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Summary Organization Theory, Concepts and Cases (Robbins)
Te gebruiken bij
Auteur(s): Stephen P. Robbins and Neil Barnwell
Druk/Jaar van uitgave: 5th, 2006
Zoek recente samenvattingen & studiehulp
Voorbeeld hoofdstuk
H1 – Basics of organisation theory
An ORGANISATION is a consciously managed and coordinated social entity, with an identifiable boundary, which functions on a relatively continuous basis to achieve a common goal or set of goals.
The above definition implies that:
There is a management hierarchy involved in decision making in the organisation.
The unit is composed of people or groups of people who interact with each other.
Organisations have a boundary that differentiates who is and who is not a part of the organization. Organization's boundary can be created through explicit or implicit contracts between members and their organisation (e.g. contract of employment).
Organisations exist to achieve something and it is reflected iWn the organisation's goals.
ORGANISATION STRUCTURE defines:
how tasks are to be allocated,
what are the areas of responsibility and authority of each employee,
what are the reporting relationships, and
the formal coordinating mechanisms and interaction patterns that will be followed in the organization.
Organization's structure has three components:
Complexity, which considers the extent of differentiation within the organisation. This includes:
the degree of specialisation or division of labour (the number of different occupations and tasks that exist within the organization)
the number of levels in the organization's management hierarchy, and
the extent to which the organization's units are dispersed geographically.
Formalization, which is the degree to which an organization relies on rules and procedures to direct the behaviour of the employees.
Centralisation, which considers where the responsibility for decision-making lies.
It is important to recognise that an organization is not either centralized or decentralized. Organisations tend to be centralized or tend to be decentralized. The same applies to the concepts of complexity and formalisation.
Organization design is concerned with constructing and changing an organization's structure to achieve the organization's goals. Organization theory includes the study of the structure and design of organizations. Organizational behaviour is the study of the way in which individuals and teams behave in the workplace.
A system is a set of interrelated and interdependent parts which interact to produce a unified output. A SYSTEMS PERSPECTIVE offers important insight into how organizations operate.
Organizations can be considered to be systems – inputs go through a transformation process to emerge as outputs that are different in form to the inputs.
Systems are usually classified as either closed or open. A closed-system is a system that is self-contained – it essentially ignores the effect of the environment on the system and does not interact with it. An open system recognizes the interaction of the system with its environment and its dependence upon it.
Characteristics of an open system are:
Environment awareness – open systems acknowledge the interdependence between the system and its environment. In an open system it is recognized that changes in the environment affect one or more of the systems and subsystems and changes in the system affect its environment.
Feedback – open systems receive feedback from their environment. That is, they absorb information which helps the system to understand and adjust to environmental changes by taking corrective action to rectify deviations from its planned course.
Cyclical character – open systems consist of cycles of events; the repetition of the cycle is possible as system's outputs furnish the means for new inputs.
Tendency towards growth – open systems import energy from their environments and consequently they are able to repair themselves, maintain the structure, avoid death and even grow (as they can import more energy than they put out).
Steady state – there is generally a balance between inputs from the environment and those spent to counteract the terminating of the system. As a result, the system experiences a relatively steady state with the character of the system remaining almost unchanged over long periods of time.
Movement towards growth and expansion – the many subsystems within the system usually import more energy from the environment than is required for the system's output. Consequently, the steady state is applicable to simple systems but, at more complex levels, becomes one of preserving the character of the system through growth and expansion.
Balance of maintenance and adaptive activities – open systems seek to achieve the balance between two sets of activities:
Maintenance activities are those activities which ensure that the various subsystems are in balance and that the total system conforms to its environment. This, in effect, prevents rapid changes that may unbalance the system. Examples of the maintenance activities are: the purchase, maintenance, and repair of machinery; the introduction and enforcement of rules and procedures.
Adaptive activities are necessary so that the system can adjust over time to variations in internal and external demands. Examples of adaptive activities are: planning, market research, and recruitment.
Equifinality – the concept of equifinality argues that a system can reach the same final state from differing initial conditions and by a variety of paths. In other words, an organizational system can accomplish its objectives with varied inputs and transformation processes.
The ORGANISATIONAL LIFE CYCLE refers to the pattern of predictable change through which the organization moves from start-up to dissolution. It is important to be aware that:
there are distinct stages through which organizations proceed,
the stages follow a consistent pattern, and
the transition from one stage to another is a predictable rather than a random occurrence.
Marketers identify that products move through four stages:
Birth or formation,
Maturity, and
An organization's life cycle follows a five-stage model:
Entrepreneurial stage – this is when the organization is in its formative years. At this stage:
goals tend to be fluid or ambiguous, and
creativity and managerial input is high.
In order to progress to the next stage an organization needs to acquire and maintain a steady supply of resources (e.g. capital and labour).
Collectivity stage – at this stage the organization's mission is clarified and its chances of survival have increased. The innovation from the earlier stage continues. Communication and structure within the organization is still quite informal. The organization is generally quite small, with intensive, hands-on management.
Formalization-and-control stage – at this stage the operation of the organization stabilizes (i.e. its production of goods and services becomes more established). Formal rules and procedures are introduced as predictability increases. Innovation is de-emphasized and efficiency and stability become more and more important. Decision making within the organization is clarified and established management positions emerge. At this stage, the organization exists beyond the presence of any one individual. As the roles within the organization have been clarified and defined the changes in organizational membership do not cause a threat to the organization.
Elaboration-of-structure stage – at this point, the organization has reached a large size with the characteristics of a bureaucracy. Management searches for new products and growth opportunities. The organization structure becomes more complex and elaborated. Decision making is decentralized.
Decline stage – as a result of competition, poor management, etc. the organization at this stage experiences falling demand for its products or services. Employee turnover is high and decision making becomes more centralized. Eventually organization ceases to exist.
Figure 1.3 on page 19 illustrates organizational life cycle.
Most important approaches to research in the organization theory field are:
Positivism is an assumption that the world may be known and improved by extending knowledge through research. Positivism leads to the development of normative theories. That is, researchers try to develop theories that are applicable across a wide range of situations.
Critical theory is an approach to studying organizations which concentrates on their perceived shortcomings and deficiencies. Critical theorists consider work in a capitalist system as inherently dehumanizing, oppressing and exploitative, particularly of minorities. They also tend to view managers not as an essential part of the organization but as an exploitative group allied with the forces of capital and management as the agent of capital against the worker. Most critical theorists seek to create conditions and organizational structures and practices that promote the emancipation of people.
Postmodernism theorists challenge the claim that science is objective and impartial. They think that it falsely promotes the concept that the world is capable of being known and controlled through reason. They propose that positivist approaches structure knowledge in ways that do not represent what is occurring in organizations. Postmodernists consider knowledge to be socially constructed and interpreted.
H2 – Management theories
In the 18th century the concept of division of labour was developed. The division of labour is the breaking down of tasks into simple components which can be undertaken on a repetitive basis by job specialists. Adam Smith was one of the first to write about the economic advantages of the division of labour and he concluded that the division of labour can bring about significant efficiencies. The introduction of division of labour implied that:
someone had to decide what to produce,
how to produce it, and
provide the capital equipment and then staff.
Additionally, a far more sophisticated system of exchange was required to trade the outputs of the division of labour. Adam Smith recognized that market forces played this role, and he was the first to describe the role of markets and the price system as mediators in economic exchange (the concept of 'invisible hand').
In the 19th century two major industrial innovations took place: the emergence of mass production and the introduction of railways. These had serious implications on the organization theory.
The development of the mass production system became the basis of the modern industrial structure, with workers, lower- and middle management, and general managers. New departments emerged to improve flows of information and assist management control (e.g. accounting and planning) and to promote innovation and the introduction of new techniques and products (e.g. research and development).
The development of railways was also quite influential. Railways were very knowledge and labour intensive and large numbers of people had to be employed with many different job specialisations. The railways were structured along departmental lines, with each department specialising in a particular task - this promoted effective work effort and minimized complexity. Additionally, clear lines of authority were introduced and areas of responsibility spelt out.
The main aim of theorists during the 1900-1930s was to identify universal principles and management techniques that could be applied in a workplace. The output of the various theorists from that period is called the classical school. Although many different approaches were developed at that time, the classical theorists had in common the view that organizations were established, and managed, to achieve rational goals (e.g. profit). They viewed the ideal organization as a closed system created to achieve goals efficiently.
Frederick Winslow Taylor was a mechanical engineer who after years of conducting experiments with workers proposed four principles of scientific management, which, according to him, would result in significant increases in productivity. These principles are:
the replacement of inexact methods for determining each element of a worker's job with scientific determination;
the scientific selection and training of workers;
the cooperation of management and labour to accomplish work objectives, in accordance with the scientific method; and
a more equal division of responsibility between managers and workers (he proposed that the managers should focus on the planning and supervising, while the employees should focus on the execution).
Taylor's approach was widely criticised by workers for the shift in power from the worker to the manager, which leads to centralization in organizations.
The Frenchman Henri Fayol developed principles of organization. Fayol was more concerned with the problems of management than Taylor, thus he attempted to develop general principles applicable to all managers at all levels of the organization. He proposed 14 principles that, according to him, were universally applicable. These are:
Division of work – specialisation increases output as employees become more efficient.
Authority – it gives managers ability to give orders. To be effective, a manager's authority must equal his or her responsibility.
Discipline – employees should obey and respect the rules that govern the organization. Effective leadership, a clear understanding between management and workers regarding the rules, and the sensible use of penalties for violation of the rules provide for a good discipline in a workplace.
Unity of command – every employee should receive orders from only one superior.
Unity of direction – each group of organizational activities that have the same objective should be directed by one manager using one plan.
Subordination of individual interests to the general interest – the interests of any one employee or group of employees should not take precedence over the interests of the organization as a whole.
Remuneration – workers must be paid a fair wage for their services.
Centralization – whether decision making is centralized (to management) or decentralized (to subordinates) is a question of proper proportion; thus, the challenge is to find the optimum degree of centralization for each situation.
Scalar chain – the line of authority from top management to the lowest ranks represents the scalar chain and communications should follow this chain. Cross-communication can be allowed if agreed to by all parties and if superiors are kept informed.
Order – people and materials should be in the right place at the right time.
Equity – managers should be kind and fair to their subordinates.
Stability of the tenure of personnel – managers should provide systematic personnel planning and ensure that replacements are available to fill vacancies. They should keep in mind that high employee turnover is inefficient
Initiative – employees who are allowed to originate and carry out plans will exert high levels of effort.
Esprit the corps – promoting team spirit will build harmony and unity within the organization.
The German sociologist, Max Weber proposed the 'ideal-type' organization structure. He developed a structural model that, according to him, was the most efficient means by which organizations could achieve their ends.
He called this ideal structure bureaucracy. Such organization was characterized by:
division of labour,
a clear authority hierarchy,
formal selection procedures,
detailed rules and regulations, and
impersonal relationships.
Yet another contribution of the classical theorists is the rational-planning perspective. Ralph C. Davis proposed that structure was the logical outcome of the organization's objectives. The rational-planning perspective offered a simple and straightforward model for designing an organization – because management's formal planning determines the organization's objectives, these objectives determine the development of structure, the flow of authority and other relationships.
During the 1930s-1960s the main aim of theorists was to accommodate human needs in work practices with the focus on individual and group work. They looked at achievement of social goals with a closed system perspective. It became clear to these researchers that the motivations and actions of the workforce had a major impact on organizational effectiveness. They recognized the social nature of organizations and viewed organizations as made up of both tasks and people. Their movement is called human relations school.
Elton Mayo was an academic researcher involved in experiments being undertaken between 1924 and 1927 at an electrical manufacturing plant in the United States. His research became known as the Hawthorne studies. These studies emerged from work being undertaken by industrial engineers at the Hawthorne plant. They examined the effect of various lighting levels on worker productivity. Over the years, numerous additional experiments covering the redesign of jobs, changes in the length of the work day and work week, and introduction of rest periods were undertaken. The Hawthorne studies had a dramatic impact on the direction of management and organization theory. The outcome of the experiments caused that managers no longer considered the issue of organization design without including the effects on work groups, employee attitudes, and manager-employee relationships.
The notion that an organization is a cooperative system is generally credited to Chester Barnard. He merged the ideas of Taylor, Fayol, and Weber with the results from the Hawthorne studies. As cooperative systems, organizations should be seen as composed of tasks and people that have to be maintained at an equilibrium state. Attention only to technical jobs or to the needs of people who do the jobs sub-optimizes the system. Consequently, management should organize around the requirements of the tasks to be performed and the needs of the people who will perform them. Barnard challenged the classical view that authority flowed from the top down by arguing that authority should be defined in terms of the response of the subordinate; he introduced to organization theory the role of the informal organization; and he proposed that the manager's major roles were to facilitate communication and to stimulate subordinates to high levels of effort.
Another important approach from that time was developed by Douglas McGregor. He proposed two distinct views of human beings Theory X and Theory Y.
McGregor concluded that management's view of the nature of human beings is based on a certain grouping of assumptions and on the fact that managers style their behaviour towards employees based on those assumptions.
Under Theory X, management's assumptions are quite negative. Managers tend to think that:
Employees dislike their work and, whenever possible, will attempt to avoid it.
As employees dislike work, they must be persuaded, controlled or threatened with punishment to achieve desired goals.
Employees will avoid responsibilities and seek formal direction whenever possible.
Most workers are not very ambitious as they place security above all other factors associated with work.
Under Theory Y, management's assumptions are rather positive:
Employees can view work as something completely natural.
Employees will exercise self-direction and self-control if they are committed to the objectives.
Employees can learn to accept and even seek responsibility.
Most people can handle responsibility because creativity (the ability to make good decisions) and ingenuity are common in the population.
McGregor argued that Theory Y assumptions were preferable and that they should guide managers in the way they design their organizations and motivate their employees.
In the 1950s-1970s theorists were concerned with improving the manageability and decision-making processes of organizations.
The Peter Principle was proposed by Laurence Peter and Raymond Hull. They suggested that in large, stable, hierarchical bureaucracies which offered lifetime employment, managers would be promoted until they reached a level at which they were incompetent. This meant that in the absence of redundancies and downsizing, many managers were essentially incompetent, limiting the amount of effective work being accomplished in the organization.
Parkinson's laws – C. Northcote Parkinson proposed a number of laws relating to organizations. The best known of these is that work expands to fill the time available for its completion. Another of Parkinson's laws noted that in meetings the time spent on any item on an agenda is in inverse proportion to its importance.
Herbert Simon proposed that the assumption of rationality in decision making, as typified by 'economic man' is misplaced. He suggested the term 'administrative man' to describe decision-making behaviour. According to him, rational decision makers sought to optimise the outcomes of decision making, while 'administrative man' was satisfied with adopting a course of action that was barely satisfactory or 'good enough.' Simon proposed that decision making could be placed upon a continuum with programmed and non-programmed decision making at either end. He suggested that advances in information technology would lead to a move towards programmed decision making and, hence, greater rationality in decision making.
In the 1960s-1980s theorists focused on determining the most appropriate structural form. They looked at achievement of rational goals with an open systems perspective.
The CONTINGENCY APPROACH views the structure of organizations as contingent. It means that the structure is dependent on pressures that can be identified and analyzed. The researchers noted that organizations do not have an infinite number of forms, thus their structures could be predictable depending on the contingency factors. One of the main aims of their research was to help with improving organizational effectiveness by, given the contingency factors, providing managers with guidance as to the most appropriate structure.
Research in the 1960s by Joan Woodward, Charles Perrow, and the conceptual framework offered by James Thompson, have made an impressive case for the importance of technology in determining the appropriate structure for an organization. Other researchers looked at the importance of environment and organization size as the factors influencing structure.
Raymond Miles and Charles Snow published a book in which they proposed a categorization of strategy. They argued that in order to successfully implement the chosen strategy the organization needs to adopt an appropriate structure.
A paradigm is a model used as a framework of ideas. Paradigm proliferation refers to the emergence of a number of new frameworks with which to view organizations. These have emerged because the study of organizations is multidisciplinary and also because researchers approach their task from varying perspectives.
Symbolic-interpretive perspective views the organization as a social construct. It considers itself more with behavioural than with structural issues. The approach concentrates on how organizational participants interpret language and symbols in organizations and attribute meanings to relationships between people. It then examines how these interpretations and meanings influence the interactions between organizational participants.
Peters and Waterman popularized the idea that organizational culture had a significant impact on effectiveness. Their observations popularized the view of the culture of business organizations and redirected the research attention of management and business researchers.
A number of other approaches to organization theory have been developed and refined over the past 20 years and these approaches have little in common, which has contributed to the paradigm proliferation in the field.
One of the applications of economics to organization theory is that of agency theory. A manages in an organization has a number of subordinates, who are considered to be the manager's agents. The manager has the natural motivation to obtain as much benefit from his or her agents as possible, and the agents in turn have the incentive to avoid or otherwise cheat on the contract. The resulting behaviour is an outcome of the bargaining process. Another common application of agency theory is where the managers of a company are the agents of the shareholders.
Agency theory examines these relationships, particularly where there is asymmetrical knowledge – that is, where more is known about the transaction by one party than the other.
Institutional theory claims that organizational responses are often repetitive and products of past actions and practices, thus, over time, responses become institutionalized. These institutionalized practices are often the result of social pressures to conform to convention. As a result, many organizational actions and management decisions are imitations of past practices and many management decisions are seen to be cloning the practices of other successful organizations.
ORGANIZATIONAL EFFECTIVENESS is the degree to which an organization attains its short-term (ends) and long-term (means) goals, the selection of which reflect strategic constituencies in the organization's environment, the self-interest of the evaluator and the life stage of the organization.
It is important to remember that a company might be efficient but not effective. However, it is difficult to find a company which is effective but not efficient. Efficiency in resource usage is not a substitute for the wider measure of effectiveness.
There are various approaches to the study of organizational effectiveness, namely:
- the goal-attainment approach,
- the systems approach,
- the strategic-constituencies approach, and
- the balanced scorecard approach.
The GOAL-ATTAINMENT APPROACH states that an organization's effectiveness should be judged by whether it has achieved what it sets out to achieve (its organizational goals). Examples of organizational goals are:
- achieving certain quality outcomes,
- achieving certain profit objectives,
- increasing market share.
The goal-attainment approach assumes that organizations are:
- rational,
- deliberate,
- goal-seeking entities.
Consequently, successful goal accomplishment can be considered an appropriate measure of effectiveness. But the use of goals implies additional assumptions that must be valid if goal attainment is to be a viable measure of effectiveness. These assumptions are:
- organizations must have goals;
- the goals must be explicit, adequately clear, and widely known;
- there should be a manageable number of goals which reflect areas important to the organization (thus, organizations cannot set to achieve too many goals); and
- progress towards goals must be measurable and there should be a time limit attached to them.
Disadvantages of the goal-attainment approach are:
- Potential difficulties with choosing whose goals should be applied – should these be the goals of shareholders, top management, or goals of environmental pressure groups?
- Organizations tend to have "official" and "unofficial" sets of goals. "Official" goals are usually influenced strongly by standards of social desirability (e.g. 'to be a responsible member of the community' – such goal sounds desirable, but it does not really help to understand what the organization is trying to achieve).
Many organizational goals are confidential in order not to become known to competitors. Consequently, it may be difficult to assess whether organizational goals are achieved.
- Organizations usually have both short- and long-term goals. Thus, the problem is which goals should be used when applying this approach?
- Essentially all companies have multiple goals. In order to assess effectiveness management must decide which goals are the most important and rank them somehow. The problem arises – how to rank goals which tend to be quite different? That is, the goals of a financial department are quite different to those of a research and development, but which ones are more important for the organization?
In order to increase the validity of the identified goals managers should:
- Make sure that input is received from all those who have a major influence on formulating and implementing the official goals, even if they are not part of senior management;
- Recognize that organizations pursue both short- and long-term goals;
- Reduce the degree of incompatibility between goals;
- Aim to set tangible, verifiable, and measurable goals rather than rely on vague statements attempting to meet societal expectations;
- Be aware that goals usually change / evolve over time.
Some argue that defining effectiveness only in terms of goal attainment results in a incomplete measure of effectiveness. Thus, an organization should also be judged on its ability to:
- acquire inputs,
- process them efficiently,
- distribute the outputs, and
- maintain stability and balance between the various subsystems of the organization.
This means that the organization can maintain itself through a repetitive cycle of activities.
SYSTEMS APPROACH views end goals as only one element in a more complex set of criteria. Systems models stress additional criteria that will increase the long-term survival of the organization. These are:
- the organization's ability to acquire resources,
- maintain itself internally as a social organization, and
- interact successfully with its external environment.
In contrast to the goal-attainment approach, the systems approach focuses on the means necessary to ensure the organization's continued survival. Thus, it can be said that in the systems approach the main focus is not on the goals but on the way in which those goals are achieved.
One of the implications of the systems approach to effectiveness is that organizations are made up of interrelated subparts and, consequently, if any of these subparts performs poorly, it will negatively affect the performance of the whole system. Additionally, the system needs to acknowledge and interact with important environmental constituencies. In order to survive, the system needs a steady replenishment of resources consumed in production.
However, management needs to remember that the resources of the system are not just physical assets - they also include such intangibles as inventions and patents, brand names, etc. Failure to replenish these as they decay will result in the organization's decline.
The systems view looks at factors such as:
- the ability to ensure continued receipt of inputs into the system and the distribution of outputs,
- the efficiency with which the organization transforms inputs to outputs,
- the clarity of internal communications,
- flexibility of response to environmental changes,
- the level of conflict among groups, and
- rates of innovation.
These measures may be benchmarked against other organizations in the same industry. Table 3.2 on page 84 gives some examples of measurement criteria that could be used.
Another systems application of organizational effectiveness is the concept of added value, developed by John Kay. The cycle of absorbing inputs from the environment, turning them into usable products and services and then marketing these should leave a surplus of cash over and above that needed to maintain the system in its repetitive cycle. This surplus is called the value added, and Kay argued that the larger it is the more successful the company will be. He also argued that a commercial organization that does not add value cannot justify its existence in the long run.
Disadvantages of the systems approach are:
- Some process variables are specified and easy to measure; however, other critical ratios may not be as easy to quantify (e.g. rate of innovation).
- Where environments change very quickly, a certain set of measures may easily become irrelevant, making certain measures less important, while raising the importance of what previously was not considered significant.
- The systems approach seems to focus on the means necessary to achieve effectiveness rather than organizational effectiveness itself.
Advantages of the systems approach are:
- Management using this approach is less likely to make decisions that trade off the organization's long-term health and survival for ones that will make them look good in the near term.
- The approach increases the managers' awareness of the interdependence of organizational activities.
- It is applicable where end goals either are very vague or defy measurement.
The STRATEGIC-CONSTITUENCIES APPROACH proposes that an effective organization is one that satisfies the demands of those important parts of the environment, the constituencies, from which it requires support for its continued existence. Thus, it seeks to satisfy only those in the environment who can threaten the organization's survival – that is, the strategic constituencies.
Under this approach, organizations are assumed to exist within an environment where demands are placed on the organization by various important groups, or constituencies.
In such a context, organizational effectiveness becomes an assessment of how successful the organization has been in satisfying those strategic constituencies on which the survival of the organization depends. The 'political arena' metaphor highlights that the organization has a number of important constituencies, each with different degrees of power and each trying to have its demands satisfied. Additionally, the strategic-constituencies approach assumes that managers pursue a number of goals and that those selected represent a response to those interest groups that control the resources necessary for the organization to survive.
The stakeholder approach recognizes not only the importance of strategic constituencies but also of those who may not have the political power to influence the existence of the organization or even its direction (e.g. families of workers, environmental activists). Such groups, even though they may not be formally organized as a pressure group, are considered to be affected by the organization and should therefore be considered when important decisions are made.
Disadvantages of the strategic constituencies approach are:
- It is not always easy to identify the strategic constituencies, especially if the organization's environment is large.
- Because the environment changes rapidly, what is critical to the organization today may not be so tomorrow. Today's strategic constituencies may not be any threat to the organization tomorrow, while overlooked groups may suddenly threat the organization's existence.
- As with the goals in the goal-attainment approach, managers must rank the strategic constituencies somehow. It is often difficult to decide which strategic constituencies are more important than the others.
The BALANCED SCORECARD, developed by Kaplan and Norton, seeks to balance the various demands on the organization with its capabilities. The main aim of this approach is to provide an integrated measure of organizational effectiveness. Kaplan and Norton suggested that there is no one measure that can assess an organization's performance or that can focus attention on critical areas of the business; thus, the balanced scorecard attempts to view performance in several areas simultaneously and identify not just results but how the results were achieved.
The various components of the balanced scorecard are illustrated in Figures 3.1a-b on pages 92. The components attempt to identify four basic perspectives facing any organization. These are:
- Financial perspective – financial measures enable an organization to determine how profitable it is and its rate of return on assets. Thus, the financial measures indicate whether an organization's strategy and its execution are contributing to profitability, or covering costs.
- Customer perspective – goals and measures under this heading typically include assessment of time to delivery, product utility, market share etc. which, when combined, show how the product or service contributes to creating value for customers.
- Internal perspective – these measures concentrate on what the company must do internally to meet the customers' expectations.
This is a process-driven measure, examples of which may include quality attainment, costs of production, etc.
- Innovation and learning perspective – this goal is associated with the ability to develop and introduce new products of value to customers or clients. It also includes measures of continuous improvement and production efficiencies.
Kaplan and Norton stress that it is possible to have too many measures of organizational performance. They suggest that management should identify just a few goals for each of the four perspectives. The measures developed for each goal should be easy to understand and contribute to deciding whether the goal has been achieved or not.
The disadvantages of the balanced scorecard approach are:
- The identification and ranking of goals by importance is not an easy, subjective process; thus, there is no certainty that chosen goals and measures are the most relevant ones.
- The utility of the balanced scorecard may be limited if what is chosen to be measured is not important.
- As noted before, what is important usually changes over time, thus goals and measures may need to be changed quite often.
The disadvantages of the balanced scorecard approach are:
- It brings together in a single report many areas of importance to an organization's competitiveness. These include both short-term efficiency issues and those relating to the long-term adaptability of the organization.
- As senior managers need to consider all important operational issues together, they have to evaluate whether improvement in one area may have been achieved at the expense of creating problems in another.
Table 3.4 on page 97 summarizes each of the approaches discussed above.
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|968 sq. ft.
|Property type
|Minimum Stay
|7 nights
The Kirchmaier House is almost in the centre of the village of St. Johann. The house is in a very quiet area. The St. Johann ski-area, with its Bergbahnen, is 0.5 km from the holiday home. The Waidring ski-area, the Steinplatte, is 12 km away. The 74 km long Koasa ski-run is 200 metres from the home. The very spacious holiday home is on the first floor and is very pleasantly furnished. The holiday home has a balcony.
Classification: On 1st floor: (Hall, Kitchen diner(TV(satellite), cooker(ceramic), oven, fridge freezer), bedroom(Single bed, Double bed, washbasin), bedroom(Single bed, Double bed, washbasin), bedroom(Single bed, washbasin), bathroom(bath, shower), WC)
balcony, garden, garden furniture, BBQ, parking
These costs are charged on site. They are not included in the rental price.:
Deposit; No
Final Cleaning; Mandatory: € 45
Pets; Not allowed
Bed linen; Included
Bath towels; Included
Kitchen linen; Included
Electricity; Included
Gas/Oil; Included
Wifi; € 3/night
Tourist tax; Mandatory, indication: € 2 /person/night
Property very well located close to the center. Very friendly and helpful hosts. We got to the garage for bikes available at no extra charge. Large balcony. Near the swimming pool. Polecam.Przy seven people was felt no dishwasher.
The stay was very pleasant. Had the weather was often rainy ... patience! We relaxed a lot ... The owners are really nice and helpful! The "furniture is functional and the rooms really spacious, very well in the living room would be a couch. Recommended!
nice apartment, clean and bright. An easy chair available.
We have the experience as if we were friends and feel at home.
- Well located and clean apartment - Hospitable landlords
Beautiful and nice house worth, very clean we missed only one bank to any great to sit on.
Centre 500.00 km., Forest 1000.00 km., Lake 5000.00 km., General supplies 500.00 km., Public swimming pool 200.00 km., Public indoor swimming pool 200.00 km., Ski slope 500.00 km., Ski Bus 200.00 km., Cross Country 200.00 km.
*Plus compulsory or optional charges based on actual occupancy or consumption. The payment has to be made in the currency offered by the property manager, before use of conversion tool. Payments in other currencies have to be negotiated beforehand with the property manager. The currency conversion tool is provided for your convenience only and is non-binding.

subset: commoncrawl


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Mist The Tale Of A Sheepdog Pup
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Mist is one of three pups born at Borough Farm. From the moment that she
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interests at heart. Can Mist really learn her craft, and one day prove herself
worthy of a place in the team of Sheepdogs at Borough Farm?
Interactive menu
Region 2
Screen 16:9
Languages English
Duration 1 hour and 15 minutes (approx)
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Beautiful and salubrious eyes are craved by wholly but earned by few. Maintaining the health of your eyes is very easygoing simply is implied by few. Increasing figure of the great unwashed these days sound off of having grim circles about the eyes, wrinkles more or less the eyes or tumescent eyes. Eyes are the most victimised harmonium of our organic structure. It is of import to subscribe suitable tutelage of wimpernserum test our eyes and the shinny close to it.
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UPDATE: Traffic back to normal on Highway 30 in Linnton
UPDATE: 4:21 p.m.
The high water has receded in Linnton on Highway 30 and traffic is now moving at a regular pace.
The previous report follows:
Commuters should be prepared for significant delays on Highway 30 at Linnton today as the eastbound lanes have been temporarily closed because of flooding.
As of 2 p.m. on Jan. 19, the Oregon Department of Transportation says drivers should expect estimated delays between 20 minutes to 2 hours because of high water. Traffic is being diverted into the westbound lanes at Harborton Drive. ODOT says to use caution when commuting.
View a cell phone video of the flooding here:


text:
Meet Eli A. Finkelstein
Dr. Eli A. Finkelstein is a board certified, fellowship-trained physiatrist in Roswell and Cumming, Georgia. Dr. Finkelstein specializes in electromyography (EMG), nerve conduction studies, spinal injections and non-surgical treatments.
Dr. Finkelstein is a member of Resurgens Orthopaedics.
Directions to our primary location in
How Eli A. Finkelstein Can Help You
- Physiatrist
- Arthritis
- Degenerative Disc Disease
- Facet Joint Syndrome
- Muscle Strain
- Osteoarthritis of the Spine
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Accolades for Eli A. Finkelstein
Professional Affiliations
- American Academy of Physical Medicine and Rehabilitation
- American Society of Interventional Pain Physicians
- Physiatric Association of Spine, Sports and Occupational Medicine
- American College of Sports Medicine
- American Medical Association
Board Certifications
- Board Certified, American Board of Physical Medicine and Rehabilitation
- Board Certified, American Board of Physical Medicine and Rehabilitation; Subspecialty-Pain
Office Information for Eli A. Finkelstein
Primary Location:
1285 Hembree Road
Suite 200-A
Roswell, GA 30076
View Dr. Finkelstein's Bio on the Resurgens Orthopaedics Website
Additional Locations
1100 Northside Forsyth Drive
Suite 340
Cumming, GA 30041
Driving directions
Suite 340
Cumming, GA 30041
Driving directions
This information was supplied by or on behalf of the provider.


text:
Rolling in Rejection
My new Denfield clock had let off it's blaring squeal to many times to count by the time I dragged myself from my down filled cocoon of depression. The inscription above the face reads "tomorrow is another day" I contemplate sleeping until then.
The sun shining it's annoying shade of orange reminds me again it is after noon and I am again awake to greet the day. Crap. I accidentally glance up into the mirror as I brush the sod off my teeth and wash the night out of my hair in the sink, I look like hell. My eyes rimmed in a deep red from nights staring at a blue screen alone, wishing it were easier to just pump out a top grade idea that would finally get my name on some sort list they would read. Or at least consider to read. Lately I have been trying to focus mainly on magazine stories, independent horse manure that might catch someone's attention, anyone. I find myself falling repeatedly into this rut of wanting the next American novel; that is where the recognition is, the praise. The real money! and thats what I NEED.
I quit my job three months ago and wrote a 400-page manuscript, I pretty much eat KD, spend what's left of fairly substantial savings on a house my father left me in a will filled with good wishes and not much more and I currently live off my soon to be ex's' parents, who love me possibly more than they should. See, I'm not completely useless I just could not look at another stapler or copywrite promo for another useless DIY project. I knew it only takes one publisher and I was sure it was Ruth Gudgeon from Harpers Inquire, I read she found Tom Clancy or Wally Lamb or some other note worthy mind hacker. I sent my polished manuscript direct to her office (it helps to have insiders) unfortunate for me I received not only a note of rejection but also an unopened envelope containing all 400 pages untouched. The note read:
"Harpers Inquire does not now accept unsolicited submissions or query letters. Please refer all future correspondence through agent or person of interest with in the Harpers Family of subsidiaries"
Not a thank you to be seen; just an F-YOU BUDDY GET AN AGENT! but I cant afford an agent, I can hardly afford to pretend to pay off the bills I already have.
I pull on a pair of umbro track pants and a tank top heading out the back door to make a round trip to pick up my mail from the front as i do every morning since the quit. Lounging in my bathrobe until 3pm may be alright by me but I see my neighbors judging stares, "Can't a good young person get a job?" or that "I couldn't possibly have enjoyed the day". I find it better to fain a life than to have one at this point.
I am pleasantly surprised to find when I open my letterbox, fifteen letters all addressed to myself from several publishing agencies, no large brown envelops good news, I have learnt the smaller the response the better. Though I have no reason to, if my past luck persists, I am largely optimistic. I throw the flyers and postmarked pat due billing notices on the counter next to the fridge and take a seat in the light of my dining rooms large bay window, I don't eat in here it should be used for something.
I open the letters one by one.


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Published bySusana Ong Modified over 2 years ago
Lyndee Knox, PhD LA Net A Project of Community Partners THE PCMH
Change is Hard . . .
Objectives Create a common departure point for discussion to follow
A 101 overview, not a deep dive into PCMH Introduce PCMH efforts underway in L.A.
Presentation Outline Defining the patient-centered medical home model
PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model PCMH Evaluations & Results Resources for practices LA Area
What is a Patient Centered Medical Home (PCMH)
The patient-centered medical home is "a model for care provided by physician practices aimed at strengthening the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship." (NCAQ) A recent Journal of General Internal Medicine provides a core definition of the PCMH as a team of people committed to improving the health and healing of individuals in a community.
According to the ACP, it is:
…a vision of health care as it should be …a framework for organizing systems of care at both the micro (practice) and macro (society) level …a model to test, improve, and validate …part of the health care reform agenda
Other descriptions The PCMH is a political construct that includes new ways of organizing and financing care, while attempting to remain true to the proven value of primary care (Stange et al, 2010) PCMH requires a compact between payers and primary care practices. Simultaneously, Practices improve their care Payers pay the practices more to help them improve their care Neither practices or payers can do it themselves. Both are needed (T. Bodenheimer)
Based on the Joint Principles
Team-based care: NP/PA RN/LPN Medical Assistant Office Staff Care Coordinator Nutritionist/Educator Pharmacist Behavioral Health Case Manager Social Worker Community resources DM companies Others… Personal physician in physician-directed practice teams Whole person orientation responsible for care or arranging care for all health care needs Coordinated care, integrated across health care settings and community facilitated by registries, IT, HIE etc Quality and safety emphasis with EBM, point of care support, performance reporting, patient input Enhanced patient access to care through open scheduling, expanded hours, new option for communication Supported by payment structure that recognizes services and value
Principles were created by the
ACP, AAFP, AAP, and AOA—representing 330,000 physicians—and IBM and other major businesses in March 2007 To provide a standard definition of the delivery model and describe the environment necessary to support it (2007)
Referred to as the Patient Centered Primary Care Collaborative (PCPCC)
The Patient Centered Primary Care Collaborative (PCPCC), which formed in 2007, has over 700 member organizations Organizations representing over 350,000 physicians—including ACP and other primary care societies, American College of Cardiology, American Academy of Neurology Organizations representing over 50 million employees, including large employer umbrella groups, and individual companies such as IBM, General Motors All major health plans CVS Caremark, including MinuteClinic Consumer organizations including AARP Bridges to Excellence National Association of Community Health Centers PCPCC organizations attest to their support of the PCMH Joint Principles, including the belief that the PCMH will "improve health of patients and the viability of the health delivery system," and support a better payment model to facilitate implementation PCPCC on the web:
Critique of the PCMH: Some feel it doesn't go far enough
The rushed 15 minute visit and lone doctor model are central to the problem Driven by payment models and tradition Team based care is essential to practice of the future PCMH may not go far enough in addressing these issues T. Bodenheimer
Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model PCMH Evaluations & Results Resources for practices LA Area
How do you Know a PCMH When you See One?
Process needed to recognize practices that have and use the capability to provide patient-centered care Practice recognition ostensibly provides purchasers (employers, government) and patients with prospective assurance that the practice has capabilities National Committee on Quality Assurance (NCQA) announced a voluntary recognition process based on its Physicians' Practice Connection (PPC) module, the PPC-PCMH in January 2008 ACP, AAFP, AOA, and AAP helped NCQA develop the module Undergoing revisions now, with new version to be released in January 2011 Other entities are developing PCMH recognition/accreditation processes - Joint Commission, URAC, CARF, AAAHC. MacColl Institute just published a new measure as a teaching/learning tool, and based on the 8 joint principles.
Recognition Programs for PCMH Developed or Under Development
Quality Organizations PCMH Standards Activity 2010
NCQA PPC-PCMH Recognition Module; Major Domains/Standards
Access & Communication Patient Tracking & Registry Functions Care Management Patient Self-Management Support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting & Improvement Advanced Electronic Communication Each standard contains sub-elements – 10 of which are considered "must pass" Each standard contains sub-elements 10 of which are considered "must pass" Standards are currently under revision and will be available Jan 2011 – Integrate IT w/in core domains For more information: 15
Key Points for Level 1 PCMH
Does not require electronic health record Does require registry & tracking functions Emphasis is on providing better care through: Access to care Organization of office structure & processes Enhancing patient self-management; addressing health literacy issues Introduction of evidence-based guidelines, measurement & quality improvement
Level 2 → Level 3 Advanced access options for patients
Electronic health record More, and more complex care coordination and patient support Robust population management Advanced reporting and quality improvement initiatives Additional technology solutions
More Features of a PCMH Practice
Uses each team member to his/her highest capability Supports cultural competency training for clinical team Understands health literacy Establishes connections to the community and available resources Provides extensive self-management support Engages a Patient/Family Advisory Group
NCQA Recognition Activity
>1500 practices have received recognition 33% Level 1 5% Level 2 62% Level 3 58 % of practices have < 5 physicians at the site 47% of practices are part of multi-sites Concentration in the Northeast and Mid-South Practices more likely to seek recognition when/where tied to reward About 66% are adult primary care practices; 15% are pediatric practices 31 (17%) are community health centers SOURCE: NCQA, July 2010
SOURCE: NCQA, December 2009
Critique of NCQA Beal et al created a patient centered definition of a medical home w/ 4 questions: Do you have a regular doctor or place of care? Can you easily contact your provider by phone? Can you easily get care or medical advice on weekends or evenings? Are your physician visits well organized and running on time? Practices doing well on these could flunk NCQA Many standards require that a practice have a "plan" to improve, but do not require demonstration of improvement and no clear benchmarks in many cases T. Bodenheimer
Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Efforts to test the PCMH model PCMH Evaluations & Results Resources LA area
Complex Delivery Health care delivery is complex – e.g., the typical primary care physician coordinates care with 229 other physicians working in 117 practices H H Pham, et al Ann Intern Med. 2009;150:
Specialty Care Connections
PCMH is NOT a gatekeeper system Emphasis on transitions in care & continuity (e.g., referral agreements, care transitions programs) ACP Council of Specialty Societies PCMH workgroup: Developed FAQs on the relationship of the PCMH to specialty physicians* Facilitating the development of the "PCMH Neighbor" concept * FAQs available at: running_practice/pcmh/understanding/specialty_physicians.htm
Patient Centered Medical Home Neighbor (PCMH-N) Draft Definition
A specialty practice recognized as a Patient Centered Medical Home Neighbor (PCMH-N) engages in processes that: facilitate communication, coordination and integration with a PCMH practice to promote high quality and efficient care facilitate appropriate and timely consultations and referrals that complement the aims of the PCMH practice facilitate the efficient, appropriate and effective flow of necessary patient and care information effectively addresses issues of responsibility in co-management situations support patient centered care, enhanced care access and high levels of care quality and safety recognize the PCMH practice as the provider of whole person primary care to the patient and as having overall responsible for ensuring the coordination and integration of the care provided by all involved providers These processes would take the form of service agreements (compacts) between/among the participating practices.
Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model PCMH Evaluations & Results Resources LA Area
Combined Commercial and Medicaid/CHIP PCMH Activity
Thirty -seven (37) states trying to improve medical home availability in Medicaid/CHIP programs Commercial projects under way in 39 states. = Identified to have both a private payer and a Medicaid and/or CHIP medical home initiative = Identified to have a Medicaid and/or CHIP medical home initiative = Identified to have at least one private payer medical home pilot under development or underway * As tracked by the American College of Physicians (updated March 2010)
Federal PCMH Efforts Medicare Medical Home Demonstration Project Authorized under Section 204 of the Tax Relief and Health Care Act of 2006 October 26, 2009: Project put on hold by CMS pending legislation that would repeal it and replace it with a similar pilot Medicare "Advanced Primary Care" Demonstration Project New 3-year project announced by HHS Secretary Kathleen Sebelius on September 16, 2009 Will allow the participation of Medicare beneficiaries in state-initiated medical home projects that also include Medicaid and private payers Currently seeking applicants – due by August 3, 2010 CMS/Health Services and Resources Administration (HRSA) Announced by President Obama on December 9, 2009 Will evaluate the impact of the advanced primary care practice model on the accessibility, quality, and cost of care provided to Medicare beneficiaries served by Federally Qualified Health Centers (FQHCs). For more information on CMS/Medicare PCMH Efforts:
Federal PCMH Efforts (cont.)
Veterans Administration 820 primary care sites 4.5 million primary care patients Using the ACP Medical Home Builder Department of Defense National Naval Medical Center PCMH Pilot Air Force Family Health Initiative Tri-Service Medical Home Summit 2009; Second Summit being planned for 2010 "The PCMH model of care will be implemented across the Services" – MHS Policy Statement on September 18, 2009 PCMH Activities also occurring in: AHRQ, SAMHSA, CDC
Safety-Net Medical Home Initiative
Launched by The Commonwealth Fund, Qualis Health and the MacColl Institute for Healthcare Innovation Project duration: April 2009 – April 2013 Project goal – to develop a replicable and sustainable implementation model for medical home transformation Five Regional Coordinating Centers (RCCs) have been selected: Colorado Community Health Network Executive Office of Health and Human Services & Massachusetts League of Community Health Centers Idaho Primary Care Association Oregon Primary Care Association & CareOregon Pittsburgh Regional Health Initiative Source:
Common Practice Support Approaches in PCMH Demos
Payment – e.g., PMPM, performance bonus, shared savings Learning Collaboratives – face-to-face and and/or virtual Practice facilitation– on-site and/or virtual ACP Medical Home Builder Provision of and support for information technology – e.g., registries, EHRs Data services – e.g., aggregation for patient population management and performance reporting Engagement of patients as advisors
Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Growing support for the PCMH model Efforts to test the PCMH model Evaluations & Results on he PCMH Resources LA Area
Evaluation Collaborative sponsored by Commonwealth
Approximately 14 independent evaluations represented in the PCMH Evaluators' Collaborative. The evaluations are examining a breadth of demonstrations: From one payer to multi-payer pilots Involve anywhere from 5-70 primary care practices with clinicians Include 27, ,000,000 beneficiaries Many include safety net centers, pediatric sites and Medicaid as a payer Variety of payment models (hybrid, PMPM, annual comprehensive PC fee) All of these independent evaluations have comparison groups
Community Implications - Published Results of PCMH Projects to Date
Group Health Cooperative of Puget Sound 29% reduction in ER visits; 11% reduction in ambulatory care sensitive admissions Improvements in diabetes and heart disease care Cost neutral after 1 year Geisinger Health System 14% decrease in hospital admissions 9 % reduction in costs ROI greater than 2 to 1 Source: PCPCC Pilot Guide, 2009
Community Implications – Published Results of PCMH Projects (cont.)
Colorado Medicaid & SCHIP Median annual costs $785 vs $1000 Reduction in ER visits & hospitalizations More well-child visits (72% vs 27%) Lower median costs for children with chronic conditions ($2,275 versus $3,404) HealthPartners Medical Group (MN) 39% decrease in ER visits 24% decrease in hospital admissions Better diabetes and cardiac care Reduced costs Source: PCPCC Pilot Guide, 2009
Community Implications
Metcare of Florida/Humana PCMH Program Started in November 2008 & Concluded in October 2009 Studied the impact of the PCMH model in a Medicare Advantage (MA) capitated group Hospital days per 1000 customers dropped by 4.6 percent compared to an increase of 36 percent in the control group Hospital admissions per 1000 customers dropped by three percent, with readmissions running six percent below Medicare benchmarks Emergency room expense rose by only 4.5% for the Metcare group compared to an increase of 17.4% for the control group Recent study – National Demonstration Project Practices made changes, process measures improved, docs happier, but patients were dissatisfied and felt disconnected from physician Source: Metcare Press Release, February 23, 2010
Community Implications
Not yet published: WellMed Advanced PCMH All cause mortality down 34% in last 8 years. CVD patients BP under control last visit > 90%, LDL under control >90% Diabetes - similar numbers Actual improvement in care are possible and realizable but it will take huge payment reform on top of the PCMH model. Source: Metcare Press Release, February 23, 2010
Future of Family Medicine
Estimates on Co$t? Future of Family Medicine Transition costs of $23,000 - $90,000 per physician $15 PMPM for patients with chronic conditions Deloitte Analysis Initial investment of $100,000/FTE Ongoing expenses would increase $150,000 per year/FTE Future of Family Medicine Report (http://www.annfammed.org/cgi/reprint/2/suppl_3/s1 ), 2004 Deloitte: The Medical Home, Disruptive Innovation for a New Primary Care Model (http://www.deloitte.com/dtt/cda/doc/content/us_chs_MedicalHome_w.pdf), 2008
AMA Relative Value Update Committee (RUC)
What Does it Co$t? AMA Relative Value Update Committee (RUC) Average of $40–50 PMPM for patients with qualifying conditions Commonwealth report Using cost data from Medical Group Management Association and ACP Checkup Tool for 2006, from 35 practices, found less than a $1-per-month difference in patient costs between highest PPC-PCMH scores and those in the middle and lower thirds. (Zukerman et al 2009) AMA (http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/ruc-medicare-medical-home-demonstration-project.shtml), 2008 Urban Institute Report - Co-Funded by The Commonwealth Fund and ACP – Available at: 2009
Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Efforts to test the PCMH model PCMH Evaluations & Results Resources to support PCMH Advancement LA area
Some resources for Practices
PCPP --- Tools for practices, patients Meaningful Connections: IT and the PCMH National Academy for State Health Policy AAP Toolkit ACP Medical Home builder TransforMed resources NCQA webex training on accreditation MacColl Institute's Tool PCMH-A Planned: AHRQ National Learning Collaborative for Facilitating PCMH advancement Recent Journal supplements on the PCMH AFM Supplement Health Affairs, 29, no. 5 (2010) supplement on the PCMH Annals of Internal Medicine Links are available to much of this material on LA Net's website:
Presentation Outline Overview of the patient-centered medical home model PCMH recognition program Specialty Care Connections Efforts to test the PCMH model PCMH Evaluations & Results Resources to support PCMH Advancement Projects in LA
Local Activities to Support PCMH
L.A. Care PCMH Initiative LA Net CCM and PCMH funded by AHRQ L.A. County initiative
LA Net Is a Practice-Based Research and Resource Network (PBRN) for the region Focused on improving quality and reducing disparities and through: provider-led research on issues that matter supporting local learning and innovation implementing best practices
Network for generating & disseminating good ideas
LA Net (cont) Consists of 16 FQHC/CHC "partners" representing 116 practice sites Governed by a board of 80% clinicians, 20% researchers, others. John Kotick – Current Chair Felix Nunez – Past Chair
LA NET Part of a national network of more than 100 PBRNs in the U.S.
Some recent projects Management of Obstructive Sleep Apnea in Primary Care (AHRQ/CMS) National Children's Study pilot (NICHD) Study of AHRQ's web-based medication errors and adverse drug event reporting system for primary care (MEADERS)
Examples of projects Replication of a diabetes self-management program in 23 PC practices in Texas (AAFP, Lilly, WHO) Development of low-cost "talking" survey software to use with low-literacy patients available in 7+ languages
AHRQ funded CCM and PCMH project
Evaluating use of practice facilitation to support 20 FQHC/CHCs in CCM and PCMH changes Based on input from steering cmt: Tom Bodenheimer, Jim Mold, Grace Floutsis, Rich Seidman And experts from US and Canada during Consensus Panel hosted by LA Net in January 2010 Blueprint Vermont, CareOregon, Oklahoma, IPIP, Impact BC, Quality Counts, QIIP, and others Continuation of project by MacColl, RAND, Safety Net Institute
Long-term goal: Provide sustained workforce to practices
Demonstration of Primary Care Extension Program Created by recent reform legislation –modeled after agricultural extension program Jim Mold was author - working with us to design demonstration PCMH projects and REC in LA might provide foundation
Acknowledgements Shari M. Erickson, MPH
Senior Associate, Center for Practice Improvement & Innovation Tom Bodenheimer, MD UCSF Katie Coleman, MPH MacColl Institute Jim Mold, MD U of Oklahoma
References American College of Physicians The Advanced Medical Home: A Patient-Centered Physician Guided Model of Healthcare. American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA) Joint Principles of the Patient-Centered Medical Home. March American Academy of Family Physicians (AAFP) The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Annals of Family Medicine 2 (1): S3-S32. American Academy of Pediatrics, Council on Pediatric Practice. Pediatric Records and a "medical home." In: Standards of Child Care. Evanston, IL: American Academy of Pediatrics; 1967: 77–79
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Lillth stood on the stairs, smiling her evil little bastard smile.
"That leaves you to go to hell." I said.
"Shut up, Bitch."
"Shut up, slut." I replied.
"Your one to talk." she spitted. I laughed and tossed my head back.
"I can kick your ass, Lillth. Even if I'm pregnant."
"Good to know."
Hephzibah placed her hand on my upper arm.
"Think about what your about to do."
"I'm about to do what I should have done the day she come into my home." I replied. I walked up the steps toward her, grabbed her hair, and pushed her down. She grabbed my leg, and tried to pull me down. I just laughed, and walked away.
"Your not going to win." I said coldly. She murmured something to herself and returned to her room.
"So, shall we go to Olympus?" I asked. They both nodded. I clapped my hands.
"So, your pregnant?" Alcatraz asked me later as we walked.
"I would believe so." I said.
"Hmm..and it's a girl?"
"What do you want to name her?" he asked. I bit my lip and sighed.
"I don't know." I sighed. "Something Greek?" I asked.
"Sounds right."
"Hmm.." I thought. I knew no Greek names.


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Our expert Celia Rufey answers your questions
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|Property type
|Minimum Stay
|3 nights
Twistlewood is a highly desirable,comfortable,bright and airy accommodation, tastefully furnished throughout.and decorated in calm rural tones.Set in a peaceful location Wootton is approx. 1/2 a mile from the village of Bashley where you will find a Post Office/shop petrol Station,2 Garden centres,and 2 very good farm shops. Venture further afield and you will find the town of New Milton with a well appointed High Street with Banks, Supermarkets and gift shops. A main line Train Station and an excellent bus service to take you around the forest. Just 8 miles away you will find the Georgian town of Lymington with plenty of shops, bars, cafes and restaurants. The beaches of Barton on Sea, Milford on Sea, Highcliffe and Mudeford are all within easy reach.
Hi We are Kelvin & Kay and we have spent many happy holidays in the New Forest, a year ago we decided to take the plunge and move away from the hectic county of Surrey. We were very fortunate to have found Twistlewood and have wasted no time in sorting out the garden, making Vegetable beds, and buying 6 Indian Runner Ducks which have been laying well and many guests have enjoyed the eggs. We are an easy going couple and when we have time enjoy visiting our local pubs and restaurants.
Kay Searle purchased this bungalow in 2013
We chose this location for its rural feel and closeness to the beaches at Barton on Sea and
Highcliffe. New Milton High Street has all we need on a daily basis or we can get to Bournemouth or Southampton if we want to.
At Twistlewood you can enjoy peace and quiet, hear the birds sing from dawn to dusk, unwind and relax in the tranquil setting.
Enjoy the well appointed kitchen facilities or head out to one of the local pubs for your meals and after a long day exploring the Forest you can return to Twistlewood and pamper yourself in the beautiful shower room.
We had a really lovely time and everything we needed was left for us, the owner left a basket full of little necessities, the kitchen was fully equipped and the shower room was clean and practical. The only fault we could both find was the bed was a little small for us both due to the fact we have a king size bed. All in all we had a wonderful stay and would recommend it to anyone
Fantastic annex, clean, modern, just perfect. The welcoming basket was a surprise and you had thought of everything we could have wanted. Lovely comfortable bed and the shower was heaven!. Kay and Kelvin are very welcoming cannot recommend this property high enough - thank you
The property was clean very modern well equipped and high quality . Although no sitting room the bedroom is really spacious so it's not a problem. Every thing had been done to a high standard and resembled a boutique hotel. Wouldn't hesitate to return but next time we would take our bycycles as we could have explored the new forest in detail. Great location and very private a truly memorable place. The owners were very welcoming but not intrusive and always round about if you needed them. We will definitely return.
Had a lovely lovely, peaceful, tranquil, idyllic week here. Despite having to work during the day I felt like I was on holiday . How much better can it be. Everything you want in a snug little place for 2 .... Starter pack of breakfast, all the facilities, comfy bed, Internet and freshly laid ducks eggs c/o Norman and the girls! Even ponies outside and when you opened the windows......... the silence was bliss. I'll definitely be back.
We were so lucky to have found this perfect little oasis in the New Forest National Park!
When I initially booked, I hadn't really taken much notice of the facilities etc, we had just wanted to get away for a break. How excited we were when we arrived and found the most, cosy, clean and accommodating little annexe with `high spec' facilities; lived in the shower!!
Thank you Kay and Kelvin! Although we were unable to meet you personally during our stay, you left us in the capable hands of your lovely neighbours, Evan and Beth. Thank you Evan for our chats! Great fun.
We will certainly be back. Ian and Joy
This was a last minute booking as our previous accommodation was cancelled due to a double booking by the owner. I must say The Annexe more than made up for our disappointment. A real hidden gem that is fantastically situated for exploring the New Forest. The accommodation is extremely comfortable and well equipped with everything thought of by Kay & Kelvin.The bathroom is very 'boutique hotel' with the remainder of the accommodation thoughtfully appointed giving a modern clean comfortable feel. The welcome hamper was a lovely surprise, especially the duck eggs! There is ample choice locally for eating out, we enjoyed meals at the Hare & Hounds pub (Sway) and The Anchor (Tiptoe). Buckles Hard at Beaulie is a good day out for some local history and great scenery. We had a great weekend which was made all the better by our accommodation to which we WILL be planning a return visit. If you're looking for an ideal base for two look no further!
Bournemouth and Southampton airports are less than 15 miles away.
New Milton, Brockenhurst, Lymington train stations are all within 8 Miles
A car is recommended to reach us, just off the A35 on the B3058.
Bashley 1/2 mile
New Milton 3 Miles
Lymington 8 Miles
Brockenhurst 6 Miles
Burley 3 Miles
Christchurch 6 Miles
Bournemouth 12 Miles
Further Details:
There are plenty of things to see and do in the New Forest, leading attractions such as The National Motor Museum at Beaulie, Exbury Gardens and Steam Railway, Bucklers Hard, Highcliffe Castle to name but a few.Fishing trips are available from both Lymington and Keyhaven and a car ferry runs from Lymington to Yarmouth on the Isle of Wight.
Historic bustling towns of Bournemouth, Winchester and Sailsbury are only a short drive away.
For the nature lover vast areas of the New Forest have abundant wildlife and plants along with free roaming Ponies, Donkeys, Cattle and Pigs, making it a perfect place to come and enjoy your holiday.
|Rate Period
|Weekend Night
season two
Apr 1 2017 - Sep 1 2017
3 night minimum stay
season three
Sep 2 2017 - Dec 30 2017
3 night minimum stay
My Standard Rate
3 night minimum stay
|No additional mandatory fees
Booking Notes:
Prices are based on 2 people sharing
conditions of booking, a deposit of £75 is payable at time of booking to secure your dates, with the balance payable 4 weeks before your stay.
All cancellations must be telephoned if made more than 28 days prior to your arrival date you will incur no penalty. Please ask to speak to Kay or Kelvin, and always check with us for any possible last minuet discounted bookings.
Changeover Day:
Saturday is our preferred day but we can be flexible.
Arrival from 1pm
Departure by 10am.
Notes on prices:
Short breaks are available, 3 nights high season, 2 nights low season, please always check with us for late availability prices