The Psycho of Wall Street Diagnosing Patrick Bateman in...

Fifty years ago, a person breaking the law would either be called crazy or a criminal. Today, the mental health community has much more specific diagnoses. However, the explanation of certain behaviors may be difficult because there is much overlap among mental conditions. In Bret Easton Ellis’ American Psycho, the protagonist, Patrick Bateman, is apparently simply a psychopath. However, Bateman can be diagnosed with other mental illnesses such as Asperger’s syndrome, obsessive-compulsive disorder, schizophrenia, narcissism, and antisocial personality disorder. In both the book and film adaptation, Bateman’s actions can be understood more accurately when analyzed in light of modern psychology. Asperger’s syndrome is one of the mental†¦show more content†¦Ã¢â‚¬Å"In ‘Old Antone’s’ one can catch the zydeco influences that the band has picked up†¦it gives it a Cajun flavor that is utterly unique,† says Bateman speaking about a Huey Lewis song (Ellis 336). He repeats such conversations before killing different victims in his apartment. This recurring routine before his murders is another symptom of Asperger’s syndrome. Also having to do with Bateman’s obsession with some musical albums and their history, the mere fact that Bateman has these obsessions is another symptom of Asperger’s syndrome. â€Å"People with Asperger’s develop intense interests and obsessions in things such as music and history or schedules of sports teams† (What is Aspergers Syndrome? Symptoms, tests, Causes, Treatments. WebMD). Bateman’s interest in some bands and artists is far beyond that of a normal fan. His deep analysis of musicians shows that he has an intense obsession with music history that someone with Asperger’s syndrome would have. Not only do individuals with Asperger’s become obsessed with a certain thing, but they also have a generally limited range of interests. Bateman does not show such interest with anything else as he does with music history and analysis. Aside from routines and rituals, another essential symptom in Asperger’s is poor or nonexistent social skills. People with Asperger’s syndrome have difficulty during conversation and are awkward when starting conversation (What is Aspergers Syndrome?

The Family Aspect Of The Quilt - 1139 Words

In a perfect world, the Caribbean is like a quilt that has been stitched together by a mother or grandmother. It eventually comes together to form a unique blanket that incorporates a multi-dimensional group of different pieces of colors and sizes in its final product. The maternal aspect of the quilt, represents the Euro-colonial influence that was responsible for the colonialization of the Caribbean region. All patches have their own unique shape and design, and eventually come together to make a fragmented image on the quilt. The fragmented image, created by different colors, shapes and patterns, represent the different cultures and races that are all interrelated to each other in the Caribbean. And each individual patch, represents a different island nation, and the thread, cotton and embroidery that weaves the patches together, represents the languages and ideologies that have come together over the course of history, to bond these island nations together. Today, however, the Caribbean countries struggle a great deal with human development. These struggles have arisen as a result of the lack of unity in self-identity, with respect to the idea of fragmentation. Mintz describes fragmentation to be a patchwork quilt of societies and cultures, which arose through the colonization and exploitation of the Caribbean region. This exploitation of the regions resources, such as sugar, coffee, gold and other natural resources, by the colonizing country (France, England, SpainShow MoreRelatedIn His Poem, â€Å"Aunt Ida Pieces A Quilt,† Melvin Dixon Presents1373 Words   |  6 Pagesâ€Å"Aunt Ida Pieces a Quilt,† Melvin Dixon presents the protagonist Aunt Ida experiencing an internal as well an external dialogue with her family members. Initially, the poem starts off the mother of Junie, a young man who died of AIDS handing all the clothes to Aunt Ida. Automatically, the feeling of nostalgia and agonizing construct the atmosphere of the poem. However, as the poem continues it is revealed Aunt Ida is handed down the clothes to make a quilt. As she starts to quilt the atmosphere ofRead MoreClay Wall Quilt : The Ultimate Family Craft Project1307 Words   |  6 PagesThis clay wall quilt is the ultimate family craft project! Each member of the family can continue a number of clay square to build this quilt to hang on the wall! I love quilts, but sewing a quilt is a daunting task. You can use a kid friendly (and adult friendly) material like clay to create a quilt art project ot hang on the wall that does not require any sewing!! To Make a Family Quilt Clay Wall Art Project You Will Need: Nail (optional) Air drying clay or oven firing clay Acrylic paint Read More A Stitch in Time Essay1364 Words   |  6 Pages Quilting has different meanings for different people, but all quilts have a unique appearance and tradition. â€Å"What makes art is its life – pulsing and shining with the energy and intent ions of its creator. The art of quilting glows with a respect for all generations that have come before – putting thread, needle, and cloth together with vision and love† (Wilson 7). Starting out in antiquity as a necessity and a work of art, quilting has changed over time, but it is still practiced in a myriadRead MoreAlice Walker s Everyday Use906 Words   |  4 Pagesstory that will eventually come up, or to give an underlying message about what’s going on in the story. In Alice Walker’s short story, Everyday Use, she uses a title that isn’t blatantly seen within the story, but is explained through different aspects of the dialogue and actions of the characters. Walker could’ve chosen to explain the title more obviously within the story, but instead she sort of left it up to the interpretation of the reader. Alice Walker could’ve named her story â€Å"Everyday Use†Read MoreValue the Intangible in Everyday Use by Alice Walk er623 Words   |  3 Pagescharacters Dee and Maggie, both wanted the two hand stitched quilts. Rather than looking at the physical aspect of the quilts the author wants the reader to know that the meaning is much deeper. The quilts are used to depict the struggle, triumphs, oppression, joy, pain, and love of each hand that helped to create the prized works of art. The quilts needed to be put to everyday use, rather than a mere decoration on the wall. Through the quilts Walker was able to show what each character valued: Dee valuedRead MoreEssay on Alice Walkers Everyday Use1658 Words   |  7 Pagesbeen placed in. Through the use of symbolism, the tangible object of a family heirloom quilt brings out these issues relating to heritage to Mama, and she is able to reasonably decide which of her daughters has a real appreciation for the quilt, and can pass it on to her. Dee and Maggie shed a new light on the actual meaning of heritage through their personality traits, lifestyle deci sions, and relationships with specific family members.   Ã‚  Ã‚  Ã‚  Ã‚  Although all of the character’s views on heritage areRead MoreThe Meaning of Heritage in Everyday Use1652 Words   |  7 Pagesbeen placed in. Through the use of symbolism, the tangible object of a family heirloom quilt brings out these issues relating to heritage to Mama, and she is able to reasonably decide which of her daughters has a real appreciation for the quilt, and can pass it on to her. Dee and Maggie shed a new light on the actual meaning of heritage through their personality traits, lifestyle decisions, and relationships with specific family members. Although all of the characters views on heritage are expressedRead MoreEveryday Use By Alice Walker1111 Words   |  5 PagesAlice Walker’s short story, Everyday Use is stylistic, ironic and narrates profound interpretation of unique views and approaches to African-American culture. Walker’s use of characterization, contrasting family views on self-concept, family, tradition, and heritage show that these are important aspects of life and everyday use. The story of â€Å"Everyday Use† is a story in which Alice Walker, the author, presents the story told in first person view by the â€Å"mama,† The story’ setting takes placed in 1960’sRead MoreHeritage, a Theme in Alice Walker ´s Everyday Use652 Words   |  3 Pagesolder daughter, Dee, is coming home to visit them after being away for a while. Walker sets the tone of the story by displaying how poor and uneducated the family is and how Dee while growing up was always looking for better things never appreciating the aspects of her life. As the story develops, the focus of the story is on a set of quilts made by the mother from pieces of clothing that belonged to her grandparents and the personal battle of who should really keep them in order to appreciate theRead Moreâ€Å"Everyday Use† by Alice Walker Essay1310 Words   |  6 Pagesits simplest form, a child is a product of a man and a woman but Alice Walker one of the foremost authors during the twentieth century, adds depth to her black American women by focusing on the role that race and gender played in their development. Family reunions can be times of great anticipation, excitement and happiness but for Dee, a young, beautiful, African American and our leading character, it was a reunion with underlying, unspoken tensions. Dee was Dee but Dee had changed; a new husband

Technology and Happiness in Civilization and Its...

Technology and Happiness in Civilization and Its Discontents and Waiting for Godot Happiness is something most humans value above everything else. The various things in life that make us happy, such as family, friends, and cool cars, to name a few, are the very things we hold dearest to us and place the most value on. People fill their lives with things that please them to ease the gloom that comes as a result of the seemingly never-ending trials and tribulations of life. We gladly accept any amount of pleasure we can extract from the monotony of our daily lives, and we will do almost anything to achieve happiness. Throughout Civilization and Its Discontents, Freud talks about happiness-why we dont have it and how to†¦show more content†¦They do not feel comfortable without it. When this aggressive drive is repressed, man becomes unhappy. Another drive is the sexual drive, or Eros. Civilization suppresses this drive in much the same way as it suppresses the aggressive drive, and this leads to more unhappiness. Freud also claims that technological advancements in society are counterproductive. The disadvantages of technology are not too far behind the advantages of technology. On page 40, Freud offers a perfect example of the relationship between the advantages and disadvantages of technology when he says, If there had been no railway to conquer distances, my child would never have left his native town and I should need no telephone to hear his voice. It is thrilling that we are able to travel long distances because of railroads, but this easy mode of transportation makes it simpler for a person to leave his/her family and go to a new and exciting place. So we invent the telephone so we are able to talk to distant family members, but that is never as good as having a conversation with them sitting right beside you. The technological advances of a society are meant to further peoples happiness, but in reality they do nothing more than get in the way of that happiness. One of Freuds suggestions for finding happiness was forming relationships with other individuals. He believed in

The Battle Of The Civil War - 1073 Words

The Civil War was a war that was thought to would have lasted no longer than ninety days. After all was said and done, the war lasted more than four years and claimed tens of thousands of lives of both The Union and The Confederate States. There were several battles fought on Northern and Southern soil, battles that forced bloody mortal combat between brothers in the fight for equality amongst all men. It tested the strength of the foundation that the United States was built upon. The Civil War was the first war that was documented both by the writings of the men and women involved in the war, and by photographers who were able to capture the true, raw emotion of life on the battlefront. The best way to learn about the Civil war is by exploring and learning about the brave people who sacrificed so much for their respective causes whether it be to liberate slaves from their masters and strengthen the Union, or to defend a newly founded Confederate states who fought to preserve their w ay of life in South. The men fighting in the Civil War endured very harsh conditions. The soldiers on both sides not only had to witness bloody carnage on a daily basis, but also had to cope with subpar living conditions such worm infested rations and the spreading of diseases among the camps. Soldiers sometimes had to march hundreds of miles with 40 pound packs on their backs. I found very interesting through my reading of the material that soldiers only carried half of a tent and had toShow MoreRelatedThe Battle Of The Civil War1127 Words   |  5 Pagesshaken by the Civil War because some states wanted to separate themselves from this unity that had lasted for approximately 100 years. The American Civil War is a historic affair and one of the bloodiest battles in history of the US (Engle, Krick, 2003). It is considered one of the bloodstained happenings in the history of the US because more than 600, 000 people died. A majority of this number were soldiers. This fatal battle happened between the ye ars 1861 to 1865. The Civil War emerged becauseRead MoreThe Battle Of The Civil War Essay1424 Words   |  6 PagesThroughout the years 1861 to 1865 the American Civil War took place and it is known as Americas bloodiest war. The cause of the Civil war was the debate between free states and slave states over the government trying to prohibit slavery. In 1860 Abraham Lincoln became president of the United States and ran on the platform to keep slavery out of the new unclaimed territories of the United States. Once Lincoln became president seven southern states seceded from the Union ultimately creating the ConfederateRead MoreThe Battle Of The Civil War1666 Words   |  7 PagesThe Civil war was one of the biggest turning points in United States history. The nation’s failure to compromise on the subject of slavery led to an outbreak of war. Battles such as Gettysburg, Vicksburg, and Shiloh led to what we know of today as a free nation. Great technological advancements in weaponry led to mass c asualties among both north and south, often making death inevitable. Those who bravely served and those who were forced to serve lived a life of fear, starvation, and commitment toRead MoreThe Battle Of The Civil War1191 Words   |  5 PagesWhen the Civil War started both sides thought the war would be over by Christmas. But little did they know this small war would turn into the deadliest war in American history. The Civil War was fought between the Confederacy and the Union. The Confederacy was consisted of Southern states that did not agree with the views of the Union states. After years of sectional differences in the United States between the north and south, tension between the states grew and a war between the north and southRead MoreThe Battle Of The Civil War960 Words   |  4 PagesHave you ever wondered why the Civil War happened or why it was so substantial to American History? What was the battle that changed it all; that made it the history it is today? Many people have made speculations on the causes of the war and what the major turning point was, but cannot really narrow it down. In James McPherson’s Crossroads of Freedom: Antietam he points out the pivotal moments in American history that led up to and changed the Civil War, so that the reader can get a better insightRead MoreThe Battle Of The Civil War1197 Words   |  5 PagesMarianna, FL. The battle will be virtually unknown in the history of the Civil War, but its success marked the longest successful incursion of Union troops into Florida (Cox, 2014). This raid had two goals; the first was to rescue the reported Union prisoners and the second was to liberate and enlist any slaves that were found along the route (Calvin, 2014). The prisoners were not located, but more than 600 slaves were liberated along their route (Cox, 2014). The subsequent battle did not last longRead MoreThe Battle Of The Civil War1163 Words   |  5 Pageshad already decided to secede from the Union. Those 7 states started the Confederate States of America, run by their own President, Jefferson Davis. This same issue was the catalyst for the Civil War which started on April 12, 1861. One of the major and well-known battles of the Civil War was the Battle of Gettysburg. It was on this backdrop that Abraham Lincoln delivered a speech that is â€Å"universally recognized by historians and scholars alike as the most famous and most important speech everRead MoreThe Battle Of The Civil War1233 Words   |  5 PagesIt is evident that the Civil War helped shape America into the country it is today. The strong factional division -based on slavery- between the Union and the Confederacy guaranteed certain achievements of both sides. Much of what we consider history today remains a part of the outcome from these multiple bloody battles. Activist John Muir of the Civil War-era stated, â€Å"the traces of war are not only apparent on the broken fields, burnt fences, mills, and woods ruthlessly slaughtered, but also onRead MoreThe Battle Of The Civil War1133 Words   |  5 Pagesfierce battles were fought to secure the rights and freedom of both men and women, irrespective of their religion, gender, and race. Of all of the battles, the American Civil War stands out. Divided into the Union and the Confederacy, the American civil war broke out after the southern states seceded due to slavery that spread in many parts of the country. The Civil War began in the year 1861 and ended four years later. The end result was the Union becoming victorious in 1865. The Civil War was aRead MoreThe Battle Of The Civil War1736 Words   |  7 PagesAbstract: As the first major battle of the Civil War the First Battle of Bull Run was an end to the illusions of a quick war and instead offered a first glimpse into the long and bloody four-year struggle the Civil War would become. In this paper the battle and its many repercussions across the political, social and military spectrum of the Union and Confederacy will be explored. Background: With the formation of the Confederate States and the outbreak of hostilities at Ft. Sumter only a few months

Sap Bw Parallel Data Load Free Essays

Scenario You have an SAP BW system with several (application) servers. You would like to distribute the workload of the data loads and other data warehouse management activities in a way that fits your needs best. This could mean that you would like to have all processes distributed across all available servers or that you would like to have one dedicated server for these processes. We will write a custom essay sample on Sap Bw Parallel Data Load or any similar topic only for you Order Now 2 Introduction SAP uses the terms instance and application server synonymously. In order to avoid misunderstandings we use the term instance for an SAP instance (application server) in this document. For a physical machine we use the term server. Some of the settings described in this document are done on an instance level, some on a server level. If you don’t have several instances (of the same SAP system) on one server you don’t have to draw this distinction between instance and server when reading this document. There are a host of functions and settings in the area of load balancing provided by the basis system (Web Application Server). However, these have been designed primarily for SAP’s ERP system. Customizing these features for optimal use with SAP BW requires further considerations. The challenges presented with data load processing originate from the fact that many fairly long running processes can be started almost simultanesouly. The standard SAP load balancing approach takes the quality of the instances into consideration when distributing the load. This quality is evaluated in regular intervals (five minutes by default). Within one interval a lot of parallel processes may be started on the best instance, using a lot of work processes while the other instances are idle. An optimal distribution of BW OLAP workload or data load resource consumption cannot readily be achieved with this standard method. Without adequate planning, and under heavy workload (peak) conditions, the risks can increase that hardware becomes a bottleneck; a limited number of servers can become saturated with processes consuming resources, and performance (and stability) can potentially suffer significantly. A successful load balancing approach optimally utilizes the hardware resources that have been allocated to the BW system. Note that this discussion assumes that an adequate sizing has been performed to properly size the SAP BW system (see SAP Service Marketplace alias â€Å"quicksizer† for more information). This document describes load balancing approaches for typical SAP BW activities. Commonly these activities process large amounts of data. Data (within one process) is split into packages and can thus be processed in parallel on one or across several servers or instances. On the other hand, several processes can run in parallel on one or on several servers or instances. This means that we can have parallel processing (and consequently achieve load balancing) both within one process and across processes. In our examples we will use a system called XXX as SAP BW system and a system called YYY as an SAP source system of XXX. During data load processing, data is extracted from the source system and sent to the target SAP BW system. Other load processes involve the SAP BW system as source system, as well as the target system (for example, DataMarts, activation of data in ODS objects). The instances and servers on XXX are as follows, the server ab1234 being the database server: How to cite Sap Bw Parallel Data Load, Papers

China’s Exchange Rate Regime Reform

Question: Describe about the Chinas Exchange Rate Regime Reform? Answer: Chinese Economy- A Move from Investment Based Growth to Consumer Based Growth Summary: Every economy around the world is looking for growth and they try to achieve the productive resources that the country possesses and taking steps according to the options available and the state of technology of the nation. The growth of an economy generally is achieved in the three modes namely investment based growth where country can through investing in capital goods and capital markets, consumer based growth which means investment of resources in areas of government and household consumption as well and finally growth led from the export led growth within the country. Talking about the Chinese economy which had been famous for the investment based growth had led to a great growth in the last decade. The Chinese economy had a great boost in the years after 2001 through investment led activities as it made the highest contribution in the growth of the economy. But the trend completely changed in the past 5 years where the investment led growth has a lower contribution in the growth of the Chinese economy. The Chinese economy then understood that there is a possible scope of growth only in the consumption sector as the economy started facing constraints due to the unavailability of important sources of production that are required in the investment led sectors of the economy. So it could be said that at this present scenario the investment in agriculture and service would be preferred over the investment in the real estate and manufacturing sector of the country. (Cuia*, 2015) Thus the unallocated and unutilized resources of the economy can be only utilized if the company makes a strategy to move toward the consumption led growth in the near future(Il Houng Lee, 2013) 1: The issue of misallocation of resources had been dealt in the Economic Work Conference where this problem was raised and outcome was decided to be that investments needs to be properly allocated in the areas where the production possibilities are greater and the global economy slow down should be accounted into before framing the economic decisions of the county and its economy. The country like China is highly dependent on exports and so its investment based sector also is highly affected due to the slowdown of the global economy. This problem here highlights the fact that there should be change in strategy so the economic resources are fully utilized and the Production possibilities can move towards the reduction of the unallocated resources of the country as a whole. The concept of PPC implies here as when the resources are non allocate fully there is a under utilization of resources and it needs to be employed on the other available options for the economy so that the point of allocation does not lie inside the curve but lie on the curve at least due to the fuller use of the resources by the country. The PPF helps in determining the allocation of resources in a best possible manner among the output options to provide better employment of resources in the economy.(Elvis Picardo, 2013) 2: In the diagram above it is has been shown that resources of the country are underutilized as the point on the PPF is lying inside the curve which shows that there is a scope of usage of resources but the company is not able to utilize it due to the lack of opportunities of growth in the investment sector. The company is to balance the resources by allocating it to the consumption based growth sector that means that there is a scope that the company will be able to use the resources very well and help the country to analyze the resources in a positive manner so that the growth could be achieved. (CNN, 2014) As shown in the other part of the diagram that the economy is able to utilize the resources in a better manner by the reason of the investment of the unused resources in the consumer based sector due to the global slowdown and badly affected Chinese economy. (Fleisher, 2012) The proper diversion of resources wood help the Chinese economy to boost with great power and support for the country and this would help the country to adapt to the changes as it would provide proper allocation of resources and would help lower the unemployment rates and would be able to solve the problem of choice for the economy as a whole. The change in the economic circumstances would led to the increase in the countrys development and the change in the frontier of the country for the upcoming times as presented here under.(Das, 2014) 3: The Chinese economy has faced the problem due to the attitude towards the investment growth of the country and focused on the consumption based growth of the country had changed many things as this was demanded by the Chinese economy. When the time o f economic slowdown came it was evident that the Chinese government faced challenges and the only way to create a win - win situation was to shift the strategy of the country to the consumer expenditure based growth in the long run. The Chinese economy also witnessed changes as soon it shifted to this consumption based growth as positive results were shown when more than 55% of the total growth was from them only. The path of China was led by the fall in the growth due to the investment functions that it had belief on but the efficiency was improved when the company shifted to other areas of resource where it handled them very nicely. The economy had changed a lot from its end by using the excess investment as a mode to add value to t he future good and service of the company as a whole. The country experienced a better GDP growth in the first year of deciding in solving the economic problem. The excess of money when investment in the sector of household had created the trust of people that China can also survive when the world economy is facing problems. (ECONOMIST, 2012) Bibliography CNN. (2014, April 14). CNN Money. Retrieved from Money.Cnn.com: https://money.cnn.com/2014/10/20/news/economy/china-gdp/ Cuia*, Y. (2015). Chinas exchange rate regime reform: Implications from the experiences of Japan, Korea and Taiwan. China Economic Journal , 1-17. Das, S. (2014). Heres whats killing Chinas economic growth. market Watch , 1-1. ECONOMIST, B. S. (2012). China's consumer-led growth. THE ECONOMIST , 1-1. Elvis Picardo, C. (2013). India Is Eclipsing China's Economy As Brightest BRIC Star. InvestopediA , 1-1. Fleisher, B. (2012). The official journal of The Chinese Economists Society. China Economic Review , 1-1. Il Houng Lee, M. S. (2013). Chinas Path to Consumer-Based Growth:Reorienting Investment and Enhancing Efficiency. IMF Working Paper , 1-1.

Improving Healthcare Quality free essay sample

Improving Healthcare Quality Purpose The purpose of this paper is to identify aspects of quality improvement in healthcare. This research is conducted by examining and reviewing various literature regarding the definition and makeup of quality healthcare, need for improvements in healthcare, various quality measures or indicators and weighing the cost of improving healthcare quality. Defining Healthcare Quality Before any discussion can take place regarding improving healthcare quality, an examination of the definition of healthcare quality must be conducted. There are legitimately varying perceptions of what is consider to be the critical dimensions of quality healthcare. These views on quality largely results from the perspective one adopts as a patient, healthcare provider, health care manager, purchaser, payer, or public health official. The same health care experience may be assessed differently depending upon the person’s role. For example: ? The patient may view his or her experience with the health care system both by its outcome and personal feelings, such as whether the physician listened well, communicated clearly, and was compassionate as well as skilled in delivering healthcare services. ? A healthcare provider may view quality in a technical sense, such as whether an accurate diagnosis is made, whether a surgical procedure is performed proficiently and whether the patient’s health has improved. From this view, quality is the difference between what is technically sound and possible, and the actual practice and delivery of healthcare services. ? The health care manager, payer, or purchaser (employer health plan, or government program) may want to know if the healthcare services provided are cost effective. ? Public health officials may want to know if resources are being utilized appropriately to optimize population health and provided equitably within the population. Quality as defined in Clair G. Meisenheimer’s book, Improving Quality: A Guide to Effective Programs, is â€Å". . . the totality of features and characteristics of a health care process that bear on its ability to satisfy stated or implied needs; a process or outcome that consistently conforms to requirements, meets expectations, and maximizes value or utility for the customer. For the customer: getting what you were expecting and more; for the supplier: getting it right the first time, every time. The Institute of Medicine of the National Academies (IOM), a not-for-profit, non-governmental organization whose purpose is to provide national advice on issues relating to biomedical science, medicine, and health, and to serve as adviser to the nation to improve health, defines healthcare quality as the â€Å"degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. à ¢â‚¬  (Retrieved July 11, 2009 from http://www. iom. edu). Further expounding the definitions provided, the IOM developed six dimensions of quality healthcare: 1. Timeliness – refers to the length of time it takes to provide care to patients. For example, how long it takes a patient to receive a treatment or follow-up care once a breast mass is detected. Delays should be shortened to increase the efficacy of treatments and to ease the patient’s fears. 2. Safety – refers to the ability or need to avoid injuries that result from the provided care that is intended to help the patient. Injuries such as those resulting from administering the wrong drug or wrong dosage, incorrect diagnoses, etc. 3. Effectiveness – the extent to which healthcare service is provided based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit, that is avoiding over-and underuse of resources. 4. Equity – the extent to which quality care is provided without regards to a patient’s gender, geographic location, gender and socioeconomic status. 5. Efficiency – the extent to which equipment, supplies and energy waste is avoided. 6. Patient-Centeredness – the extent to which the patient’s preferences, values and needs are taken into account when providing healthcare service. Care should be provided respectful of and responsive to the patient. Comparatively, in his book An Introduction to Quality Assurance in Health Care, Avedis Donabedian provides seven components of what he considers quality in health care. Three of these components are included in the IOMs dimension of quality healthcare; effectiveness, efficiency and equity. The remaining four are: 1. Efficacy – the extent to which healthcare technology and science are able to bring about health improvements when used under the most ideal circumstances. 2. Optimality – balancing the cost of healthcare improvements against the actual improvements, or in other words, by use of cost/benefit analysis ensuring that costs are not incurred which do not result in benefits do not exceed the cost or investment required. 3. Acceptability – the extent to which the expectations, desires and wishes of the patient and responsible members of their families are conformed to. There are five parts to the development of this definition: ? Accessibility – the ease with which patients can obtain healthcare ? The patient-provider relationship – the extent to which the healthcare provider exhibits towards the patient personal concern, good manners, honesty, truthfulness, attention to the preferences of the patients, making efforts to provide explanations, patience, empathy, respectfulness and the avoidance of condescension. ? Amenities of care – the desirable aspects of the circumstances and/or environment under which healthcare is provided and includes cleanliness, adequate parking, convenience, privacy, comfort, restfulness, availability of refreshments, good food, etc. Patient preferences regarding the risks, cost and effects of care – recognition that the patient’s value of the consequences of care may differ for that of the healthcare provider and from patient to patient. Healthcare providers should take the time to explain to the patient the expected cost, risk and effects of alternatives and be guided by the informed opinions of the patients or responsibl e family member. ? Patient’s definition of fair and equitable As initially mentioned there are various legitimate definitions of what constitutes healthcare quality. In developing this research paper, each of the definitions above will be utilized to address the issue of improving healthcare quality. The State of Quality Healthcare Surveys show growing concern over the eroding performance of the health care system. In November of 1999, the Institute of Medicine released a report entitled To Err Is Human: Building a Safer Health System, which concluded that 44,000 to 98,000 people die each year in hospitals due to preventable medical errors. In 2003 The National Committee for Quality Assurance (NCQA) released their first annual State of Healthcare Quality eport which found: More than 57,000 Americans die needlessly each year because they do not receive appropriate health care. The majority, almost 50,000 die because known conditions – high blood pressure or elevated cholesterol – are not adequately monitored and controlled. Others die or are at increased risk of death because they have not received the right preventative or follow-up care. [This is because] people with high blood pressure do not have it controlled, . . . people who have suffered a heart do not have their cholesterol levels monitored . . . and] smokers receive no advice to quit. Put simply, the healthcare system regularly fails to deliver care we know to be appropriate. (Nash Goldfarb (2006) p 7-8) Although quality improvements have been made in some areas since that first report, the NCQA’s 2007 report illustrated significant room for improvement. In the area of medication management and prescription, the report found inappropriate use of some treatment medications, specifically antibiotics. Americans suffer an estimated one billion upper respiratory infections or common colds annually. Colds are especially common among children, who suffer approximately three to eight colds a year. Because the common cold is most often viral, existing clinical guidelines do not prescribe the use of antibiotics as a treatment measure. Nevertheless, antibiotics are frequently prescribed to children with colds. Complications ranging from fevers and rashes to drug allergies, prolonged hospital stays and even death often arise from antibiotic treatment. Additionally, inappropriate antibiotic use contributes to bacterial resistance to antibiotics and represents wasted health care resources. Annually $227 million is spent for inappropriate treatment for the common cold. The impact upon the elderly is just as damaging. Despite medical consensus that certain medications increase the risk of adverse effects to the elderly and should generally be avoided, these medications are still often prescribed to the elderly. One in 20 prescriptions filled by the elderly are for drugs deemed as â€Å"always avoid†. More than 1 in 10 filled prescriptions are for drugs that would rarely be considered appropriate. Studies show that 21 to 37 percent of elderly patients had prescriptions filled for at least one potentially inappropriate drug and more than 15 percent had filled at least two. More than 40 percent of serious, life-threatening or fatal adverse drug events and 80 percent of adverse drug events in the elderly are avoidable. One study found that almost 3 percent of all elderly patients in a managed care organization suffered a preventable adverse drug event in a year. Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings. Conservative estimates of extra costs due to potentially inappropriate medications in the elderly average $7. 2 billion a year. The 2007 State of Healthcare Quality report found in total between 38,300 and 88,900 avoidable deaths due to unexplained variations in care and avoidable hospital costs between $1. 9 and $3. 5 billion. Additionally, the report determined an estimated 51. 6 million avoidable sick days due to unexplained variation in care at a cost of lost productivity of approximately $8. 5 billion. These findings alone suggests and supports the employment of continuous improvement measures in the quality of healthcare. Quality Indicators â€Å"In health care as in other arenas, that which cannot be measured is difficult to improve. Providers, consumers, policy makers, and others seeking to improve the quality of health care need accessible, reliable indicators of quality that they can use to flag potential problems, follow trends over time, and identify disparities across regions, communities, and providers. (Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions, 2007, p 4) There are a number of measures that have been developed or defined by various organizations, measures that are utilized to determine, adjust and/or improve healthcare quality. One such organization has developed and implemented quality indicators (QI) to assist providers, policy makers, and researchers in the analysis of data to identify variations in the qualit y of either inpatient or outpatient care; the Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ). The AHRQ’s aim is to improve the quality, safety, efficiency and effectiveness of healthcare and does so through researching: quality improvement and patient safety, outcomes and effectiveness of care, clinical practice and technology assessment, health care organization and delivery systems, primary care including preventive services, healthcare costs and sources of payment. The indicators defined by the AHRQ are used to measure various aspects of health care quality based upon hospital administrative data. The quality ndicators or QIs are grouped into four modules: ? Prevention Quality Indicators (PQI) – used to identify ambulatory care sensitive conditions (ACSC) which are â€Å"preventable hospitalizations† or conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease. Despite these indicators being based upon hospital inpatient data, PQIs pro vide insight into the quality of healthcare outside the hospital setting. For example, a diabetic patient may be hospitalized for complications associated with diabetes if their condition is not sufficiently monitored, if they do not receive proper patient education or if they do not manage their condition. Even though other factors outside of the healthcare system may result in hospitalization such as patient failure to follow treatment recommendations, or poor environmental conditions, PQIs are a good beginning point for assessing the quality of healthcare within a community and â€Å"serve as a screening tool rather than as definitive measures of quality problems. They can provide initial information about potential problems in the community that may require further, more in-depth analysis. † (AHQR, (2007), p 2) Despite the strengths of these indicators, there are a few weaknesses that should be considered. First, differences in socioeconomic status have been shown to explain a large part of the variation in some PQI rates across areas. The intricacy of the relationship between socioeconomic status and PQI rates makes it difficult to delineate how much of the relationships are due to true difficulties in access to care in potentially underserved populations, or due to other characteristics, unrelated to quality of care, that vary by socioeconomic status. â€Å"For some of the indicators, patient preferences and hospital capabilities for inpatient or outpatient care might explain variations in hospitalizations. In addition, environmental conditions that are not under the direct control of the health care system can substantially influence some of the PQIs. For example, the COPD and asthma admission rates are likely to be higher in areas with poorer air quality. † (AHRQ, p 17). Second, the question of whether effective treatments in outpatient settings would reduce the overall incidence of hospitalizations has not been adequately addressed. The degree to which the reporting of admission rates for ACSC may result in changes in ambulatory practices and admission rates also is unknown. Patients may be admitted who do not clinically require inpatient care or patient may not be admitted who would benefit from inpatient care. Inpatient Quality Indicators (IQI) reflect quality of care inside hospitals including inpatient mortality for medical conditions and surgical procedures and comprises three types of measures: ? Volume Measures are indirect measures of quality based upon evidence suggesting that hospitals performing more of selected inpatient procedures may have better outcomes for those procedures. Volume indicators shows the numb er of admissions in which these procedures were performed. ? In-hospital mortality indicators measure death rates for selected common surgical procedures or medical conditions. Utilization indicators focus on the volume of selected procedures for which research has suggested issues of overuse, underuse, or misuse. The weakeness of these indicators is that they are based upon data which is collected for billing pruposes and not research or measuring quailty. Dispite the insight that may be offered from these indicators, they should not be used as a decisive source of information on the quality of health care. At least three limitations of administrative data warrant caution: ? Coding differences across hospitals. Some hospitals code more thoroughly than others, making â€Å"fair† comparisons across hospitals difficult. ? Ambiguity about when a condition occurs. Most administrative data cannot distinguish unambiguously whether a specific condition was present at admission or whether it occurred during the stay (i. e. , a possible complication). ? Limitations in ICD-9-CM coding. The codes themselves are often not specific enough to adequately characterize a patient’s condition, which makes it impossible to perfectly risk-adjust any administrative data set, thus fair comparisons across hospitals become difficult. In short, the AHRQ IQIs are a valuable tool that takes advantage of readily available data to flag potential quality-of-care problems. (AHRQ, 2007, p 18) ? Patient Safety Indicators (PSI) measures harm or adverse effects resulting from healthcare services. These indicators are defined on two levels; provider level indicators which measure preventable ill effects by patients who received care and the adverse effects within the same hospitalization, and area level indicators. Area level indicators measures all cases of preventable ill effects that occurred within a specific area. Pediatric Quality Indicators (PDI) like PSIs include provider level and area level indicators to identify potentially preventable complications but as they apply to pediatric patients, that is those under the age of 18 years. The measures and indicators developed by AHRQ are not exclusive nor do any of the indicators alone provide a complete quality assessment of healthcare systems. However, these QIs take adv antage of existing data and data collections systems in place in order to develop areas of improvement and some bases of comparison between healthcare organizations, standards, benchmarks, etc. Once areas of improvement have been identified by QI, the job of addressing those identified shortcomings may begin. Methods abound which addresses improving quality, such as Six Sigma, Total Quality Management, etc.. These may be employed within a healthcare setting with as much success as doing so in a manufacturing plant. Conclusion This paper sought to examine one side of the healthcare triad, quality. The other two being cost and access. However, by no means should one presume that quality or any of the three is more critical than the other. In fact, improving healthcare quality will effect the cost of healthcare, which in turn will effect access to that quality healthcare. Just as, effecting cost will impact quality and access. Admittedly, this paper fails to address in detail the intricate relationship between these three factors – but acknowledges the existence of this relationship. Improving quality requires a clear definition of â€Å"health care quality† . Ideally, this definition is based upon identifiable and measurable scientific indicators but without disregarding other indicators such as patient satisfaction. Once a definition has been formulated, indicators or measures may be developed and employed to identify areas of improvement and to then address those short falls in quality. 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