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(SENATE-Thursday, 23 March 2000)
- Committee front matter
- Committee witnesses
Senator KNOWLES
Prof. Phelan
Senator LEES
Senator CHRIS EVANS
Senator TCHEN
- Committee witnesses
Senator KNOWLES
Senator LEES
Dr Brook
Senator CHRIS EVANS
Senator TCHEN
Mr Thwaites
- Committee witnesses
Senator KNOWLES
Senator LEES
Senator TCHEN
Senator CHRIS EVANS
Ms Morieson
Ms Iliffe
Ms Gilmore
- Committee witnesses
Senator KNOWLES
Senator LEES
Senator CHRIS EVANS
Senator TCHEN
Mrs Smith
Mr Swinden
- Committee witnesses
Dr Gallichio
Senator LEES
Senator CHRIS EVANS
Mr Linke
Senator TCHEN
Ms Linklater
Mr Capp
- Committee witnesses
Senator LEES
Mr Woodruff
Senator CHRIS EVANS
Mr Rhodes
Mr Stokes
- Committee witnesses
Senator LEES
Ms Segal
Senator CHRIS EVANS
Senator TCHEN
Prof. Richardson
Ms Watts
Content WindowCOMMUNITY AFFAIRS REFERENCES COMMITTEE - 23/03/2000 - Public hospital funding
CHAIR —Welcome. The committee prefers all evidence to be given in public, but should you wish to give any of your evidence in camera you may ask to do so and the committee will give consideration to your request. The committee has before it your submission, No. 62. Do you wish to make any alterations to that submission?
Mrs Smith —No, we do not.
CHAIR —I invite you to make a brief opening statement and then field questions. I also place on record our appreciation for your adjusting to our time needs. Thank you.
Mrs Smith —Thank you for the opportunity to make this submission to the inquiry and to give evidence today. I would like to give a bit of background on the college and then give an overview of our submission. The college was established in 1945 and aims to develop and foster excellence in health service management through education and ongoing professional development. We are a national body and we have about 3,000 members. We provide a network for all health service managers from the various professions, so we represent general managers, doctors, nurses, allied health professionals et cetera. The college also has strong links with academic institutions and we have a major role in accrediting health service management courses. We also have well-established international links.
The key purpose of the college is to be the professional membership body for all health professionals involved in management. We strongly believe that well-skilled and professional health service managers are vital to the ongoing success of the Australian health care system. You will note that the college submission is also supported from submissions from the Queensland and New South Wales branches. We think these two submissions generally support the key issues that we have raised in our major submission.
As members of this inquiry well know, there are growing pressures in our health care system. There is a great deal of debate about how we can develop a more effective system in the context of growing demand and constrained resources. We are all aware that these are global issues. We are all desperately trying to control health expenditure as a percentage of GDP. We are dealing with issues of increased technology, increasing demand and increasing consumer expectations and we are also trying to `up-end the pyramid' so that we are focusing more on health promotion and prevention rather than just cure.
Our current planning, policy, funding and service systems need to be reformed to develop pathways for a different approach to the provision of health services in Australia. In particular, we believe that communities and key stakeholders need to have some discussion and debate about the resources that are available and what our expectations, needs and key priorities should be. I am aware that a lot of other people have said that, and we understand that it is a very difficult process, but we do believe that it is an important pathway to pursue. We also believe that there is a need to provide education to communities and consumers about health care and, in particular, about health choices and health outcomes and to facilitate the understanding of what opportunities they have in terms of their own health care. We noted recently that the New South Wales Health Council has put out a major report. I want to highlight the following statement in the report:
We highlighted honesty as an important value and principle, particularly about the resources available and what is reasonable to expect from the highly professional staff within the system. We need to be open and honest with each other about what we are prepared to pay for our health services and how we want the money to be spent: on community and preventive care or acute care in hospitals.
We strongly believe that we need to move to this sort of honesty level so that we can reduce blame shifting and help to address the real issues and resolve some of the critical problems we have, such as the work force issues that we are currently trying to deal with. The college supports the principles of Medicare but would argue that Medicare, in its current form, is not sustainable.
With respect to the key points in our submission, there is a need to: address the split responsibilities for health between the Commonwealth, states and territories; have one funding source to achieve risk sharing across providers for episodes of care; in this regard, collocation of health service providers may well be a useful initiative; focus on health services, not just on hospitals; and pursue the change in emphasis to prevention and health promotion. A very important pressure on us is to increase investment in information technology development, particularly unique patient identifiers, sharing of information, providing better information and choices for consumers, the development of clinical pathways, care plans and evidence based clinical support systems. There is a need to develop a national health planning and health policy framework; to set national health priorities and outcomes and develop consistent national standards for measuring outputs and outcomes; and to recognise that the increase in private health insurance levels does not necessarily reduce the demand pressures on the public hospital system.
We have also emphasised in our submission that the role of public hospitals is unique in terms of teaching, research and complex care and that private hospitals do not generally pursue these roles to the same extent, or in that package of services, and they also must provide returns to their shareholders. We do support the need for a greater emphasis on the development of quality systems and we support the development of national accreditation standards and more flexible, less costly arrangements for achieving accreditation status. Jim Swinden is going to make a brief opening statement.
Mr Swinden
—As Mavis said, our fundamental interest is in ensuring that there are competent and skilled managers in the system. This is a voluntary association with a couple of employees at our national office. As a person who has been in the industry for 20 years and who has been actively involved in the college, I feel that there has been a significant amount of change over that time. Managers in many respects now feel, to an extent, that they are players in a meat in the sandwich situation. They are really the brokers between the clinicians and the health department. There are funding pressures from the health departments and there are pressures from clinicians in terms of advocating for their patients. Equally, the department is there between the federal and state governments. There are a whole lot of pressures in the system that our members feel, and a lot of those do relate to funding.
As an association, we found it more difficult in recent years to provide continuing education, particularly because our members are generally under a greater pressure than they have been in the past. So we have had to change the way we deliver continuing education using videoconferencing, shorter, sharper education sessions and so on. I think they are just indicators of the pressures that are in the system.
Our belief is that health services management requires particular skills. It is not about business management. It is about business management in part, but it is also about dealing with the human aspects. It is unique from the point of view that we are dealing with health professionals who are highly intelligent, highly skilled people, and that requires managers with a great deal of skill in dealing in a very complex system. That is our introduction.
CHAIR —Thank you very much.
Senator KNOWLES —Mrs Smith, I noticed you said that a major part of the responsibility was developing a quality assessment system. What has been done by your managers in terms of setting standards to get qualitative and quantitative measurements for value for money?
Mrs Smith —Most of the managers involved in the various health agencies would be looking at their own business practices, looking at standards that are available through the various accreditation processes, responding to those, assessing what is required where the gaps are, and feeding back through various mechanisms to agencies like the Australian Council on Health Care Standards.
Senator KNOWLES —Is there a standard computer program or whatever that every manager in the health system is now using to be able to put a qualitative and quantitative outcome measurement by which—
Mrs Smith —No.
Senator KNOWLES —What has your organisation done to try and achieve such an outcome?
Mrs Smith —The Australian College of Health Service Executives is largely involved in education and professional development. We do have a formal input to the Australian Council on Health Care Standards. We are certainly talking to them about what we perceive as shortfalls in the system, for example, the need to develop standards and approaches that actually facilitate internal development and responses to accreditation standards.
Senator KNOWLES —How would you do that?
Mrs Smith
—There has to be a better engagement of the industry in changing practices and looking at health outcomes. There needs to be, from a government perspective, a framework and again a broader engagement and probably some investment. We have moved from a system of funding inputs to funding outputs, and I think we have all supported that. We are now talking about achieving better health outcomes, and there is a lot of work to be done there. There has not been a lot of work in that regard. The fairly low investment in information technology makes the process even more difficult. So we need a vision and a plan about how we are going to develop this.
Senator KNOWLES —Concerning the recommendation you are saying you put to government, have you got that so that you could provide it to the committee?
Mrs Smith —We have certainly through other mechanisms put forward the concept of developing national standards. The college, apart from its role with the Australian Council on Health Care Standards, has not formally, apart from what we have said here, put forward a proposal. But we would be happy to do so.
Senator KNOWLES —I just want to come to page 3 of your submission in terms of cost shifting. Forgive me for saying it, but I do not understand a syllable of what is in that paragraph. You say:
Cost shifting is unproductive in terms of administrative and consumer effort. It reflects the imperfect but apparently intractable structure of joint Federal/State funding responsibilities. Private/Public sector cost shifting is also a dynamic. Where consumers' welfare is at risk governments must act to minimise such a potential.
I do not understand any of that. I am just at a loss to know what you are really meaning.
Mr Swinden —Cost shifting has occurred, I think, from the managers' point of view because they are under financial pressure to run their hospitals. I do not think they are interested in shifting costs. They are interested in maximising the revenue that they get to their hospital to provide the most care and maximise the services they can. What we are saying is that shifting between public and private sector costs is a dynamic thing. It is happening all the time. Every time there is a change in one set of rules, people will change practice to get the best benefit out of that and, as a manager, I have changed the way that we have operated the hospital to ensure that we get the maximum revenue. I do not think the hospitals themselves are concerned about whether the money comes from state or federal government.
Senator KNOWLES —As a manager, what sorts of instructions have you issued along those lines?
Mr Swinden —In relation to what changes have been made, do you mean, or to not shift costs?
Senator KNOWLES —To not shift costs or, in fact, to shift costs.
Mr Swinden —I can say that, as a manager in the past when casemix funding was introduced in Victoria, we changed the way we admitted patients to make sure that we got the maximum revenue that we could get.
Senator KNOWLES —I understand that, but that means what?
Mr Swinden
—In terms of what we did? Patients that were previously not admitted as outpatients were admitted to the hospital to attract casemix funding. So that shifted costs, effectively, from the Commonwealth to the state.
Senator KNOWLES —Have you any other examples?
Mr Swinden —I suppose I have more recently been involved in looking at emergency services in New South Wales and certainly there are issues there to do with the provision of GP services relative to emergency departments. There are certainly issues about the cross-over and the overlap in roles between emergency departments and the provision of services by GPs. It is certainly a grey area and one which causes dilemmas in terms of the extent to which you expand or contract emergency department services and the extent to which that impacts on provision of services by GPs.
Senator CHRIS EVANS —Thank you. I appreciate the submission because it has picked up a lot of points that have actually been raised with us during the inquiry on which we had not read a lot of submissions. One of the key ones is this question of capturing data in hospitals and the failure, it seems, to be able to capture data that tells us anything about outputs, about which hospitals do things well and which do not and whether we are getting value for money in the health system. You seem to recognise that and talk about what data hospitals are good at collecting. Why is it that we are not good at collecting the data that is so useful for governments in terms of determining priorities and where to put the health dollar? Are those structural barriers and how do we overcome them?
Mrs Smith —I think there are a couple of issues. I think that there have been quite piecemeal approaches to developing information systems. There is definitely a lack of money to develop what is required. There is the issue of trying to invest in systems that meet everybody's needs, so there is a question of specification, getting the players to talk together and having some vision about what it is we want as a system. So that is one part. I think the other part starts at the other end. We mention in our submission that we strongly believe that there is a need for a national health plan—a national health policy framework—so that if you cascade that down the states have a framework in which they are working and the health care providers also have a local and a broader framework within which they are working. If we had that framework and we had the sorts of outcomes we want clearly identified, then I think we could start designing our systems and data collection to focus on where we are trying to get to.
I think that at the moment there is a lack of direction about exactly what the priorities are and what we want out of information systems. Quite legitimately there are different focuses. The clinicians would say, certainly in Victoria, that there has not been a lot of development. We are really pleased we have an IT strategy but it has all been about business systems. Unfortunately that end of the game is driven by what needs to be reported for funding for those sorts of issues. If we had a plan about where we were going I think some of those matters would fall into place and there would also be an opportunity for far more strategic investment rather than sometimes, as we see at the moment, little buckets of money for all sorts of little projects. That is really not benefiting the system as a whole.
Mr Swinden
—Certainly the information varies depending on the sort of information you are talking about. For example, inpatient information is, I think, quite good generally, however information on outpatients is just hopeless, to be honest. It is pathetic because it is so difficult to define episodes and there has not been a lot of effort put into it because it is not a major component of the system. The other thing is that timeliness of information is critically important. There is not much point in collecting information if it is not timely. From my perspective, having worked in both public and private sectors, I find that private sector organisations collect information that is far less sophisticated but far more timely, so there is a difference in the quality of the information—
Senator CHRIS EVANS —You are not going to say you have a lot of information on dead patients, are you?
Mr Swinden —No. What I am saying is that, for example, private hospitals look at bed days and staff ratios per bed day and things like that, whereas the public hospitals legitimately say a bed day is not a bed day. It is a complex issue and therefore we look at DRGs, but by the time you get DRG information it is a month or two after the event. The private hospitals, I suppose, are focused on the efficiency side of it and the ratio of costs to revenues.
Senator CHRIS EVANS —From our point of view we are interested in knowing whether or not St Vincents does hips well compared with somebody else and whether we ought to be funding them to do hips, or whether we ought to say that St Vinnies does not do hips anymore because they cost twice as much. It seems we do not have any chance of getting that sort of information at all. Those sorts of decisions are not made in the system at all. We just have an argument whether we add five or 10 per cent to the budget and hope that somehow it helps. Is that fair or is that not fair?
Mr Swinden —I think there is more than an element of truth to that. One of the issues comes down to the development, I suppose, of evidence based medicine and the extent to which we do have the evidence, collect the evidence, and actually use it on what is clinically effective and what is cost effective. Certainly, there is not a lot of information in the system there at the moment.
Senator CHRIS EVANS —You picked up this point earlier, Mrs Smith, when you talked about bringing all the players together. The clinicians who have appeared before the committee have tended to the view that they do not have enough ownership about a range of these systems and it is too management driven. Your submission puts a different complexion on that discussion. The nurses were here earlier saying that nurses had no ownership of the management systems and the entering of the information and they think it is a waste of their time because it just gets filed somewhere. It is of no use to them so they do not feel any participation. Is there a problem in the sense of clinical and nursing staff versus management that they do not have an integrated approach to these things?
Mrs Smith
—I think the situation is mixed. I think that if you have an organisation, a hospital or health service, focusing on a particular project, and there are some examples of quite innovative work going on in this regard, then it tends, as a particular focus, to bring the players together. If there are attempts to develop these sorts of things on a much broader basis where there is not a focus then I think the priorities are not set and therefore, maybe, the engagement of the whole range of players does not occur. I do agree that there is a need to involve clinicians much more in these processes. It is just a question of whether you try to do it as a system thing or whether you actually focus on some key priorities, and that comes back perhaps to setting national and state priorities and then having at least a volume of activity occurring so that when you do collect the data it does make some sense and you can do something with it.
Senator CHRIS EVANS —Thanks for that.
Mr Swinden —I do not think it is just an issue between management and clinicians either; I think a lot of this data is also collected for health departments for compliance purposes as well. So even the managers would say, `We are collecting a lot of this data and shooting it off and we never see what happens to it either.'
Senator CHRIS EVANS —It is misused by state and by federal politicians to blame the other ones for the lack of funding.
Mr Swinden —I will not comment on that. It is a multilayered thing, and unless you take a comprehensive view of providing the information that is required across the system at all levels you will not solve it comprehensively.
Mrs Smith —If I could add, though, that there is a lot of information that is collected, but it is not shared. It is a pity that it seems many departments collect a lot of information but it is not put back and made available as information to the people who are supplying it, so there is something to be dealt with there too.
Mr Swinden —That is true, because the infrastructure is not there to share it.
Senator CHRIS EVANS —I will just turn to the New South Wales submission. There are some quite radical proposals there, and it is good food for thought for the committee so I am very pleased to receive them. Part of the focus is making health care much more community orientated. One of the things that has been bugging me during this inquiry is this seeming wall that exists between the hospital and what GPs or community health organisations do. There is the failure to share information, the fact that we test people when they come into the hospital with tests they might have had the day before under the GP and that we might not have admitted them if we had known what the GP had done the day before. Your proposals obviously go to overcoming some of those things. I see you talk about compulsory registration of individuals with a preferred GP provider. Could you explain to me what that means?
Mrs Smith —This is something that the New South Wales branch feels strongly about and does have a position on. The important principle is that GPs must become much more part of the care process and I guess that is one way to make that occur. I think others would say that there ought to be a bringing into the whole health care episode of the GPs, perhaps at the centre of that care, to provide incentives for GPs to provide, in a sense, better services where there is availability and access. The concept of family GP practices is deserving of further consideration and some incentives to try to get better services at that primary health care level.
Mr Swinden
—We have also talked about a unique identifier for patients and the need to link GPs, pharmacies and hospitals together from a data point of view. There is certainly the capacity to do that now. We would say that there is a major opportunity to take a lot of costs out of the system overall if other parts of the system can see what other parts are doing, so that we can monitor prescription use and we can monitor tests and know what tests have been done at different parts of the system. It requires a whole lot of issues to be addressed in relation to confidentiality and making elements of the data visible to the right people at the right time, but it requires a big investment in infrastructure and in software to make all of this hang together. And this does not just relate to patient issues, it relates to the business side of the health system as well, in terms of e-commerce business to business.
Senator LEES —I would like to pick up on that last issue where you are looking at a constant doctor, I guess partly to prevent doctor shopping as well as to keep track of treatment. When you talk about a patient identifier, could you expand on that a little for us? Privacy implications have been the reason that there has been very little progress in this area. We keep being told that the total level of medication someone is on or their interaction with other doctors is hidden for privacy reasons, so how can we get round some of that?
Mrs Smith —The unique identifier is purely having a number that lets everyone know who that patient is in a central database. The privacy issues, I acknowledge, are enormous. It appears that work in that area has been quite slow. I know there is a lot of work going on, but I have not seen any particular outcomes or proposals come out of that process at the moment; certainly in some of the states.
One of the keys to the unique identifier is to make sure that patients, clients and individuals have some control and some mechanism to say whether they want to be part of that system. I think the majority of people would say, `That's great. If my records can go on some sort of central database and also I can give approval to a provider to access that data, and if I can also have information deleted if for some reason I am not comfortable with it or have it reviewed, then I think that is probably the key to my moving forward.' Trying to develop the legal frameworks around it is probably a lengthy process. I do not know whether we are ever going to achieve that. Obviously, if you have health care providers who are one legal entity, then to be able to access data within that legal framework is relatively easily done. But I think there is a view that you must give individuals some control over what occurs with their data.
Senator LEES —So they could effectively delete items that they did not want to go on to the central database—perhaps a particular episode of care.
Mrs Smith —Yes, and there are obviously very clear areas where there would be sensitivity.
Senator CHRIS EVANS —It is an obvious point that Centrelink and people like that keep information. Now we have the Job Network where we have hundreds of individual providers who are accessing the records of people who are registered for unemployment. This obviously can be done. I do not want to diminish the privacy aspect.
Mrs Smith
—The other issue is to educate the community about what it is and what is trying to be achieved. When you mention identifier numbers, privacy issues, then people immediately feel negative about it. There is a huge education process involved there as well. I think the majority of individuals would say that that could be a good thing.
Senator LEES —If we are looking at improving our health system and improving the outcomes, shouldn't the first thing we do be to set national goals and targets? If you have got individuals in this system with their identifier where alarm bells start ringing, saying, `This is the set standard on this procedure' or `This is what is supposed to be achieved' and obviously something is going wrong, I guess I am trying to go back to square one and look at where we start the process.
Mrs Smith —I agree with you: we need to set some national priorities and have a commitment to achieving that. Having done that, I think it is far more possible to identify what best practice is, and put in clinical support decision making systems that help that. Also, underpinning that means that there is a pathway for the strategic investment that I am talking about. To have the unique identifier and to be able to collect ongoing relevant information about episodes of care obviously contributes to that process, but it also means that there ought to be improved care, more integrated and coordinated care, through having those records available to all the relevant providers.
Mr Swinden —At the end of the day, we have to get down to managing the system based on the people rather than on the episodes of care, because at the moment that is really what we are managing to—information on that. So we do not know what people are doing, moving through the system.
Senator LEES —At the moment we are just tracking DRGs.
Mr Swinden —It might be one person 10 times or 10 people once.
Senator LEES —My last question is with respect to looking at the whole casemix system. We have had some witnesses suggest it is really beyond its use-by date. Other witnesses suggested that it only works in some parts of the system. Can we have your views on casemix, its effectiveness and whether or not we should keep putting so much emphasis on it.
Mrs Smith —I guess it depends on what you think casemix is. Most people involved in the health care field would say that the development of casemix has been a good thing because it does focus on outputs. It does provide a mechanism for accountability, about funds going in and what you produce at the other end.
I should say that casemix has been used very differently in the various states. In Victoria casemix has been used to purely allocate the amount of dollars available on some equitable basis across providers. That is really what it does. It does nothing in terms of putting money where money is really needed. That is another process, and we have talked about setting priorities and having a strategic framework in which to work.
CHAIR —Mrs Smith, you just said Victoria has used casemix to allocate dollars. Have you got an example from another state that does it differently?
Mrs Smith
—You can correct me if I am wrong, but New South Wales uses casemix to essentially allocate the dollars from the central pool to the area health boards—the population based funding approach—and then there is another mechanism for the area health boards to allocate that money within the hospitals. The recommendations from the New South Wales Health Council in the recent report is to now extend that casemix approach into specific units of activity, as we do in Victoria. It depends at what level you wish to use that casemix approach to allocate dollars.
CHAIR —I just wanted to get that comparison.
Mrs Smith —I do not think casemix is by its use-by date. It is important to have costing systems that tell us what it costs for units of activity, and casemix does that. Where the difference is is then allocating on a proportional basis of the total funds available where there is a gap between the price paid for a unit of activity and the cost of delivering that unit of activity. I think that is why a lot of people are saying that therefore casemix does not work. The other argument is that if you actually looked at the costs and met those costs and put the money in, then you would have a very different scenario.
Senator LEES —The suggestion was, particularly for the larger teaching hospitals, that there are other components in the education side that are not built into their casemix funding whereas it might be working for a medium sized hospital that does not teach.
Mrs Smith —Yes.
Mr Swinden —They are arguments around the edge rather than about casemix itself. Personally, I think casemix has been extremely effective in doing what casemix does, and that the budget cuts that occurred in Victoria in 1992 could not have been done in any other way. They targeted the hospitals that had the most capacity to meet those cuts and left those alone that did not. As I said, it could not have been done any other way. At the same time, you also have to recognise the inherent dangers in casemix and adjust for those, take them into account and recognise them.
Senator TCHEN —My questions are designed to remedy my own ignorance so if it sounds inappropriate it is not a criticism on you. Firstly, I am intrigued with your written statement where you say that your members:
in all sectors have become increasingly frustrated with the balancing act they have had to perform between demand pressure and resource management.
Isn't this balancing act what you are supposed to do?
Mr Swinden —Certainly, that is true.
Senator TCHEN —That is your job, isn't it?
Mr Swinden
—That is true. It is a question, at the end of the day, of how far it goes. I mentioned in the introduction that managers, to an extent, feel that they are identified as the culprits, if you like, and the reason why the system does not work as well according to, say, clinicians or whoever. Certainly that is their job. It is a question of whether they are provided with the appropriate tools to do their job most effectively. I certainly would argue that there are some problems in our expectations. For example, in Victoria we have a 1.5 per cent productivity improvement requirement each year.
You can continue to apply that on and on, but you must get to the point where unless you provide the appropriate funding to actually resource the sorts of productivity improvements that are required, you will just be cutting at the edge. For example, I think approaches like a business process improvement—some call it patient process re-engineering—is something that would be well worth doing. The IT infrastructure that we have certainly is not integrated and it is not adequate to continue to produce the efficiencies that are required so, I think, unlike a business we do not have the resources or the capital to be able to borrow against future savings and, at some point, we have to invest in the future. At the moment, I do not believe that that is occurring.
Mrs Smith —I also add that I think there is no question that we have much better information on financial activity, patient activity, benchmarks-a whole range of information-and it is quite clear that there is not a lot left in the system to meet productivity improvements and increasing demand. So it comes back to my opening comments about it then becoming, `Whose fault is this?' And it can be the managers and it can be the clinicians; it can be a whole range of people, but at some point we have to stop and say that if there is not sufficient money in the system—and we have the objective measures to suggest that this is the case—then you have to start looking at the volume of services. It comes back again to the comments about engaging the community, about their expectations and about the sorts of rationing issues that we have to address. Some of those happen by default now in terms of waiting lists and access to accident and emergency departments and some community based services. That is the point being made.
Senator TCHEN —In that case, can I take it further to this question of quality of care which Senator Lees, Senator Evans and Senator Knowles have all touched on in questions to you. We have received evidence from various people about this quite interesting topic, but one particular set of evidence we received argues that, apart from quality of care—the improvement in quality of care apart from the direct benefit to patients—there is also a benefit of considerable savings to the system and an estimate is that that saving could be of the order of $2 billion a year. That does not seem to have been taken into account by the hospital administration manager profession because, for example, in page 4 of your submission under (h) you said:
The tension between initiatives to drive down administrative costs and creating funding initiatives to improve data/information management of clinical processes is ongoing.
Nevertheless, you are looking at it from the point of view of being a cost of improving data and administrative costs. You are not looking at the improved data or the issue of achieving savings. Is that a shortcoming in your vision?
Mr Swinden
—I suppose it gets back to what I was talking about before. To my mind, you have to have the capacity to get funds up-front to produce future savings and quality improvements and I think the improvements that are still in the system are not easy to obtain. They require an investment in systems, in education, in people and in process re-engineering, and I do not believe the money is there in the system to obtain those. I guess that comes back to the issue of frustration. There is a recognition that there are things that can be done. They are extremely difficult, they go beyond individual institutions, they are state issues, they are national issues that require an integrated approach across agencies and they require money. And while we are in an environment where that money is short and we do not have the capacity to actually invest in the future at an agency level, then those things will not occur. So I do not necessarily see them as inconsistent.
Mrs Smith —I think it is true that if we could reduce the number of adverse outcomes, then there would be money to be saved, but it really is the investment time frame and the fact that agencies work from one 12-month budget to the next rather than having a time frame to invest and then achieve a return.
Mr Swinden —We had a presentation by the Leicester Royal Infirmary on patient process redesign late last year, and that was effectively their finding. They had put some millions of pounds into patient process redesign and found that, at the end of the day, they improved the process for the patients and saved money, but it required an up-front investment.
Senator TCHEN —In that case can I ask the question that more or less begs to be asked: do you know if anyone is taking the initiative of putting this item on the agenda?
Mr Swinden —I think in a limited way some hospitals are starting to. But, again, if it is going to be done comprehensively, it requires more than an agency level approach. That is my view.
Senator TCHEN —I am talking about the profession, because you represent the college.
Mr Swinden —Sure. I guess the question is: what can the profession do in the absence of resources? I think you asked why they are frustrated. I think it is like saying, yes, they want to run the 100 metres, but it is difficult if you are hobbled. So it is not that there is a lack of commitment. There is certainly a desire to do these things.
Senator TCHEN —Do you know of anyone who is taking the initiative to put the issue on the agenda?
Mr Swinden —To put it on the agenda?
Senator TCHEN —The national agenda, if you like.
Mrs Smith —The college has supported the findings of the Porter inquiry; we are strongly supporting those recommendations. We have indicated that we want to work with that new committee and to have some input. It is often very difficult to know exactly where to put these matters on the agenda when you are trying to deal at an agency level but also at a state government and a Commonwealth level. I think it does come back ultimately to national planning strategies and priorities. If there was a process in place to develop that framework, that would be the ideal way to bring these matters forward as part of an integrated approach.
Senator TCHEN
—In your written submission, under Medicare, there is a single line which says `Federal Council supports the principles of Medicare.' In your verbal submission, you also added the comment that you think that, in its current form, it is not sustainable. Can you clarify that?
Mrs Smith —I think there is a perception by the community that Medicare is fully funded through taxes and it is basically an open-ended system. Quite clearly, the system is struggling at the moment. It could well be that either the benefits that are currently provided to all through Medicare need to be tailored to something that is affordable or perhaps the answer is to put more tax money into the Medicare system.
Senator TCHEN —What do you mean by `portable'?
Mrs Smith —`More affordable', because the system is stretched—
Senator TCHEN —I understand.
Mrs Smith —so it is either a question of more money or reducing services.
Senator TCHEN —Affordable, I can understand. Thank you.
CHAIR —What is the background of most of your members? I do not want to know if you have done jail terms. Are any of you doctors or nurses?
Mrs Smith —Yes. We have a diverse membership. The college attracts a whole range of health professionals who are involved in management in some way. So we have general managers, doctors, nurses, allied health professionals, from both the public and the private sector. So we are very diverse.
CHAIR —If somebody gets a new job and they are appointed to run hospital X, do you ring them up and say, `Hey, how about joining us?' or do they find out about you and think `That's a good thing; I'd better do it'?
Mr Swinden —It is a bit of both.
Mrs Smith —A bit of both. At a local level, usually someone will ring and welcome that person and extend the—
Mr Swinden —It does depend, however, because the membership criteria involve your qualifications as well. So, traditionally, certainly the expectation has been that you would have a qualification in health services management. Increasingly, in recent years some appointments to management positions in health have not been. Therefore, the college has been looking at the issue of how to deal with its membership criteria so that it can embrace those people in management in health.
Senator CHRIS EVANS —Is that because they are appointing outside managers, people with management experience in other industries?
Mr Swinden
Senator CHRIS EVANS —Sorry for interrupting, Chair.
CHAIR —No, that is exactly what I want to find out. What qualifications have you, up until now, expected people to tick off on?
Mr Swinden —As Mavis mentioned before, we accredit various courses in health services management across Australia. Some of those are MBA courses with health streams in them. Traditionally, there has been a health services bachelor's degree at the University of New South Wales and a range of others, postgraduate diploma courses, et cetera.
CHAIR —The stories I hear from New Zealand are that they have put managers into hospitals. I had the pleasure of meeting one who was very proud that he had absolutely no knowledge of medicine or nursing. My understanding is that since then there has been a very significant change to hospital management in New Zealand and that that period, that experiment or effort, was not successful. Is that your understanding? Do you follow things across the Tasman?
Mrs Smith —I think your comment is fair. Again, it would be mixed, and the New Zealand health system has been through some fairly difficult times. Obviously, the college view would be that you would want people to have experience and qualifications in health to be able to do the job properly.
CHAIR —Have you had any similar kind of problem amongst your own membership?
Mr Swinden —Certainly there has been a fundamental change in our membership.
CHAIR —From what to what?
Mr Swinden —I always used to say 20 years ago the membership of the college was predominantly white male public hospital CEOs, whereas now we have gone to a far broader membership. There are far more people in health who are looking to get or have obtained management qualifications, so we see our role as management in health rather than health managers.
CHAIR —Twenty years ago: white male public hospital—and doctors?
Mr Swinden —CEOs, generally not; generally probably an accounting background.
CHAIR —I cannot conclude that now they are coloured women from private hospitals?
Mr Swinden —Not necessarily. It is a far more diverse group, but, as I said, our issue is that a number of people currently in management in the system have come from outside. Certainly my personal view is that we need to ensure that we impart knowledge and involve them in our professional development.
—Why is your college involved in education? I would just like to know what you are teaching them that they are not picking up in their MBAs with health streams or whatever else.
Mr Swinden —Our education program is predominantly about current issues, so we try and deal with the things of the moment rather than skills based material. And it is about networking, about enabling people to know who they can contact for advice or support and know who to talk to to get information.
CHAIR —Do you get any of your education done by the local tertiary institution?
Mr Swinden —In terms of subcontracting?
Mrs Smith —A lot of the courses are provided through the various tertiary institutions. There are probably two things there. One is that when we are accrediting courses we are obviously looking for relevant health subjects. That does not mean it has to be a total health course; there will be finance, law and those sorts of things and there will be specific health subjects. So we are looking for a balance in those courses. The other thing that the college has involved itself in, in a variety of courses around the states, is to try and attract young graduates into the health field where they already have a qualification but have an interest in health. Then we provide two things: some ongoing education through, say, an MBA program and also a health experience, so it is a sandwich course—it's an old term, isn't it?—and the college can bring people in and provide very targeted education to meet the needs of health agencies.
CHAIR —I like it, actually. Thank you. As Senator Knowles said, it is a bit hard to remember exactly who said what and where when you have been on the road like we have for the last few days, but I think it might have been in New South Wales that we were told of a lively tension between clinical independence and management. In short, no-one is going to tell the doctors what to do, which is a bit of a challenge.
Senator CHRIS EVANS —The Chair is speaking as Dr Crowley, so you are aware of the position she is coming from!
CHAIR —On behalf of my non-conflict of interest position, that is right. Thank you, Senator Evans, that was a fantastic way to stop a person under full steam. The information we were talking about at the time was really very much about efficiencies and best practice, the combination that we have been talking about with you for the last hour. The New South Wales witnesses were saying that this must be management led, that you simply cannot have significant changes of quality and efficiency, outcome data and all those sorts of things if management is not in there up to its elbows.
We have heard that you cannot push doctors around. We have not heard that you cannot push nurses around; in fact, some people would say that they have been trained for 150 years to be pushed around. We have heard that the clinicians have to own things, they have to be responsible for initiating the changes, or at least have a large handprint across it. I just wanted to know your view about how you manage this? It would seem to me that there are two pretty powerful forces butting one against the other here, and I would have thought there is truth in both of those claims. In your experience, how have you managed to try to weave the two together?
Mr Swinden —From my personal experience, when casemix came in here I was running what was, in relative terms, the most inefficient hospital in Victoria and so it had the most to do in catch up. Yes, the managers had to lead the process but nothing would happen without the medical staff being involved and agreeing and believing that change had to be made. You cannot do it without the doctors. It is a difficult balancing act and, as I said before, it requires skill, credibility and leadership. In the case I was in, we reduced length of stay virtually overnight by probably 25 per cent when casemix came in by doctors recognising that there were probably changes that they could make to clinical practice and that it was in the interests of the organisation to do so. That is probably easier in a rural situation, which this was, than it is in a large teaching hospital where change is a lot more difficult. I do not think you can do one or the other—it requires both.
—That is very useful. Thank you very much. We have, unfortunately, to stop at this point. If there were further questions, could we please contact you to get answers on the record? I would like to thank you for your submission and your contribution. This inquiry is actually drawing input from outside the usual suspects, so we are assisted when there is that kind of broadening of the debate and some new push for ideas. Thank you.
[1.41 p.m.]


text:
Record heat, a tornado outbreak and arctic high pressure top the list of Michigan weather events on this day in history. From the National Weather Service archives here are the events that happened on March 20.
1885 - Low temperatures of -28° were reported in mining districts of Marquette County.
1895 – Lansing only observes a record cool high of 6°. This is the coolest high temperature for the month of March in Lansing.
1965 - Arctic high pressure and a very deep late season upper level trough dug from the Pacific Northwest to the Ohio Valley bringing record cold. New record low temperatures are set in West Michigan with Grand Rapids at 3° and Muskegon with 8°. Records are set for the chilly highs as well with Grand Rapids reaching 19° and Muskegon 20°.
1976 - A tornado outbreak strikes from Michigan to Mississippi. In Michigan, an F4 tornado moved through West Bloomfield in Oakland County at 7:15PM. This tornado was responsible for 1 death, 55 injuries, and over $5 million in damage. This is both the strongest and costliest tornado to ever hit Oakland County.
Many snowstorms have hit Southeast Michigan on this day with greater than 6 inches over a large area of the region including in 1967, 1983, 1989, 1992, and 1996. In 1983, the Flint snowfall of 9.6 inches is the tenth heaviest snowstorm in its history.
2012 - Highs of 82°, 84°, and 83° were recorded in Detroit, Flint, and Saginaw and respectively. Each temperature tied the warmest March temperatures ever recorded at the time. However, all records would be broken in the coming days. Ultimately March 20, 2012 would be the third warmest March day ever recorded for Detroit and the second warmest for Flint and Saginaw. West Michigan cities experience similar records. Highs of 83°, 82°, and 83° were recorded in Grand Rapids, Muskegon and Lansing respectively. Each temperature is the warmest March temperatures ever recorded at the time. However, all records would be tied or broken in the coming days. Ultimately March 20, 2012 would be the third warmest March day ever recorded for Grand Rapids, the second warmest for Lansing and the warmest day at Muskegon, which is tied on the 21st.

subset: commoncrawl


text:
It appears that I will be in Florida for a while. Nice place to do some photographic work. I am quite partial to the west coast for photographic work. I have shot a little on the east coast so this time I will concentrate on the east coast.
One of the best places to shoot is the Alligator Farm up by St. Augustine. Nice place and they let photographers buy special passes so we can get in early and stay late because the other visitors can be an issue with setting up tripods on the walk ways. They have yearly passes for those who live in the area. Best shooting is in the spring because some of the nesting sites are only a few feet of the walkways.
Merritt Island National Wildlife Refuge is another great place to shoot. It is very high on the list of places to shoot. It is part of the Space coast area which has some more interesting areas to shoot. It is a national wildlife refuge so please follow the rules.
The Everglades of course but you also need to be very careful there. The only place on the list that humans are not necessarily the top of the food chain so be careful. The sunsets and sunrises are beautiful but that is the time for the predators to be out also. You may get shots of the Florida Panther, alligators and crocodiles. Yes crocodiles. It is the only place in the US that you can find them.
Ding Darling National Wildlife Refuge is a good place to go if you have the time. This one is down by Sanibel Island so it is a long way down the state but it is well worth the effort if you have the time. Corkscrew Swamp Sanctuary is also in the general area. It is an Audubon sanctuary. The Audubon Society also has a raptor center in the Orlando area for you to check out.
There are a couple of more places on the east coast around Ft. Pierce and Port St. Lucie that might be worth your effort. One is Hutchinson Island. The northern most part was listed as pretty good but it appears that a couple of bridges have been condemned and the areas are no longer available by land.
Port St. Lucie County has the Savannahs Preserve State Park. I have never been there. The website has a gallery of images but as much of the east coast areas it seems to be lacking some of the species or quantity of birds that many like to shoot.
Lake Okeechobee is another area that has a lot of information about birding but the shoots seem to be lacking as compared to some of the other areas. Many areas in Florida are becoming less bird friendly with the droughts and encroachment. Check out this area as it used to have a bird festival in one town that might get you some better information. I have limited knowledge about this area as the last time I shot it was back in the 70s with my Nikon F2A film camera.
This place I have not been and but would love to shoot. It is the Dry Tortugas National Park. This one is a real trip for almost anyone as it is in the Gulf of Mexico about 50-75 miles west of Key West. Needless to say it will cost more to get to as a boat or plane is a must.
I have purposely left out the beaches as the birds do not act very naturally there most of the time. Anyone can get a photo of a Great Blue eating a fish on the beach when people throw the fish to them. It is like shooting in a zoo and claiming how good you are at finding wildlife. I am not saying that you cannot get good images on the beaches because you can. I have. I just prefer places like Honeymoon Island (The image here of the sunset is mine from 2007), Caladesi Island and the Ft. Meyers area to the east coast beaches. That is not against the east coast, I just much prefer the west coast. The water is calmer and the birds are lit in the evening golden hour light every day.
If you live in the area like I did for years, you can go back and work the area a lot but if you are just going to be there for a day or two or maybe a couple of weeks, I suggest places like the Alligator Farm, Merritt Island or Pinellas County. You will have many opportunities for wonderful shots even if you only have a short time. The others are a gamble.
I may personally go the middle of the east coast and shoot just to try the areas out. I will catch some flack about them so I do have a responsibility to at least check them out. That also will give me the chance to shoot Merritt Island and the Alligator Farm. I have several friends in the Clearwater area to look up and maybe we can go shooting.
Some of them I met through photography either as students, clients, customers or just people I ran into in the parks when I was out shooting. A lady named Brown has done well since I sold her a Nikon D50 back in the day. She has won awards and probably has long since gotten rid of the D50. I have not talked to her in a couple of years so I hope she is available.


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It's that time of year, when people make resolutions about exercising more, eating better, saving money and somehow bettering themselves. I don't believe in New Year's resolutions because if you really want to better yourself, you can resolve to do it right then, not wait for the calendar to dictate your life.
While I rarely make a New Year's resolution, I am constantly making lists of goals, or other resolutions throughout the year. I find that when I write it down, I'm more likely to accomplish it. As I'm nearing 30, you know, that mystical age that seems to cause major assessment of your life, what you've done compared to what you want to accomplish, I figured I should get a jump start on getting myself in order since August 2013 and that mystical birthday will arrive sooner than I'm ready for.
But, since it is the season of resolutions, I've been seeing lots of articles about it. This week I found a few I can really get behind.
First up, this one from BootsnAll, a great indie travel site. All are good travel resolutions and I genuinely believe travel makes your life better all around. Experiencing the world can make you so much more aware, not just of other cultures and landscapes, but of the world and your place in it.
No. 9 on the list is to travel solo. Of course I don't recommend everyone go jetting off to foreign lands by yourself if you're not prepared and haven't thought through such a plan. I much prefer solo travel because I know myself, I want to do everything on my own schedule and in my own way. I also force myself to get outside my comfort zone and also meet many more people while traveling solo. But, if you're not as crazy as I am, start small. Take a solo road trip to a city you want to visit. Spend a day at museums or art galleries by yourself. Take the time alone to think, see, feel and experience. Yes, you can experience with friends and travel buddies and I am planning a few trips with friends who share my love of travel and adventures, but there's a huge benefit in spending some time on your own. Plus, while in foreign countries alone, I'm not pulled into conversations about things at home, unless I'm chatting with someone from another country, a stranger turned friend, about how our lives are different and similar. It allows me to focus on where I am, what I'm doing, where I'm going and regain some perspective. Everyone can use a minute to look at your life from the outside to keep yourself going in the direction you want to be going in.
A good read on solo traveling and very true points.
Another favorite is No. 11. Be a traveler at home. You can't know the world out there if you don't know where you come from. As much as I love to leave the country on an adventure, I don't always have the time or the funds. I love to explore where ever I am, near or far. I love to play tour guide when friends come to town or play travel agent when friends go abroad. A sense of place is a great thing and you start to feel at home even in faraway lands when you explore and live like a local. There's a good chance your area has more to offer than you think and you can get your fill of art, music, food, outdoor activity, culture and more if you try. Keep your sense of wonderment alive until you can wander far from home again! If you need more reasons to get you out and about in your town town, read this list. I love it!
But my favorite of the resolutions is No. 16. Be an inspiration. I still remember when I first decided to spend a semester abroad. For a minute I thought, no, I could never do that. And then I thought, why not? And I did it. On that trip I not only survived abroad, I flourished. I explored and made new friends. I learned more about the world and my own country by being away. I saw a different way of life where going to college was a huge privilege not a right and those New Zealand students worked far harder and took their education more seriously than most American students I knew. I came back a better version of myself, but also realized at any time and for any reason, I could buy a plane ticket, hop on a jet and go anywhere in the world. On my own. At 21, that was an enormous revelation and also changed my life probably forever.
All that said, I still don't believe in New Years resolutions. These are things I strive for every day. I don't always succeed, but the goal is always there and that keeps me moving in that direction. I do, however, love this idea of quarterlies. I will definitely be making use of this approach this year and will not just hope for the best in accomplishing them, I will. Some goals will take longer or will end up changing, but I've used the write it down, then do it approach for most things and for me, it works.
Happy New Year everyone! I wish you all the best in the new year, but mostly, I wish you travel, adventure and exploration!


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I've gotten a ton of e-mails & people asking me how to make gold with alchemy so I'm going to share with you one of my favorite ways to make gold with this profession. It doesn't require you to be level 85. The recipe/item that is crafted can be bought at the AH for a measly 10g and is readily available.
Don't worry, just because the recipe is cheap and is almost listed at the AH doesn't mean this item doesn't bring in profit. The said item is rarely listed at the AH because people are too busy selling the higher level end alchemy stuff and they completely forget about the lower tier stuff or think " oh.. well it's a vanilla recipe so it simply CAN'T make gold ".
Well they're wrong - I've made thousands of gold off this recipe/item. It's a vanity item which people simply love to buy in stacks - hell myself personally I keep 2 stacks around all the time. The cost to craft the said item is very, very cheap and can be reduced further when you're able to snatch some cheap herbs. I tend to sell the said item at 10-15g/per and sometimes even more when no one has it listed at the Auction House. I list in stacks of 1s, 5s, and 10s - with 5s being the best sellers.
Can you guess what the item is? Hint: The recently buffed and now drops very often in a couple specific zones. Still don't know? Click the continue reading button to find out!
I've gotten a ton of e-mails & people asking me how to make gold with alchemy so I'm going to share with you one of my favorite ways to make gold with this profession. It doesn't require you to be level 85. The recipe/item that is crafted can be bought at the AH for a measly 10g and is readily available.
8 comments: on "Making Gold With Alchemy In Cataclysm"
Anonymous said... May 5, 2011 at 8:44 AM
That's probably VERY server specific. On my server ( Garona Eu) these kind of vanity items don't sell for 1g.
Mageshadow said... May 5, 2011 at 9:03 AM
Come back and check another day! :P
Kammler said... May 5, 2011 at 9:40 AM
@ Anon, you can also "advertise" by making a few of these potions for your own use. Run around SW or where every players are congregated, especially on high traffic days like Saturday.
People will ask you how you got so big, etc. You can also just bark in the trade channel to drive up some interest.
Many players may not know about the Elixir or may have forgotten. Run a guild dungeon or BG with the potion active just for kicks.
The more buzz you create the more you will sell.
Anonymous said... May 5, 2011 at 10:02 AM
I think is US specific.No offense, on EU servers are also plenty of players (underaged or simply too stupid) that use that elixir.
On my server, i know they are enough...but not even close to a number that can make this elixir something you can make gold off.
I like niche markets, i am not a rookie on AH ( 3 GB x 5 tabs and 1,5 mil gold cash), but this elixir is a no-no on my server.
I agree, maybe, sometimes, can sell...but the effort doesn't worth the time.
Wahlmart said... May 5, 2011 at 10:06 AM
a good tip for gold making on Alch is transmuting saronite bars to titanium. Since there isn't a cooldown and titanium bars are still in decent demand for both titansteel bars and general skillups, i've been having quite a bit of luck with them. Considering the fact that almost no one is in Northrend anymore, that oh-so-familiar Icecrown mining circuit is deserted. Lots of titanium and as much saronite as your bags can hold. I spent an hour mining saronite, smelted them into bars, and muted the bars to titanium on a mute speced alch - profit!
Silverthorn said... May 5, 2011 at 11:40 AM
I don't know if there's any sales potential in these other items, but I like Swiftness potions (Swiftthistle and Briarthorn) for just that added burst of speed when you need it. Often just the thing to get that flag up that hill in a BG or run away from a lethal mob.
I also try to have some Tracker Snacks (Shoveltusk Flank + Northern Spice), for when the City Cooking quest has you hunting crabs, crawfish, lobsters, etc. The critters show up on the minimap. It really speeds things up for non-hunters. Not to mention Pilgrim's Bounty's turkey kill achievement.
Anonymous said... May 11, 2011 at 1:25 PM
Ive been making these since this post came out and making a killing on them - 100GP a stack of 10. The fish needed to make them is expensive on AH server so I just spend a few minutes in the barens fishing for them. Likely making 100gp in 30 mins
I agree with the above post, this is extremely server specific and entirely depends on the economic circumstance for these items on your server.
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text:
Operating System: CP/M 80
MP3 player of choice: ダイハツ ミゼット
Favourite cartoon character: Dexter
Personal Quote: your mom
'Winter Kisses' by ~neonsquiggleWinter Kisses by :iconneonsquiggle:'Winter Kisses' by ~neonsquiggle by Dani-the-Naiad
Your winter kisses
are fragile snowflakes in my memory;
Beautiful, spectacular,
coming in flurries or blizzards
or all by themselves.
Falling snow by Iardacilsnowflake by felixw
Yet they were anything but cold.
Snowflake kisses by RurouniOneXana x Roxas Snowfall by HeartlessKeyWielder
Light as a feather, more passionate than red
the falling snow by Riza-Tukudo-KunSummer kisses by Jole22
drowning me in melodious flames
The Kisses of winter. by Natsza' ' by theluckynine
from my head to my toes.
Whisper by SilaynneIce Queen by punkyxxxchick
Arms around your neck
hands at my waist
:thumb70813502:Hands by SKAnkLikeUmeanIT
interlocked in our sweet embrace
Wake Up Sleepy Head by Crazy-Little-DollKiss on the neck by tsukopathe
Your lips meet mine
Winter Kisses by ZindyKisses by Parken
travel down to my neck,
SUPER-KAWAII Feature!! [4]okiey, soo this is all of teh newest kawaii artz I found in here, check it out, ~nyaaah~!SUPER-KAWAII Feature!! [4] by chibikawaii-chan
~Special Feature~
~Digitalz[Bullet; Pink]~
I Don't like the dark Bersh by Coraline123pachirisu for netharu by Thari-wont-loseRainbow by ColaChuGSM request26 by DrownedMadness:thumb167623347::thumb175452920::thumb174295629:Zombie Doodle by Cafe-Chaos:thumb175453809::thumb175453794:Little black cat in the bottle by KeiKyouSailor Moon- Moon Bubbles by lemontree11playing games with skully by YerBlues99:thumb175454206:.Chibi Me. by RainbowOttyHenry Hippo by kiddomerriweather:thumb175728794:
vampire sunset by elotta
~[Bullet; Pink]Traditionalz[Bullet; Pink]~
Chibi Fox by Hatsune-Miku01diezo gift by kdurst14Adult Nibbles in the library by myluvmuffin4ever:thumb175454318:Super Axe by xXKawaiiAkumaXx-Hello- by Yuna-kemikitty by nyx-vampire:thumb175451677::thumb175450671:
~[Bullet; Pink]Avvieyz[Bullet; Pink]~
juuust testinn' by PipoTico:thumb175752153::thumb175741981:Pink Kitty Icon by jelleed98:thu
dA still alienates gay community with prejudiceSince the beginning of this site, dA has been repeatedly criticized for its homophobic approach to art. Homosexual couples (specifically male-male representations because lesbians are hawt, guys) in particular have been repeatedly targeted by the site's admins for deletion, an occurrence so pervasive that one deviant, reapersun was able to hold an entire contest to attempt to illustrate the line of discrimination.dA still alienates gay community with prejudice by missveryvery
You might say, "the site is simply prudish!" Not true. They have an entire section labeled "fetish". Pictures of women having intercourse with tentacle monsters? De rigeur. Buick sized breasts oozing buckets of milk? Fine. But two consenting adults (especially male adults) touching? Kissing? My GOD, what filth!
The newest and most blatant example of dA's skewed treatment of gay people is a new stamp by prosaix
Try reporting it. You can't.
Why? Because tons of people have already tried and dA administrators have marked the case "invalid".
Their stock answ


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i Need Media
Best fiends: The League gets to the rotten, hilarious heart of true friendship.
By Matthew Singer 10/18/2012
"No hugging, no learning."
Of all the ways Seinfeld innovated the modern sitcom, that guiding mantra has had the most lasting impact. At least, it has on cable, where shows about irredeemable jerks are not just acceptable but becoming the norm. When Larry David and Jerry Seinfeld built an entire program around that principle in 1989, it was a reaction against the notion that televised comedy had any greater responsibility than simply making the audience laugh, and their descendents have taken that idea even further. In the decade-plus since Seinfeld went off the air, sitcoms have become grounded in even flimsier morals, with protagonists growing ever more sociopathic. It's Always Sunny in Philadelphia has stretched those boundaries the most outlandishly, and Eastbound and Down has traveled to previously unexplored levels of darkness. But no show honors the notion of the pure, undiluted, no-frills TV comedy better than FX's The League.
Coming from the network that also produces Louie, perhaps the most original television series to come along since Seinfeld, The League can seem unambitious. It's about a group of alleged friends in suburban Chicago whose lives revolve around their eight-member fantasy football league. The dialogue is mostly improvised, the humor derived from the endless stream of (primarily genital-based) insults flung among the characters. Wives betray husbands (and vice-versa), people stage clandestine porno shoots in their buddys' apartments as part of elaborate pranks, and, in the recent season 4 opener, dads trade the naming rights to their second-born children to their dangerously dim younger brothers for better draft positioning. No one hugs, no one learns a damn thing, and there isn't anything under the surface. Even It's Always Sunny shows a vague heartbeat at times. The League is utterly soulless.
And, perhaps because it gives itself over completely to the comedy and nothing but the comedy, it's one of the funniest shows on TV.
It walks a very fine line, though. On a show like The League, where the point is that everyone is a selfish prick, one false joke and the whole thing becomes unpalatable. A few months ago, I interviewed Nick Kroll, who plays the show's Napoleonic evil genius, Rodney Ruxin, and asked him how he and the other actors keep the characters from losing their humanity completely. "We all like each other a lot in real life," he said, "so while we're super-cruel to each other on the show, it's underlined by the affection we have for one another. The characters make each other laugh, like friends."
It's a telling statement. What The League — and really, any successful comedy about a close-knit group — portrays is not a collection of assholes being mean to one another: It's a collection of assholes who've earned the right to be mean to one another. In other words, they're friends in the truest sense. That's what we recognize in them, and what redeems them, even if it's a subconscious understanding. No one can hurt you as the people who love you the most can, and nowhere on television is that better understood than The League.
I Need Media is a biweekly media column. Matthew Singer watches everything from PBS documentaries to Community and Showtime's Gigolos, but mostly he's just happy Breaking Bad is back. Follow him on Twitter@mpsinger.
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Chrissy Lampkin Arrested For Aggravated Assault
Lady Vamp owner and "Chrissy & Mr. Jones" star Chrissy Lampkin was arrested and charged with aggravated assaulted and disorderly conduct early Sunday morning.
According to reports, Chrissy Lampkin was arrested around 2:30 a.m. Sunday morning for beating the breaks off of a female in an Edgewater, New Jersey bar after a war of words on a sofa in the VIP section escalated and got ugly really fast.
Chrissy unlucky opponent was left a bloodied mess, required stitches for a wound over her eye, and was hospitalized.
After she was booked, Jim Jones posted her bail and Chrissy Lampkin was released a few hours later. Peep Chrissy's mugshot below courtesy of TMZ.
We all saw Chrissy's work back on season 2 of "Love & Hip Hop" when she snuffed Kimbella Vanderhee out of nowhere. In case you forgot…allow me to jog your memory.
Hopefully, Chrissy doesn't end up being Chris Brown's neighbor at angry rehab.


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Dustin is a teen with autism. On a recent visit to the Thompson Center, his mother was completing the Return Patient Form. Among the many questions about her son's medications and health-related concerns she found one that you don't often find on a patient form. It read, "Tell us one GREAT thing that your child did last week!" To this she indicated that her son had helped her water the garden and carry laundry down to the laundry room. While many would see these as simple, uneventful tasks, Dustin's mom and Nurse Clinician Shawna Mabe recognized these as great accomplishments for a young man who struggles with social interactions.
"From his mother's comments I saw that Dustin was engaging in positive behaviors toward others," Mabe says. "It's great to hear about all of the good things our patients are doing."
In an effort to recognize the accomplishments of patients like Dustin, Mabe developed the "Proud of You" postcard program. The idea behind the program is to send a postcard to a child or adult patient recognizing the positive behavior noted on the intake form.
"We want our patients and their families to know that we appreciate the good things they are doing," says Mabe. " We also want parents of our patients to know that we value the time, love and effort that they give to help their children be successful. It only takes a few minutes to tell someone that you appreciate what they are doing. That is why we began this program," she adds.
Through the "Proud of You" program Mabe is making sure that patients, and their families, know that they are important to the faculty and staff at the Thompson Center.


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Frank Hernandez, a researcher at the University of Iowa, and colleagues announced their development of the first fast, inexpensive, and noninvasive test for staph bacteria in the Feb. 2, 2014, issue of the journal Nature Medicine.
Present technology requires a biopsy that can take several days to reveal the presence of an infection from Staphylococcus aureus, a species of staph bacteria common in hospitals. Over 20,000 people in the United States die each year from Staphylococcus aureus infection.
The new method involves a small molecule that has one end that emits light and one end that cancels out the light. There is no light emitted as long as the molecule remains intact. If the molecule is broken into pieces the light emitting end begins to emit a specific frequency of light.
The new molecule takes advantage of the normal action of Staphylococcus aureus spread by cleaving molecular DNA.
Tests with mice and human subjects show that the new test is accurate in detecting Staphylococcus aureus and takes about one hour to make an accurate determination of infection.
Waiting one hour instead of days is predicted to save thousands of lives and millions of dollars in treatment costs for staph infections contracted in hospitals as well as in any environment.


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TruBerber Cargo Mat
Reviewed By Robert S (Santa Rosa, CA) Reviewed for a 2013 Dodge Ram —11/12/2013 12:12 PM
The TruBerber Mat is a PERFECT fit . It enhanced the trunk space ,Very nice !
Reviewed By Mark A W (Wappingers Falls, NY) Reviewed for a 2014 Dodge Ram —4/26/2013 10:03 AM
Received this order in just about 1 week. Very nice product, Do be fooled, its not really a cargo liner. That's what its meant to be, but its too nice to get dirty. Now I need something to protect my cargo liner.


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PCAV welcomes support from individuals and organizations willing to donate time, knowledge, and tangible or financial resources that can help positive parenting become the norm in all homes and communities across the state.
Please print and complete the PDF version of the Volunteer Application and fax it to (804) 359-5065 or email it to Allison Gilbreath at email@example.com OR fill out the Volunteer Application Online Form listed below and hit submit when it is complete.
Online Volunteer Form


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Valentine's Day doesn't have to be a bummer if you're single. After all, it incorporates things that girls like such as chocolate, flowers and hearts. Why not surprise a girlfriend, daughter or mother with one of these great Valentine's Day finds. From jewelry to makeup, you may even want to treat yourself!
Packed Party Package
Packed Party is a modern take on the care package. The San Francisco based company curates boxes of beauty and gift items by theme. For instance, the " You Don't Need Him Anyway" box is filled with comforts to nurse a breakup. Contents of the boxes change each month so you gift the same theme more than once. Packed Party has a special edition box for Valentine's Day called "Cue Cupid" $45 each, packedparty.com.
Chippendales The Perfect Party Package by Rain Cosmetics
Get your single girl ready to go out on the town with this cute beauty kit from Rain Cosmetics. Rain partnered with sexy brand CHIPPENDALES® to create The Perfect Beauty Package. The $12 kit includes Rain Cosmetics classics like lip gloss, bronzer, eyeliner and mascara. Available at RainCosmetics.com.
Candy Chrome Bow Hello Kitty necklace
Whether she likes Hello Kitty or not, she'll love this cute necklace by Hello Kitty. The famous kitten's bow adorns a black matte necklace and is perfect for work or play, $66 at sanrio.com.
Sexy reading material
The Kindle has both broadened the availability and variety of books. Why not send your friend a steamy novel with a click of a mouse? A married woman gets more than she bargains for when she signs on as personal assistant to Lucien Knight, owner of an adult club empire. Lucien hates men who cheat on their wives and Sophie is about to learn about her husbands infidelity. Pick up the Knight e-trilogy by Kitty French for under $12 at amazon.com.
Body Shop bath goodies
It just isn't Valentine's Day without chocolate and strawberries. Pick up the Chocomania Body Scrub, formulated with real cocoa butter and organic cane sugar and pair it with their best selling soap-free Strawberry Shower Gel. Calorie free goodies starting at $6, thebodyshop-usa.com.
WTF Necklace by Sydney Evan
This necklace sums up what a lot of single girls feel like on Valentine's Day. Sydney Evan's WTF necklace is 14k rose-gold plating over sterling silver with a .015 carat bezel-set diamond, $125 at sydneyevan.com.


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The UK Climoor and Recovery roof
experimental field-sites
Some forms of pollution have fallen dramatically since the 1980's – for example sulphur dioxide from burning fossil fuels like coal has fallen by 60% since the mid 80's. Sulphur dioxide and smoke from the burning of domestic coal produces a visible dark haze in the air, and reduction of this pollution has made the air look a lot cleaner. But, other pollutants in the air have remained high within this time, for example nitrogen oxides emission have increased, from the increase in the number of cars we own. Nitrogen oxides react with other chemicals in the air to produce ozone and nitrates, which are bad for human health as well as damage crops and natural communities. Climate change is bringing changes in weather patterns and increased temperature, and this will also impact on the communities of upland areas and will effect the abilities of these habitats to recovery following pollution.
The Recovery roof project looks at how fast and well our moorlands will recover from pollution and how this will compare with changes brought about by climate change.
The Peak District is historically one of the most polluted upland areas, mostly because of its proximity to large cities like Manchester and Sheffield. The experiment replicates future predicted changes in pollution levels and climate. We aim to see how the plants, animals and the soil react to less pollution and the changes in climate that we might see over the next few decades. Our hope is to identify any changes that come from climate change and falling levels of pollution. This is important for land managers, who have to decide when to act to preserve these habitats and when nothing can actually be done at a local scale. For example, climate change and many pollution issues need a national solution – we're hoping that our project will help land managers focus on what they can do to save and improve these areas.
The Recovery Roof experiment is one of the few manipulation experiments that compares the impact of climate change with pollution reduction (i.e. looks at multiple drivers of change within the ecosystem). At the site we have similar climate change manipulations as are carried out at Climoor. These are replicated drought and warming treatments using Automated roof technology. In addition to the climate change manipulations, there is also a pollution treatment. This operates using a drought roof (that covers the experimental plot whenever rain is detected by a tipping bucket rainfall sensor), unlike the drought treatment, the pollution treatment operates year-round. Underneath the automated rainfall exclusion roof there is also an irrigation system which sprays polluted rain onto the experimental plots, in equivalent volumes and rates as rain falls at the site. The polluted rain is a reconstituted solution, consisting of rainfall collected at the site from large collection surface, which is deionised to pure water and then mixed with a chemically reconstituted rainfall solution, with nitrogen and sulphur related pollutants added.


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The aline silhouette and pleated sash accentuate the waist creating a slimming effect. A band of crystal starburst beading adds just the right amount of glamor. Functional fabric covered buttons beautifully line the rear zipper extend to the hem. Complete with a built in underskirt and American bustle.
EBI inspected and certified to be in excellent condition.
For further inquiry, email us or visit EncoreBridal.com
- Label Size: 10
- Street Size: 8
- Bust: 35.5
- Waist: 27.5
- Hips: 38
- Height with Shoes: 5'11
- Alterations: N/A
- Color: White
- Silhouette: Fit to Flare
- Material: Organza, Silk
- Neckline: Sweetheart
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- Condition: Sample
- Original Owner:
- Has Original Receipt:
- Preservation Method: Professionally cleaned. Some discoloration on some of the buttons - not highly noticeable
- Terms of Sale: Returns Accepted
- Location: San Francisco,
- Will Ship to: Other
- Payment Methods Accepted: Other
Please read our BUYER'S GUIDE before purchasing a dress online.


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275 members257 Comments 6 Likes
341 members285 Comments 21 Likes
Posted on June 23, 2016 at 7:40am 22 Comments 12 Likes
The American Left is just plain evil. Not only do they not seek truth, they suppress it. Everything the Left does, including shamefully exploiting the slaughter of Americans in a nightclub, is to further their deception and their power to force their unpopular agenda down our throats.…
Posted on June 17, 2016 at 7:37am 55 Comments 12 Likes
I was in the paint department. I placed the color sample next to the vase I had brought from home. "Excuse me, ma'am. Do these colors match? My wife says I'm colorblind." She replied, "Yes." Then she said, "Lloyd? You are Lloyd, right?"…
Posted on June 5, 2016 at 6:39am 11 Comments 7 Likes
Quoting the Pointer Sisters song, "I'm so excited!" Black pop icon Snoop Dogg's comments about the remake of the "Roots" TV series, in essence, is what I have been preaching to fellow blacks for decades (without his profanity).
Snoop said, "I'm sick of this s---. They are going to just keep beating that s--- into our heads about how they did us, huh?" Snoop spoke against new shows and movies…
Posted on June 1, 2016 at 8:10am 11 Comments 10 Likes
Folks, I got angry the other day. Mary and I were on the road most of this year campaigning for Ted Cruz. We're back home in Florida. My grass is over a foot tall, neighbors are still polite, and my lawnmower won't start. I dropped off the lawnmower for Darrell, our mechanic, to fix. But that is not what made me angry.…
Hi Lloyd: I listened to a part of your New-Years Eave special until my computer crashed. It was so nice to hear the voices of the people on the Conservative Campaign Committee. I will donate again as soon as I get my credit card paid off. Thank you for all all of you do for our great yest it's still a great country despite what's going on. May god bless you & keep all of you.
Thanks for fighting for America Lloyd!
Hi Lloyd - Please look this over as your schedule permits. Thanks for fighting for America. Cy Mallinson
www. constitutionalsupporttax.net
The CONSTITUTONAL SUPPORT TAX (the CST)
A States-based system to pay for Federal
expenditures that ends the Federal Government's
power to tax and borrow money
The States of the USA, and the People, have granted the U.S. Federal Government, through Congress, the power to tax, borrow and
create money. (Article I, Section 8, Paragraphs 1, 2, and 5 of the U.S. Constitution plus the 16th Amendment. The "Big Four.") The Federal Government has monopoly control over its own financing. Has this monopoly control worked out well?
On December 31, 2000, the U.S. National Debt was $5.662 trillion. December 31, 2008, $10.700 trillion. December 31, 2011, $14.025 trillion. And, despite the November 2010 election results, $15.675 trillion on May 10, 2012. A 277% increase in less than eleven years, six months. ((Source: www. TreasuryDirect.gov Debt to the Penny (Daily History/Search.))
It can arguably be said that these taxation, borrowing and money creation powers, granted with a sense of fiduciary trust by the People and the States to the Federal Government have been seriously and shamefully misused.
Changes need to be made to end this misuse. However, the needed changes go far beyond electing more responsible congressional and Presidential representation, as necessary as these steps may be.
Despite decades of talk about ending "waste, fraud and abuse" in spending, all three continue to thrive. The Government Services Administration (GSA) and Secret Service scandals of spring 2012 are only two examples. Surely there are many more.
The misuse, and potential for continued future misuse, will not be curtailed until the monopoly financing control created by the Big Four to pay for Federal expenditures is replaced by a States-based system. The CONSTITUTIONAL SUPPORT TAX (the CST) should be that States-based system.
In summary the CST will do the following:
With the power to raise money through taxation, borrowing in the credit markets and through the Federal Reserve ended, Congress will have a powerful incentive to prepare yearly budgets that are well within the bounds of what the Constitution will allow. The States and People will be very skeptical about paying for anything beyond providing for the "common defence" stated in the Preamble to the Constitution. The Founding Fathers intended such non-defense expenditures be handled and financed at the state or local levels. GSA Las Vegas outings and more should become closed history, never to return. Think about this fully, and you will correctly conclude that the CST is the only way to end the Federal overspending problem.
Please read the website at your convenience. Give it some time to "mentally digest." If you like the CST, please spread the word about it among your friends, family and colleagues. Questions can be submitted through the website or to me at the following contact information.
On the TEA party express events I attended, your positive spirit, your outreach to the attendance, your emphasis that there is not a black, white, or any other color America, but only always one America, were one of the major highlights of the events.
As an old white man, there is something I want to share with you. For many years I was perplexed by the dichotomy between what I heard and what I felt to be true. It is this. The black folks are just as conservative if not more so than me and yet their predominate political persuation was liberal.This in spite of evidence that Human nature says the closer to slavery we have been the brighter the fire of liberty in our belly.This fire in the belly has been held hostage far too long by the seductive tool of socialist contrived dependancy. The very presence of Herman Cain has helped to ameliorate this injustice.Too soon he was crucified.
Lloyd - this is little tboca here and I wanted to send you my last little blog and ask you if this might not be a good way to get some of the leaders engaged in "taking back our Country."
A Letter to Reverend Al Sharpton
Greetings Al Sharpton – I have observed you for many moons now and today here's a question for you as you fight what some call the "Good Fight." "Wouldn't you like to be a leader with solutions - in other words wouldn't you prefer being the solution rather than the problem? Below you'll find my answer to that question.
My answer to that is I want to be part of a positive solution that restores our Nation as One Nation Under God With Liberty and Justice for all. Knowing that you're a Baptist minister make me believe in my heart of hearts that down deep you want the same thing.
Isn't it time to give up the "Good Fight" whatever that is – none of us know anymore? Wouldn't you like to be a leader who fights for African Americans, Hispanics, Caucasians and all Americans in finding solutions to restore our Nation, which is tottering on a very weak foundation as we speak?
As I mentioned to Maxine Waters and the Black Caucus, it's alright to agree to disagree on issues, but let's hone the art of communication and problem solving once again. Let's be respectful of one another and join hands to bring solutions to the table.
Al, I believe we need to can the name tags at this time, because whether we're Republicans, Democrats, Liberals or Progressives we can work together regardless of race, religion or political preference. It's time to turn our eyes and hearts to our Country; it's time to unite for a common cause to restore our Nation back to a Government of the people, by the people and for the people.
Martin Luther King said, "I have a dream that one day this nation will rise up and live out the true meaning of its creed. We hold these truths to be self-evident that all men are created equal."
Billy Graham's vision for America is one of "peace and unity. Spiritual awakening would be No. 1," he says. "I think many people are praying that that will take place. And I think God will answer that prayer."
Two wonderful leaders who were brothers working together for a common cause – "Little Mike" said "Had it not been for the ministry of my good friend Dr. Billy Graham, my work in the civil rights movement would not have been as successful as it has been."
These two world leaders laid aside race and political preference; they believed that all men are created equal and their guidance and direction came from "God." So what say you, Al Sharpton lets walk away from politics and walk back to the people (Americans).
Let's lay aside our differences so we can be the solution, not the problem. Here is my email address and I hope you have time to contact me in the near future. firstname.lastname@example.com
May God Bless America
Lloyd Good Luck on Today.. Make the Tea Party Strong and heard. if you place it on You Tube send me the link or post I am sure I am not the only one who would want to hear the song and you singing. Thanks again for your thoughts.
I have one other thing I would like to email you I have been working on. if you can send me an email address I will send it to you and take a look at it. I would like to hear what you think about it. I am not a politician or a great speaker just a retired man with health problems on disability, that the mind will not slow down on.
Again Good Luck and Make us Proud.
© 2016 Created by Judson Phillips. Powered by


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The ratings are in for the week of July 28th and it seems Days of our Lives has the most gains. As it is the same week Kristen DiMera showed her lovely, evil face back in Salem we can assume this had something to do with the gains. The Daytime Emmy Winner's story began with Kristen kidnapping Daniel (Shawn Christian) and has gotten better and better each day as have all of the storylines going on right now.
DAYS was up in the key demo's with Women 18-49 up 73K, , Women 18-34 up 6K, it was the only soap to show gains and Women 25-54 up 81K which was the most of all soaps.
The Young and the Restless lost the most total viewers for the ratings period with -140,000, though since Y&R always has 4.5 million viewers, the -3% is of no importance especially since Y&R is number one in all the demos including 18-34, now beating GH in that rating.
.The Bold and the Beautiful lost -66,000, and then General Hospital which lost only -14,000. DAYS still remains in fourth place.
Total Viewers
4. DAYS 2,356,000 (+70,000/-100,000)see entire Soap Opera Network ratings here
To be among the first to receive news from the New York Soap Opera Examiner, please subscribe at the top or bottom of the page. It's anonymous and completely free. You can contact me at email@example.com or comment below. You can also visit my Facebook page Soap Savers Inc and leave comments or add some soap news yourself


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PODCAST PAGE: The WCCO Morning News With Dave Lee 7-14-14A busy ALL STAR show! Click the link to listen back to interviews from today.
Miss Minnesota Siri Freeh Ends Reign Next WeekSiri Freeh has been representing the state as Miss Minnesota for the past year.
Bachmann's Memoir Critical Of Both Bush And Obama Minnesota Congresswoman Michelle Bachmann will release a memoir on Monday recounting her journey from state senator to presidential candidate.


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