steps and costs that a review would entail.
Ib cite a different example with respect to screening for hearing loss,
the Preventive Services Disk Force (1989:198), recommends that "screening
of workers for noise-induced hearing loss should be performed in the con-
text of existing worksite programs and occupational medicine guidelines."
Such a statement may have some value for patients or clinicians without
itself generating a review criterion in the context considered in this report.
Definition of Appropriate Care
Because the concept of appropnate care or appropriateness is crucial
to the committee's definition of practice guidelines and is itself the subject
of some differences and confusion in usage, the committee considered it
necessary to explicitly define this concept. Brook and his colleagues at
the RAND Corporation define appropriate care as follows: when "the
expected health benefit [exceeds] the expected negative consequences. . .by
a sufficiently wide margin that the procedure [is] worth doing" (see, e.g.,
Park et al., 1986:6~. Conversely, care is inappropriate when the expected
harms exceed the expected health benefits.4
Care may range from clearly appropriate to clearly inappropriate. Care
that is not described by scientific evidence and expert judgment as either
clearly one or the other may be termed equivocal. A practice might be
4Health benefits include increased life expectancy, beuer functional status, and reduced mor-
bidity, pain, and anxiety. Negative health outcomes are the opposites of these qualities. Both
short-term and long-term positive and negative outcomes should be examined to determine ap-
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labeled equivocal for empirical reasons; that is, the benefits and harms are
uncertain. It might also be described as equivocal because of ambivalence,
for instance, when the benefits are known to exceed harms but to such
a trivial or small degree that raters are reluctant to call the practice
appropriate. In this latter case, value judgments may have much to do
with whether a practice is considered "worth" providing (or receiving), and
these judgments may rest on considerations of cost and other matters.
Guidelines and Costs
The committee's definition of appropriate care does not require that
guidelines be based on judgments about the cost-effectiveness of particular
clinical practices; neither does it preclude it As discussed in Chapter 3,
the committee concludes that, insofar as feasible, developers of guidelines
should consider costs and should include information with the guidelines
that allows others to make their own cost-benefit or cost-effectiveness judg-
ments. The committee's decision not to incorporate an explicit reference
to costs in the definition of practice guidelines or appropriate care reflects
a value judgment that was not shared by all committee members. The
majority, however, believed that the emphasis on clinical decisionmaking
should be paramount.
In addition, some committee members strongly disagreed with the
committee's decision not to refer explicitly to third-party payers and oth-
ers in the definition of practice guidelines. As a prachca1 matter, OBRA
89 requires that the needs of the Medicare program and peer review or-
ganizations be considered by AHCPR in selecting topics for guidelines
development, encouraging the dissemination and use of guidelines, and
evaluating their impact. In addition, the agency must arrange for the de-
velopment of medical review criteria and other practice evaluation tools.
These factors appear sufficient to ensure that the needs of payers, con-
sumer groups, and similar parties will be addressed during the guidelines
development stage.
As defined above, practice guidelines are meant to assist patients
and practitioners in making health care decisions. Medical review criteria,
standards of quality, and performance measures, which the committee
groups together as practice evaluation instruments, are designed to assist
health care organizations, payers, and others (including practitioners and
payers themselves) in evaluating those decisions and health outcomes.
Sometimes such evaluations will focus on individual instances of care (for
example, to determine whether a hysterectomy is appropriate for a patient
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CLINICAL PRACTICE GUIDEl rNES
with specific clinical characteristics); at other times they may focus on
patterns of care (for example, to compare rates of hysterectomies for
groups of patients with similar clinical characteristics).
Because the committee was not asked to provide principles for trans-
lating guidelines into evaluation instruments, it did not give in-depth con-
sideration to the issues the Forum may face in moving from a given set
of practice guidelines to the corresponding evaluation instruments. The
committee did not, for example, discuss whether different principles and
translation strategies might be needed for guidelines that focus heavily on
nursing care compared tO those that mainly emphasuze care provided by
physicians. The recent IOM report on quality assurance in the Medicare
program (1990) discusses some of the attributes that good review criteria
should have.
Given the expectations that guidelines will be used to improve the
quality and effectiveness of health care, the task of clearly translating
guidelines into evaluation tools is a critical one that needs to be considered
during the process of guidelines development rather than at its end. At
this early stage in the Forum's work, however, it may not be feasible for
each set of guidelines to be accompanied by all three types of evaluation
instruments.5 As the Forum and its expert panels tackle specific decisions
about evaluation instruments, they may well suggest some adjustments
in the definitions offered below. This seems a possibility in particular
for the definition of standards of quality and the provisional definition
of performance measures, both of which gave the committee substantial
difficulty in their formulation.
According to the Random House Diciionary, a criterion is "a standard
of judgment or criticism; a rule or principle for evaluating or testing
something." The OED offers three definitions: an organ, faculty, or
instrument of judging; a test, principle, rule, canon, or standard, by which
anything is judged or estimated; and a distinguishing mark or characteristic,
-attaching to a thing, by which it can be judged or estimated.
5 For the initial set of conditions for which guidelines are due by January 1, 1991, OBRA 89 is
somewhat inconsistent about what is required of the Forum. Section 912(d) of the law (part
of the amendments to the Public Health Service Act) calls for the development of guidelines,
standards, performance measures, and review criteria, whereas section 1142(a)~3~(A) requires
only guidelines.
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AAL4 (J. Kelly, director of the Office of Quality Assurance, letter
dated April Z6, 1990~: Review criteria are "bases for evaluating quality and
appropriateness of medical care."
IOM (1974:28~: " 'Criteria' are identifiable elements of care used to
judge the appropriateness of that care...."
Professional Standards Review Organzzanon fPSROJ Manual (cited in
Donabedian, 1981~: Medical care criteria are predetermined elements
against which aspects of the quality of medical services may be compared.
Avedis Donabedian (1981:411~: Although he apparently wishes to
avoid use of the term cntenon, Donabedian notes that it could usefully
be employed to mean "an element or attribute that is to be used in
evaluation, and that often comes accompanied by an explicit or implicit
norm. . .or, even, by a standard." Elsewhere (p. 410), he says criteria
are "discrete, clearly definable, and precisely measurable phenomena that
belong within the categories of process or of outcome, and that, in some
specifiable way, are relevant to the definition of quality."
Kathleen Lohr and Robert Brook (1981:761-762~: "Quality-of-care cri-
teria are commonly characterized in several ways. One is whether they
are explicit (i.e., stated in detail in advance) or implicit (i.e., based on
judgments of experts without direct reference to a priori standards)....
Criteria may be thought of as minimal, average, or ideal.... [M]inimal
criteria place a base under which the care-giver should not fall, lest the
individual be judged as practicing severely substandard care. Those who
fall below this level might well be classified as outliers. Average criteria
represent a community standard; they are often thought of as a range
within which care Is considered acceptable. The lower bound [of average
criteria] is likely tO be the minimal point.... The upper bound is likely
to be a fairly high, 'ideal' point toward which the profession may simply
Heather Palmer and Miriam Adams (forthcoming): Criteria are "prede-
termined elements of care against which aspects of the quality of a medical
service may be compared." Prescriptive criteria are "criteria written by
asking providers tO decide what ought to be done in a given circumstance
Physicians writing such criteria have been found sometimes to specie care
at an unrealistically high level. Also called normative critena." (emphasis
in the original)
Hannl1 Vu on (1989:156~: "Criteria of good care are structural elements
of care or procedures to be performed and information to be gathered when
treating a patient with a given problem. . .or outcomes of care." Moreover,
Vuori states that "criteria. . .identi~ the most important elements of good
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Cr. rlvIcAL PRACTICE GUIDELINES
Medical review criteria are systematically developed statements
that can be used to assess the appropriateness of specific health
care decisions, services, and outcomes.
For medical review criteria, the committee definition stresses the eval-
uanon of health care processes and outcomes rather than assistance to
practitioners and patients in making decisions. The definition offered here
is reasonably consistent with legislative language and most professional and
common usage. It is also reasonably succinct and not tautological. As
noted earlier in this chapter, the committee's definition of appropriate care
does not require that judgments be made about the cost-effeciiveness of
particular clinical practices.6 Neither does the definition preclude it.
Medical review criteria have many different uses and users. They
may be used (1) prospectively, for example, to review a proposed hospital
admission or surgical procedure; (2) concurrently, for instance, to assess the
need for continued hospitalization; or (3) retrospectively, for example, to
make decisions about insurance claims. Critena-based reviews may focus on
patterns of practice or on individual cases of care. For example, reviewers
concerned primarily with assessing the quality of care may concentrate on
retrospective analyses of patterns of care; they may also rely heavily on
case-finding screens applied retrospectively to identify individual potential
problems for further evaluation using more detailed criteria (IOM, 1990~.
Users more concerned with cost management have increasingly emphasized
review criteria that can be applied prospectively on a case-by~ase basis to
certain relatively expensive procedures (IOM, 1989~.
Traditional criteria for judging the process of care most often specify
only the things that should be done and ignore things that should not
be done. In contrast, criteria used for insurance clanns review tend to
screen for the inappropriate service rather than list everything that is
appropriate. (Claims review may also include a variety of nonclinical
matters, such as whether the general category of service, setting, aIld
provider was covered under a patient's benefit plan and whether the service
was correctly coded.)
As noted earlier, some practice guidelines may translate into or be used
as medical review criteria in a straightforward fashion just as some foreign
words and phrases for example, caveat emptor are easily used by English
speakers). For practical or technical reasons, other guidelines may be more
difficult or less suitable for use in this way. Of the initial conditions being
6A recent IOM report (1989) noted that most private payers and review organizations claim
that their retrospective reviews of care for specific patients focus on clinical factom, not costs,
and that their emphasis is on detecting clearly inappropriate care.
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considered by the Forum for guidelines development (see the list presented
in Chapter 1), the agency may find, for example, that medical review criteria
are easier to develop from the cataracts guidelines than from the guide-
lines for treatment of depression in the community setting. Similarly, the
guidelines for managing incontinence may give rise to criteria for reviewing
quality but none for making cavment decisions.
~ ~ ,
The term standards is particularly difficult to clanfy. In common
parlance it is often used synonymously with criteria; in the quality assurance
lexicon, however, it has rather different connotations. Even in everyday
use, standard has many different senses.
The Random House Dictionary offers more than 25 meanings including
the following: "1. something considered by an authority or by general
consent as a basis of comparison; an approved model. . . 3. a rule or
principle that is used as a basis for judgment. . . 4. an average or normal
requirement, quality, quantity, level, grade, etc.... 24. of recognized
excellence or established authonty; and 25. usual, common, customary."
This dictionary suggests that a standard differs from a criterion in that
the former implies a model against which the quality or excellence of
other things may be determined ("she could serge as the standard of good
breeding") whereas the latter does not ('~wealth is not a criterion of a
person's worth"~.
The OED sets forth the following different meanings and definition for
standard (some of which are centuries old): "1. the exemplar of a measure
or weight; 2. a normal uniform size or amount, a prescribed minimum
size or amount; 3. an authoritative or recognized exemplar of correctness,
perfection, or some definite degree of any quality (which can be construed
as a rule, principle, or means of judgment or estimation, or a criterion or
measure); and 4. a definite level of excellence, attainment, wealth, or the
like, or a definite degree of any quality, viewed as a prescribed object of
endeavour or as the measure of what is adequate for some purpose."
The most troublesome aspect of common usage is the use of standard
in quite different ways to describe either a minimum acceptable state or a
state of high achievement and excellence. The same difficulty also shows
up in the health services literature.
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A~4 (J. Kelly, director of the Office of Quality Assurance, letter
dated April 26, 1990~: A standard Is an "accepted principle for patient
IOM (1974:283: "A'standard' is the degree of adherence to the defined
Joint Commission on Accreditation of Healthcare Organizaiions (1989a):
"expectations or rules relating to the structures or processes necessary for
delivery of patient care."
PSRO Manual (cited in Donabedian, 1981~: "Standards are profes-
sionally developed expressions of the range of acceptable variation from a
norm or criterion."
Mark Chasszn (19~:43~39~: Chassin refers to "standards of care or
practice guidelines" and goes on to say that "whey can also define several
levels of quality of care, from the best attainable to a minimal level below
which care is unacceptably poor. They can also be applied to groups of
patients as well as to individuals."
David Eddy (forthcoming): In distinguishing standards, guidelines, and
options for "practice policies," Eddy makes the following point: "Apractice
policy is considered a standard if the health and economic consequences of
an intervention are sufficiently well known to permit meaningful decisions
and there is virtual unanimity among patients about the desirability (or
undesirability) of the intervention, and about the proper use (or nonuse)
of the intervention." (That is, a standard is the most stringent form of a
practice policy.)
Heather Palmer and Miriam Adams (forthcoming): Standards are "pro-
fessionally developed expressions of the range of acceptable variation from
norms or criteria." Pahner goes on to say "commonly, all-or-nothing stan-
dards (for example, 100 percent or 0 percent compliance required) are
preferred. This is coupled with peer review of all cases that vary from the
Virgil SZee (1974~: "The desired achievable (rather than the observed)
performance or value with regard to a given parameter." (emphasis in orig-
inal) Parameter is then defined as "an objective, definable, and measurable
characteristic of the patient himself or of the process or outcome of his
care. Each parameter has a scale of possible values...."
Hanr~u Muon (1989:156~: "A standard is the value of a criterion mat
indicates the border between acceptable and poor quality. Standards can
be normative or empirical.7 A normative standard equates the acceptable
performance with either the best imaginable performance or the best at-
tainable performance under ideal circumstances. Empirical standards are
7Connotations derived from "norm" and "normative" cause endless problems. Some experts,
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often based on experiences gained in 'typical' situations." In addition,
Vuori states that "standards. . .indicate which level [of a criterion] should
be reached...."
Standards of quality are authoritative statements of (1) minimum
levels of acceptable performance or results, (2) excellent levels of
performance or results, or (3) the range of acceptable performance
or results.
Given the contradictory uses of the term, the committee decided it was
pointless to try to overrule them. Instead, it takes the position that clarity
about the nature of a standard is the key issue: does the standard cleary
state that it sets a minimum level of performance or a level of excellence
or a range? Preferably, specific labels such as "minimal standards" or
"standards of excellence" should be employed.
Defining standards of quality will be a major enterprise. Another
IOM report, Medicare: A Strategy for Squalid Assurance (1990), provides an
extensive overview of quality assurance activities, methods, and problems
and recommends a Midyear strategy for improving the countIy's quality
assessment and assurance efforts and results. In that report, quality of
care is defined as "the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge" (p. 4~. One point made
about this definition is that it "encompasses a wide range of elements of
care." This suggests that standards of quality should be viewed primarily
as mea rats for assessing patterns of care, including patterns that may extend
across a range of clinical conditions, settings, and practitioners.
Advice about whether the Forum should emphasize minimum stan-
dards or standards of excellence or ranges is beyond the scope of this
report. Among other things, such advice would entail an analysis of al-
ternative views about how to assure quality of care. For example, the
concept of minimum standards seems more consistent with the structure-
processmutcome model of quality assurance than the continuous qualipr
improvement model. The 1990 IOM report cited above discusses these
models at some length, but that discussion provides no simple path for
this committee to follow in specifically advising the Forum. Such advice
including Vuori and Palmer, see norms as ideal or preferred states. Others treat norm and "av-
erage" as essentially equivalent, and they equate the normative and the empirical because em-
pirical data are needed to determine "not As." A 1974 TOM report, for instance, defined "norm"
as `'merely a statistical average" (p. 28~.
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might also be premature, given that the Department of Health and Human
Services and Congress are considering a varied of policy and strategy issues
related to broad questions of quality assurance and assessment. Decisions
on these issues presumably should influence the Forum's wore
This concept is the most unfamiliar of the four terms in OBRA 89. It
is seldom used in the professional literature and has a variety of dictionary
Random House offers for performance "the manner in which or the
efficiency with which something reacts or fulfills its intended purpose." The
TED provides two relevant definitions for performance: "1. the carrying
out of a demand, duty, purpose, promise, etc.; 2. the accomplishment,
execution, . . .of anything ordered or undertaken."
The OLD gives many different definitions for measure. As a verb,
these include "1. to form an estimate of (now especially to weigh or gauge
the character or ability of something [e.g., a person]), with a view to what to
expect [from that person]; 2. to ascertain or determine the spatial magnitude
or quantity of "something] by application or comparison to some known or
fixed unit; 3. to estimate the amount, duration, value, etc., of an immaterial
thing [perhaps, performance] by comparison with some standard; 4. to
judge or estimate the greatness or value of (a person, a qualify by a
certain standard or rule; and to appraise by comparison with something
else." As a noun, the definitions of measure include "1. an instrument
for measuring [e.g., a vessel, graduated rod, line, tape, etc....~; and 2.
a method of measuring, especially a system of standard denomination of
units of length [etc.~."
The term performance measure has been used by the Joint Commission
on Accreditation of Healthcare Organizations, but the commission intends,
in the future, to substitute the term indicator (OR. Marder, project manager,
Indicator Development, personal communication, April 24, 1990~. Com-
mittee staff found virtually no discussion of performance measures in the
literature they reviewed.
Joint Commzssion (1989b:~5~: "Performance measures provide data
and information that serge as the basis for determining whether expectations
are met." A clinical indicator is a "generic term. .intended to emphasize
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the primary importance of (outcome) measures as monitors of performance.
iThey] describe relatively precise measures of important aspects of care.
. [They] are not clinical standards or practice guidelines."
David Eddy (forthcoming): In discussing the distinction between prac-
tice policies (see the earlier section) and performance policies, he notes
that performance policies address the issue of ensuring that "whatever in-
terventions are used, are used correctly.... They are intended to guide or
review the performance of interventions, without concern for whether the
interventions should have been performed in the first place"
Performance measures are methods or instruments to estimate
or monitor the extent to which the actions of a health care
practitioner or prouder conform to practice guidelines, medical
review criteria, or standards of quality.
Given the multiple common meanings of the terns and the paucity
of professional and technical usage, the committee decided to oDer only
a provisional definition of performance measures. As practice guidelines
and related evaluation instruments are more widely developed and used, a
different or more specific meaning for this term may emerge.
The committee could have considered performance measures to be
a combination of standards and criteria-measures of whether a given
"performance" as judged by some set of criteria meets (or exceeds or falls
short of) a standard. Considered in this way, the term verges on being
synonymous with the other terms defined in this chapter. Therefore, the
committee chose provisionally to view performance measures as instruments
(for example, questionnaires, abstracting forms, measurement scales, or
computer programs) for recording or measuring data on performance. In
this sense, a distinction is made between measuring and judging. Thus, a
performance measure is more like a bathroom scale than it iS Me a table
of recommended weights by gender and body build.
In sum, it is probably valuable to maintain a distinction between the
instrument or means of measuring something and the judging of the results.
Furthermore, performance measures should be sensitive to what is not done
as well as what is done.
In this chapter, the committee has proposed definitions of the four
key terms used in the legislation establishing the Office of the Forum
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for Quality and Effectiveness in Health Care. The committee sought
definitions that were, insofar as possible, parsimonious, consistent with
common and professional usage, practically and symbolically acceptable to
important interests, not easily misused, and not tautological. The list below
recapitulates the committee's definitions of practice guidelines, medical
review critena, standards of quality, and performance measures.
PRACTICE GUIDELINES are systematically developed statements
to assist practitioner and patient decisions about appropriate health care
for specific clinical circumstances.
MEDICAL REVIEW CRITERIA are systematically developed state-
ments that can be used to assess the appropriateness of specific health care
decisions, services, and outcomes.
STANDARDS OF QUALITY are authoritative statements of (1)
minimum levels of acceptable performance or results, (2) excellent levels
of performance or results, or (3) the range of acceptable performance or
� PERFORMANCE MEASURES (provisional) are methods or in-
struments to estimate or monitor the extent to which the actions of a
health care practitioner or provider conform lo practice guidelines, medical
review cntena, or standards of quality.
For other organizations and other purposes, different terms and defi-
nitions may serve better as long as they are clearly stated. This committee
neither expects nor unlashes to dictate terminology Its objective is modest:
to provide clear definitions of key terms that the Forum can use in carrying
out its legal responsibilities with a minimum of confusion or provocation.
Definitions, however, are only the starting point. The Forum also
needs to distinguish good guidelines from bad and to communicate its
expectations to contractors, expert panels, and others. The next chapter is
a first step in that process.
Chassin, M.R Standards of Care in Medicine. Inquay 25(Wlnter):437050, 1988.
Compact Edition of the Oxford English Dictiorwy. Oxford, England: Oxford University
Press, 1971.
Donabedian, A. Criteria, Noes and Standards of Quality: What Do They Mean? American
Journal of Public Health 71:40g 412, 1981.
Eddy, D. A Manual 1~ Assessing Health Practices and Designmg P~racizce Policies (draft dated
May 31, 1989~. American College of Physicians, forthcoming. See also the articles
cited in Chapter 1 of this report.
Havighurst, C. Practice Guidelines for Medical Cam: The Policy Rationale. St Louis
University kzw lownal, forthcoming.
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Academy Press, 1974.
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Institute of Medicine. Controlling Costs anti Changing Panent Care? The Role of Utilization
Management, B. Gray and M. Field, eds. Washington, D.C.: National Academy Press,
Institute of Medicine. Medicare: A Strategy for (dually Assurance, vole. 1 and 2, K Lohr,
ea., Washington, D.C.: National Academy Press, 1990.
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Forum on Clinical Indicator Development, Chicago, March 1989a.
Joint Commission on Accreditation of Healthcare Organizations. Statement before the
House Subcommittee on Health, Committee on Ways and Means, concerning the
Medical Care Quality Research Act of 1989. Washington, D.C., May 24, 1989b.
Leape, L Practice Guidelines and Standards: An Overview. Malay Review Bullean
Lohr, K.N., and Brook, R.H. Quality Assurance and Clinical Phalmapy: Lessons from
Medicine. Drug.Intellit~nce and Clinical Pharmacy 15:75~765, 1981.
Meyer, H. Medicine Debates Parameters (Or Are They Guidelines?) American Medical
News, December 15, 1989, p. 36.
Palmer, R.H., and Adams, M. Considerations in Defining Quality of Health Care. In
Perspectn~es on (duality Assurance. Ann Arbor, Mich.: Health Administration Press,
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Medical and Surgical Procedures. R-3280-CWF/HF/PMT/RWJ. Santa Monica, Calif.:
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Confess. Washington, D. C, 1988b.
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Vuori, H. Research Needs in Quality Assurance. Malay Assurance in Health Care 1:147-159,

subset: commoncrawl


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The Bride with White Hair (Bai fa mo nu zhuan) (1993)
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Kee-To Lam (as Kei To Lam)Yusheng Liang novel Bai mao nuLists33 votes
All the Cult Flicks and Trash Pics
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The sensitive swordsman Cho Yi-Hang is tired of his life. He is the unwilling successor to the Wu-Tang clan throne and the unsure commander of the clan's forces in a war against foreign tribes and an evil cult. One day, he meets the beautiful Lien, a killer for the evil cult who is equally unsatisfied with her situation, but their lov
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Release date: 25 September 1993
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THIS RESTAURANT IS CLOSED Mario's Ristorante Italiano
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Dinner Tues.-Sun. Closed June-Aug.Features
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THIS RESTAURANT IS CLOSED Mario's Ristorante Italiano Restaurant Review: An aria with your pasta? The staff sing everything from opera to foot-tapping show tunes while you dine on Northern Italian specialties. Mario and Edalyn Lalli moved their restaurant here from its original site in La Quinta. The food and entertaining service continue to be crowd pleasers. |
Check out the 2014 edition of GAYOT's Annual Restaurant Issue, which features the Top 40 Restaurants in the U.S., Rising Chefs and more.


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Due to the current winter storm Thor in the United States, we are experiencing high volumes of site closures. We are working diligently to contact all affected candidates by email and phone. If you have any questions, please contact Customer Service.
ABA Certification Testing
The American Board of Anesthesiology (ABA) is offering the Primary Certification Part 1 Examination, Maintenance of Certification Examination (MOCA), Pain Medicine Initial Certification Examination, Pain Medicine Recertification Examination, Critical Care Medicine Initial Certification Examination, Critical Care Medicine Recertification Examination, and Pediatric Anesthesiology Certification Examination through Pearson VUE. The ABA is solely responsible for exam development, scoring, and reporting of results.
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Oct 31, 2006, 02:39 AM | |
Airdrie, AB Canada
Joined Sep 2004
1,049 Posts
Don't think you'll find many that have done this. On 4s you need a VERY small prop to be anywhere near spec.
Same prop. 4.75x4.75 you are going to jump to over 45A assuming your batts can maintain somewhere around 13V. That's a whopping 585watts. You'll fry it VERY fast. Even a 4" prop is gonna be over 40A. You'll need some serious throttle control assuming your other components can handle it. I'd be extremely careful definately run it on a wattmeter to start with. Lots would say you're over the edge. There are better calcs out there, but this will show you the basics. http://brantuas.com/ezcalc/dma1.asp On 3s you are pretty close to the limit for this motor. You can get more speed by cutting down a 5x5 to something like 4x5 or a 4x5.5 so you're pitch speed goes up. Depending on airframe you may or may not have excess thrust with the slightly oversquare prop. Good Luck, Mike |
Oct 31, 2006, 07:42 AM | |
As the model was not mentioned in the first post it is speculation but if it is a Speed 400 Racer they are about 700mm and already running over 20oz wing loading stall speeds are a lot higher I am a big fan of getting your speed by pitch on larger props not by more revs on smaller props. None of the current high end pylon planes have seen run 1:1 thrust.
Tim |
Nov 01, 2006, 10:13 AM | |
Ok guys. Thanks for the comments. I'll stay 3s until I have to get a new motor. I'm running it on a Speedwing 400 (coming today!) so It should have pleennnntyy of power.
Even though I'm only runing a 4.75x4.75. I wanted a 5 incher, but it was drawing wayyyy to much current. Maybe I'll just go with a sweet 2000mah 20C 3s pack...that would fit the bill fflyer |
Nov 01, 2006, 04:43 PM | |
Airdrie, AB Canada
Joined Sep 2004
1,049 Posts
Even though it will be out of spec. You probably won't find the motor to be unhappy on the 5x5. I run mine there all the time with fair cooling in a pylon racer. Pushed harder if it's in the wind. Controller and batts will have to be up to it. Races are under 2 minutes WOT. General flying is a non issue.
My airframe was slick enough to get away with cutting down the 5x5.5 and picking up the extra speed. Trimming down a 6x4 or the 5.5x4.5 will get you the thrust you're after. Unfortunately there's no free lunch without more watts so you have to trade thrust for speed or vice versa. Haven't done the 4.1x4.1 on 4s. But doesn't suprise me to hear it's been tried in something like a sunracer. Your wing would probably benefit by a slightly larger prop as they are no where near as slick as a mouldie. Sounds like you're right at the limits of both motor and batt... so without swapping components you pretty much have to pick thrust or speed and custom fit props till you get what you want. Then chuck it all and slam in better batts and motor Mike |
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The Texican Rangers is the oldest Cowboy Action Shooting Club™ in the Texas Hill Country and the second oldest club in Texas.
The Texican Rangers is part of a larger international organization, SASS-Single Action Shooting Society, created to preserve and promote the sport of Cowboy Action Shooting™. It is wearing tall high heeled boots with spurs and jingle bobs, leather chaps, a big sombrero, a belt of shiny cartridges and holding a pair of well oiled single action revolvers. You can walk down the streets of Tombstone with the Earps and Doc Holliday or stop a stampede or maybe a bank robbery. You can be a marshal, an army scout or a cavalry officer. Cowgirls can dress like Scarlet O'Hara in a flowing gown or wear a pair of leather britches like Raquel Welch in Hannie Caulder….you can be Calamity Jane or Poker Alice. Cowboy Action Shooting™ is the fastest growing shooting sport in the world. SASS is for the whole family, it can be an afternoon or a weekend with the finest, most polite and most safety conscious folks you'll ever meet.
Nestled in the beautiful Texas Hill Country just 8 miles north of Comfort is the Stieler Ranch, home to the Texican Rangers. We have fourteen shooting stages, a Long Range stage, Blazing Saddles and a Man-on-Man stage. Check our Calendar page and plan on coming out to one of our shoots and join us in the fun that is Cowboy Action Shooting™.
Remember you can always get back to the Home page by clicking on the Ranger badge in the top header.
WHAT'S NEW Rules for the 1911 Modern and Traditional, Bolt Action Military and Cody Dixon categories available at Texican Rangers' matches can be found under the Our Story link and then the Shooting Category link. Our next match will be on March 14th and 15th. If you are able to come out and help, we have workdays scheduled for every Tuesday in March to get the range ready for Comancheria Days, we start around 9:00, break for lunch and continue working until around 4. Hope to see you there. Congratulations to our Top Five shooters in February: Saturday Sunday CD2015 Looking for the Registration Form and Schedule of Events for CD 2015 , just click the links below or go to Comancheria Days under the EVENTS tab for all things related to CD2015.
(March 3rd, 10th, 17th, 24th and 31st)
Texas Slim
Hopalong Herbert
Skyhawk Hans
Dutch Van Horn
Calvin N. Hobbes
Whiskey Kid
Prairie Dog
Barbary Coast
Comancheria Days Registration Form
Schedule of Events


text:
Apartment with garden near the beach of Cagliari
From $56 / night
Hide Property Details
- 2 bedrooms
- 2 bathrooms
- Sleeps 4
- House
Description from the owner
The apartment GOLFO DEGLI ANGELI is a new structure located 900 mt. away the beach of Cagliari, in a semi-detached house with garden.
You can easily reach Cagliari city centre in 15 min. by car or 25 min. by bus.
The bus stop to Cagliari city centre is 100 mt away the house and the wonderful Poetto sandy beach, the most beautiful beach near the city of Cagliari, is only 900 mt. from the B&B (15 min. walking distance or 1 bus stop).
The APARTMENT, on the ground floor of the house, has 2 bedrooms, 2 bathrooms and 1 kitchen.
It is provided of towels, linen, TV, wasching machine.
THE APARTMENT IS FOR 4 PEOPLE BUT IT IS ALSO POSSIBLE A 2 PEOPLE ...Read more
Apartment with garden near the beach of Cagliari
Cagliari, Sardinia, Italy
What's Nearby:
Additional Location Information
The apartment is in is located in Via Feronia n. 5 - Quartu Sant'Elena (CA), 900 mt. away POETTO SANDY BEACH;
ARST buses from the airport to the city centre (Train Station) leave every 15 minutes from 8.45 am to 22.45 pm (tickets: € 2);
From the city centre (Train Station) to B&B;: take PQ bus line (NOT PF...) and get off the bus after 25 minutes at the bus stop 'SS 554' (at the end of the Poetto beach after the second IP gasoline).
When you get off the bus the B&B; is in the second street on the right (via Feronia n.5), 100 mt. from the bus stop.
direction QUARTU SANT'ELENA; when you arrive at the roundabout at the end of the street 554 (on the right there is an IP Gasoline) take the same street (SS 554) in the opposite direction and after 700 mt. turn right (via Biora) and then the second street on the right is via Feronia (the house is at number 5).
More About This Location
Beach or lakeside relaxation, City vacations
- Stove or Oven
- Refrigerator
- Microwave
- Toaster
- Satellite or cable TV
- Garden
- Pet friendly - ask
- Smoking allowed - ask
- Suitable for children - yes
- Suitable for the elderly - yes
- Wheelchair accessible - no
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Escapee Alastair Cross, who finished his VFX Production studies in 2010, went on to become a Studio Assistant here, but the time has come to move on, and he now faces the choice of his next role.
Maya Core Calendar Begins 30th Jan 2012
If you share my fascination with 3D and have always wanted to learn how to do it yourself, make 2012 the year your Maya calendar begins.
Learning to Master Houdini with Escape
I promised to keep you posted on how we're changing our curriculum to include Houdini in some of our courses, and that's the subject of this post.
iNuked - Part Deux (Read & Write Nodes)
After an incredibly busy couple of months dealing with students' end of courses projects, as well as completing the first shot for my own showreel, I've found the time to work on the next episode of iNuked: my personal project to explore the possibilities of using The Foundry's professional compositing software NUKE, on my MacBook Air.
Resonance Screening a Resounding Success
Last week we welcomed Simon Jones from SR Partners to Escape Studios London HQ to show our students his recent collaborative work entitled - Resonance.
Is it really Movember again?
Yes, it is. That time of year when many of us give up our face real-estate to grow some facial hair in the name of prostate cancer. This year is no exception and team "There's Mo Escape" and its 16 members of varying facial hair success, are just 10 days in...
For some of us it's hard to see we are actually partaking in the fund-raising event. But hey, we are having fun trying... If you have a spare 50p and want to see how stupid we all look as we'll post some pics then please feel free to donate!
Last Chance to Grab Your Early-Bird Discount!
Everyone likes to make a saving where they can, that's why we offer all students paying their full course fee's three months in advance, an early-bird discount of £500.
Hayes Davidson Put Our V-Ray for Max Course to The Test
Matt Clinch is an Associate Partner at world renowned architectural visualisation practise Hayes Davidson; we asked Matt to give us some feedback on one of our recent online courses, V-Ray for Max, and here is what he had to say.
Annecy Animation Film Festival
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Escapee Showcase: Roger Serrabassa Vilar
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Why Are Young People Made to Choose Between Math Or Art?
When I was picking my GCSE's and A levels I had to pick between two routes, Maths or Art. This I believe, is still the case, but I'd like to ask why?!
Do Universities Need To Teach Basic Job Skills?
An announcement by Edge, the education charity, caught my eye this week. It said that universities should now be required to teach employment skills as part of degree courses. According to its latest study, employers now believe too many graduates are unfit for the workplace.
Looking for a Summer Internship?
Are you looking for something to do this summer? Ever heard of StudioAKA? They are a London based multi-BAFTA winning animation production company, known world-wide for their amazing innovative work. And they may want you for the Summer!
They are looking for a bright spark to work in the field of DB & pipeline development (within June to August).
Escape Studios on Tour!
Escape Studios is hitting the road this year undertaking a program of talks, presentations and master classes throughout the UK universities and colleges.
Games Art Production Students Show off their Work
Here's the first look at some of the work from the Game Art Production course which finished in December.
Escapees to work on Halo Fan Film
Escape Studios has been approached to help with some of the CG and VFX work on an exciting new, non-profit project called Operation Chastity.
Kettling, the new video game...
Sometime, I just come across stories that make me laugh out loud. This one is just one of them.
Students Protest Violently Over Tuition Fees
Few of you will have missed this morning's headlines about yesterday's violent student protests in London. Taking to the streets is not something that comes naturally to British people – unlike the French, who view student protests almost as a right of passage. So, having 50,000 of them marching in London shows the level of discontent over the government's recent decision to increase tuition fees.
Escapee Jacob Flint Lands First VFX Job at The Mill
VFX escapee, Jacob Flint has just bagged a job at The Mill which as you can imagine he's pretty pleased about. The truth is, we are too. Having studied with us for 12 weeks on our VFX Production course, Jacob learned all of the vital skills that he needed to get started in the industry right away. He was pretty nervous during his interview but ultimately his skills shone through.


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Note that the Gallup survey was conducted Jan. 7-10, a few days after the White House and Congress reached a deal that averted steep tax hikes this year, but that failed to set a longer-term course toward stabilizing the national debt. The fiscal negotiations may have affected the Gallup results by underscoring a range of simmering worries in public thought, including disatisfaction with Congress, the prospect that rising debt will restrict the nation's future prosperity or force cuts in popular programs like Medicare, or concern about future stalemates in Washington over important fiscal matters.
A Pew Research Center poll in December found, for example, that 74 percent of Americans say a combination of tax increases and spending cuts in "major programs" would be the best way to reduce federal deficits. OK, public opinion polls don't reveal any groundswell for entitlement cuts or middle-class tax hikes. But this middle-ground view stands in contrast to the prevalent sound bites emanating from Washington, where Republicans lean heavily against tax hikes while many Democrats resist entitlement restructuring (though President Obama himself has left that door ajar).
Separately, some polls show rising worry among Americans about living standards in the future. A USA Today/Gallup survey asked how likely it is that today's young people will have a better living standard than their parents. In both December and in back in 2011, a slim majority said "unlikely." By contrast, the mood had been much more optimistic, even in the recession's immediate aftermath, in January 2010.


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LEGO Batman 2: DC Super Heroes Screenshots for PS3
On: PS3, Xbox 360, PC, Wii U, 3DS, PS Vita, Wii, DSBatman and Robin join other famous super heroes from the DC Universe including Superman, Wonder Woman and Green Lantern to save Gotham City from destruction at the hands of villains Lex Luthor and the Joker.
Review Verdict Read Review
8Out of 10
Back to game infoLatest Articles for LEGO Batman 2: DC Super Heroes
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It's not just the Dark Knight who could save something today.
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Batman returns, this time for Nintendo's newest console.
UK Video Game Chart: Sleeping Dogs fends off Tekken Tag Tournament 2
Square Enix's Sleeping Dogs saw an eight per cent increase in sales to earn another week at No.1 and prevent Namco Bandai's Tekken Tag Tournament 2 from claiming the top spot.
UK Video Game Chart: Sleeping Dogs back at No.1 as Guild Wars 2 falls to No.6
A third week at No.1 for Square Enix's open-world action title.