Bpo Philippines Essay

INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS Aileen S. Alava* Facing high expectations as the newest â€Å"sunshine industry†, the call center industry in the Philippines appears to have dimmer prospects in the coming years. Having experienced rapid growth from 2000 to 2003, the industry experienced a slowdown in growth from 2004 to 2006, raising the question of how sustainable the country’s competitive advantage is against neighboring competitors such as India and China. This paper uses Porter’s Diamond Model to analyze the factors resulting in competitive advantage between nations, and provides industry player and market information on the Philippine call center industry, as well as updates on how the industry’s participants are seeking to address the industry’s challenges. I. INTRODUCTION The call center industry is heralded as the newest sunshine industry in the country, earning around US$1.8 billion in 2005 alone, with revenues forecasted to reach US$5.3 billion by year 2010. Employment for this sector has more than doubled every year, from 2,400 agents in 2000 to 150,000 in 2006, and is expected to reach 300,000 full-time employed agents in 2010. The Philippines is among the top locations in the world for outsourced call centers. An SGV industry report states that in 2005, the Philippines’ share of the global call center market is 3% and 31% for the Asia Pacific market. By 2010, industry leaders target 6% global market share and 51% Asia Pacific market share. II. FRAMEWORK AND METHODOLOGY What will give Philippine call centers an advantage over call centers in other countries, such as those in India, China, Malaysia, Singapore? Michael Porter‘s Diamond Model defines competitive advantage between nations as the outcome of four interlinked factors: 1) firm strategy, structure and rivalry; 2) demand conditions; 3) related supporting industries; and 4) conditions affecting the key factors of production within the nations. This paper aims to discuss the competitiveness of the Philippines using this framework. Desk research was conducted to obtain secondary industry data on local and global call centers, while interviews _________________________________ with call center managers provided insight on opportunities and challenges within the industry. The role of government will also be discussed in this paper. Industry developments show government policies such as tax incentives and relaxation of property laws contributed to the industry’s growth. Strengthening of government support for primary education is crucial to the sustainability of the Philippines’ competitive position. Insufficiency in primary education is threatening the Philippine advantage as local players face difficulty meeting global demand with local supply of qualified call center agents. * Assistant Professor of Information Systems Management, College of Business Administration, University of the Philippine-Diliman. 2 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS III. CALL CENTER OUTSOURCING A call center is a business operation handling multiple types of customer-oriented functions such as marketing, selling and servicing, through multiple channels of customer interaction such as electronic mail, the World Wide Web, electronic messaging, voice messaging, fax messaging, and traditional mail. Call centers serve various stakeholders of an organization: from prospects to customers, suppliers to competitors, as well as distributors, partners, and employees. The term â€Å"call center† is used as a collective term to refer to these operations for the reason that the primary means of contact facilitated by these businesses are telephone calls. Call centers are categorized as Business Process Outsourcing companies or BPOs. BPOs also include medical transcription, IT support, animation, software development, financial accounting and payroll processing companies. Outsourcing in the Philippines arrived at the heels of successful deregulation in the telecommunications industry. Intense competition spurred massive investment in technology and skill among Philippine telecommunications companies, leading to innovation, quality improvement, and price competitiveness in services. The Philippines is no stranger to foreign arrangements of this kind. The semiconductor industry, one of the leading export sectors in the country, started in much the same way. From the early 1970’s to mid 1980’s this sector experienced dramatic expansion, growing at an annual average rate of 53%. International factors also impelled growth in the form of transnational companies from the developed economies (e.g., US, Europe, Japan) locating offshore plants in developing countries (e.g., Philippines, Vietnam, Singapore) for the most labor-intensive phases of semiconductor manufacturing. As with the call center sector, the Philippines’ main advantage in semiconductors is cheap and literate labor. Government response to further incite export activity in semiconductors is similar to regulatory mechanisms implemented in the call center industry today, such as the establishment of freeport zones, the relaxation of tariffs and duties on imported technologies, and the permission to employ foreign nationals. Agreements in the semiconductor industry during its period of rapid growth were covered by subcontracting arrangements. Today’s global trend for â€Å"off-shoring†, or offshore outsourcing, has very little difference with subcontracting. Offshoring is the arrangement by which one company contracts with service providers located outside the country for services that could also be or usually have been provided inhouse. Outsourcing business processes to remote locations is made possible by advancements in the telecommunications sector in the outsourcer countries. Low labor cost and improved connectivity resulting from technological advancement and deregulation in the telecommunications sec tor in the servicing countries (e.g., India, China, Malaysia, the Philippines) have made offshore outsourcing attractive from an economical standpoint. The costs of operating a call center in the Philippines, for example, is reportedly 40% lower than in the United States (55% cost savings from labor less 15% incremental cost from travel and telecommunications requirements). Offshore outsourcing in general brings in around 25% to 50% in cost savings. Globalization and its societal effects have made manageable the challenges of crosscultural communication: many offshore destinations have a Western heritage and almost all are exposed to Western culture – pop culture, even – through the internet, cable television, and other entertainment media, e.g., movies, books. The difference in time zones between the servicing and the served countries (e.g., the United States, the United Kingdom) are addressed through alternate six- to eight-hour shifts in the day, enabling call centers to maintain 24-hour service agent availability. While incremental costs are incurred for perfunctory risk management expenses, e.g., AILEEN S. ALAVA 3 hazard pay, etc., the total cost of operating a call center out of India or the Philippines are still lower compared to the cost of operating out of the US or the UK. IV. THE PHILIPPINE CALL CENTER INDUSTRY An IT-Enabled Services briefer from the Board of Investments in 2007 states that there are an estimated 146 call center companies in the Philippines. Call center companies should be distinguished from call center sites. A â€Å"site† is a facility housing a call center operation and a call center â€Å"company† may operate multiple sites. Sykes Asia, for example operates five sites in the Philippines while People Support operates four. There are three categories of call center companies: ï‚ · Foreign-owned call centers with Philippine subsidiaries. These are call centers owned by foreign companies, usually from the United States, that have branched out to offshore outsourcing. Insourced call centers of large multinational corporations. These are operations that are dedicated to the parent companies and whose objective is to bring competitive advantage by transforming an erstwhile internal backoffice function into one that is re venuegenerating. Filipino-owned call centers. These call centers are wholly owned by Filipino entrepreneurs or corporations (e.g. Smart, PLDT, Globe, etc.) that seek customers from the United States, Europe and Asia, particularly from Japan and Singapore. ï‚ · ï‚ · Estimates from the Board of Investments (BOI), the Commission on Information and Communications Technology (CICT) and the Business Process Association of the Philippines (BPAP) report the demand for call centers to reach anywhere from between 30,000-50,000 new agents hired in the Philippines per year from 2007-2010. Figure 1 Employment in Contact Centers 350000 301,000 300000 262,000 250000 218,000 200000 168,000 150000 112,000 100000 50000 0 2004 2005 2006 2007 2008 2009 2010 *2006-2010 from BOI/CICT/BPAP Forecast 64,000 331,000 Source: Board of Investments, BPAP 4 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS The success of call centers worldwide is attributable to the growth of outsourcing as a profitable business model. The BOI estimates that 2006 revenues in business process outsourcing (which includes other IT enabled services such as medical transcriptions, animation, and back office transactions processing) amounted to US$3.67 billion, and projects revenues to jump upwards 40% to reach US$4.79 billion this year. Joint forecasts from the BOI, BPAP and CICT predict that there will be 343,000 new outsourcing jobs this year (of which 64% or 218,000 will be in call centers), a 40% increase from the number of new outsourcing jobs in 2006 of about 244,000 (of which 69% or 168,000 were in call centers). Figure 2 Annual Employment (2004-2010) 1000000 900000 800000 668,1 26 920,764 700000 600000 479,51 9 500000 400000 244,675 343,01 3 262,000 21 8,000 1 68,000 99,300 64,000 1 2,000 1 301 ,000 331 ,000 300000 200000 100000 0 2004 1 62,250 2005 2006 2007 2008 2009 2010 BPO Industry Contact Centers Source: Board of Investments, BPAP The Philippine call center industry is estimated to have earned US$2.7 billion in revenues in 2006, a growth of 50% from 2005’s earnings of US$1.7 billion. The Department of Trade and Industry expects actual 2007 returns to be close to US$3.5 billion, a further growth of 30%. AILEEN S. ALAVA 5 Figure 3 Annual Revenues of Contact Centers (in US$M) Source: Board of Investments, BPAP It is interesting to note that service income of ten of the top call centers1 in the country (Ambergris, Convergys, Cyber City Teleservices, Sitel, E-Telecare, iContacts Corporation, InfoNXX, Parlance, PeopleSupport, and Sykes Asia) together account for more than 20% of the total revenues of the entire sector. Figure 4 Comparative Annual Revenues of 148 Call Centers vs. Ten Top Call Centers (2004-2005) 6 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS Activity in the industry is apparently dependent for the most part on a small number of big players. The BOI in its IT-Enabled services briefer (2007 release) states that it expects upward momentum to continue until 2010. Sources of growth have been identified as follows: a) Expansion from established call centers such as PeopleSupport, Sykes, eTelecare, PLDT, ClientLogic, InfoNXX, Citibank, Ambergris, Accenture, IBM, Caltex and HP b) Entry and consequent expansion, i.e. addition of new sites, etc. of global players such as Dell, HSBC, JP Morgan, AIG, Convergys, TeleTech, Sutherland, Deutsche Bank, and NetSuite. c) Next wave of entrants such as Accor Reservation, MiSYS, Siemens, Ericson, Alsbridge, Virgin Atlantic, Philips, Emerson, Capital IQ, DDC and Kanbar. Growth in the sector follows expansion the operations of big players. In the last two years, both Sykes Asia and People Support have established new call center sites while still others have added new projects and accounts. These activities and the influx of new players have resulted in revenues steadily growing until 2006 and expectations for further expansion until 2010. While growth is continuous, however, a slowdown in the rate of growth is expected starting 2005. Figure 5 Annual Revenue Growth Rate of Contact Centers 220.0% 166.7% 133.3% 114.3% 75.0% 50.0% 29.8% 20.2% 14.9% 10.0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 *2006-2010 forecasted by BOI/CICT/BPAP Source: Board of Investments, BPAP Slowing growth in the last two years after the steep increases of 2003 to 2004 indicates that the call center industry in the Philippines is now approaching maturity. Sales and earnings expansions of the past years resulted from the Philippines’ cost advantage over other countries. The passage of time, however, may erode this advantage as China and other Southeast Asian countries threaten to eat into the Philippines’ market share with better cost or quality AILEEN S. ALAVA 7 offerings. The challenge for the industry is to extend growth by improving the competitive dimensions where the Philippines is weak or by adjusting industry targets to create new competitive advantages. The Global Arena The Asia Pacific region outperforms other regions such as Eastern Europe, South America and Africa. Japan and South Korea are seen to increase nearshore outsourcing investments in low-cost, labor-rich neighboring China while Southeast Asian countries benefit from close-toWestern cultures, open economies, and advanced technologies for a similar cost advantage. In 2005, Frost and Sullivan forecasted that call centers in Asia will grow from 21,360 in 2004 to 39,248 call centers in 2011, at a compound annual growth rate of 9.1% Figure 6 Forecast Growth of Call Centers in Asia Pacific *at a Compound Annual Growth Rate of 9.1%, as forecasted by Frost and Sullivan. More recent studies predict faster growth rates. A 2006 Asian Contact Center Industry Benchmarking Report assessed the industry to be in a period of strong growth. The study conducted on 747 contact centers in the Philippines, India, Singapore, China, Malaysia and Thailand estimates that by 2007, the total 576,000 seats in the countries studied would increase to 704,500, a growth rate of 23%. Among the countries in the study, the Philippines has the highest forecasted growth rate. By 2007, it is expected to grow by 33%, Singapore and Malaysia by 32%, China at 22% and India by 16%. Of the Asian destinations, India is the top choice, with other nations such as the Philippines, Malaysia, Singapore, and China following closely. The Philippines, having an American-influenced culture, a proficiency in English comparable to India without the heavy accent, and a skilled labor force, was considered the greatest threat to Indian domination in this sector. However, recent years’ developments in other competitor countries such as China, Malaysia, Thailand and Indonesia coupled with a strong peso and deficiencies in the local supply of qualified call center agents have weakened the Philippines’ advantage. The A.T. Kearney Global Services Location Index in 2007, a survey conducted to measure the relative attractiveness of offshore locations with regard to financial structure (40%), people 8 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS skills and availability (30%), and business environment (30%), has ranked the Philippines the 8th most attractive country for offshoring in 2007. The top twenty-five countries are as follows: Figure 7 Source: AT Kearney 2007 Global Services Location Index AILEEN S. ALAVA 9 The 2007 study saw the Philippines decline from its 4th rank from AT Kearney’s last GLSI survey which was conducted in 2005. The top twenty five locations then were as follows: Figure 8 Source: AT Kearney 2005Global Services Location Index The Philippines’ drop in the AT Kearney rankings is attributed to the appreciation of the peso and growth in the call center industry which has driven up labor costs in terms of the US dollar, by as much as 30%, according to AT Kearney’s GSLI 2007 highlights. In other areas of performance, the country improved slightly, particularly in infrastructure, industry size and language skills. In contrast, Malaysia, Thailand, and Indonesia have either retained their rankings or moved up the index. Slower industry growth rates in these countries have tempered the effects of inflation on labor costs. 10 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS Figure 9 Philippines’ Offshore Attractiveness, 2005 & 2007 A. T. Kearney Findings 6 5 4 3 2 1 0 Financial Structure Business Environment People and Skills Availability 2005 2007 3.6 3.3 2005 2007 1.2 1.0 2005 1.0 2007 1.3 Ratio of Categories – 40:30:30 Philippines’ Score 2007 2005 Financial Structure Compensation Cost (8) Infrastructure Cost (1) Tax and Regulatory Cost (1) 7.1 7.7 0.7 0.8 0.3 0.5 8.10 9.00 Philippines’ Score 2007 2005 Business Environment Country risk / Economic and Political Environment (6) Country Infrastructure (2) Cultural Adaptability (1) Security of Intellectual Property (1) 1.9 1.2 0.7 0.3 4.1 1.8 0.7 0.8 0.2 3.5 Philippines’ Score 2007 2005 People Skills and Availability Relevant experience / IT BPO Industry size/quality (4) Size and availability of labor force (2) Education (1.5) Language (1.5) Attrition risk (1) 1.2 0.7 0.9 1.2 0.2 4.2 0.9 0.7 0.9 0.7 0.6 3.8 Source: AT Kearney 2005 and 2007 Global Services Location Index AILEEN S. ALAVA 11 India Among the top contenders for offshore locations, India is the country with the most experience. The emergence of call centers as an opportunity for national growth came upon deregulation in the telecommunications industry in the mid-1990’s, much like the Philippine experience. The outsourcing sector, the first participants of which were medical transcription service companies then followed by data management and customer support providers, began to take root in the late 1990’s. As in the Philippines, the first operations consisted of support subsidiaries of multinational companies servicing the parent company. Low-cost and highly-skilled labor, significant improvements in IT infrastructure, and a positive business environment spurred by industry organizations such as the National Association of Software and Services Companies (NASSCOM) propelled exponential growth for the industry in the years to follow. The NASSCOM estimates yearly growth of 37% for the outsourci ng segment with the call center industry leading the sector. Call centers comprised 46% of the total US$4.6billion revenue the outsourcing sector earned in 2005. India is the strongest contender in the sector and is often tagged as the world’s first-choice in offshore outsourcing. In 2005, it has 8% global market share and 68% market share in AsiaPacific. The Philippines’ greatest advantage over India is in language skill. American English being the dominant lingua franca in sales and support transactions coursed through call centers, the Philippines has a culture that is closer to the West and an English tongue that is the easiest to understand in the whole of Asia, partly to exposure to American television and pop culture, as well as English being the medium of instruction in all education levels. It has been observed that India’s pool of talent has the advantage in technical, specialized occupational skills while the Philippines’ competence is in liberal arts, which provides more general knowledge as well as capabilities needed for back-office processing, e.g., communication skills, and cultural adaptability. Increased global competition in the call center sector has led to efforts to expand the portfolio of services of the Indian IT-enabled services sector. NASSCOM reports that the last three to four years in India have been a period of diversification. India’s BPO companies have expanded to higher-value processes through vertical integration towards non-voice-based services such as back-office processing and content development. In 2005, customer care services comprised 34% of total BPO revenues in India, compared to 69% in the Philippines. 12 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS Figure 10.1 Figure 10.2 Sources: DTI (Philippines) , PriceWaterhouseCoopers (India) China China is the preferred choice as a call center location for companies targeting South Korea (attracted by ethnic Koreans living in China) with which it has the closest cultural ties. China is the only other country in the world that poses a threat to India as far as size and cost of labor supply is concerned. The yearly cost of operating a call center seat in China is the lowest in Asia. Table 1 Comparative Annual and Hourly Costs per Call Center Seat in China, India, Malaysia, the Philippines, Singapore and Thailand in USD ($) Annual Cost per Hourly Cost Seat per Seat 13,543.00 3.62 15,872.00 4.24 34,779.00 9.29 18,086.00 4.83 66,998.00 18.46 18,527.00 4.95 China India Malaysia The Philippines Singapore Thailand Source: callcentres.net China’s cost advantage, however, is dampened by its deficiencies in Englishspeaking manpower. In this regard, China cannot as of yet compete head-on with India and the Philippines in the global outsourcing market. University enrolments however have grown 25% in recent years which increased the country’s potential to compete. China’s entry to the World Trade Organization has spurred the inflow of capital as well as Western influence and analysts predict that in due time the labor supply in China AILEEN S. ALAVA 13 will be comparable to India in size as well as in skill. Singapore Despite high labor costs, Singapore enjoys a comparative advantage from reliable bureaucracy, excellent technical infrastructure, superior educational systems, political and economical stability, and stringent enforcement of intellectual property laws for information and data security. Singapore outsourcers provide high-value services differentiated from lowvalue, back-end processes provided by other Asian countries. To take advantage of this market niche, Singapore outsourcers market advanced offshore functions such as basic research, robotics, healthcare and medical diagnostics. Singapore companies in turn outsource lower-value operations to India and China to gain cost advantage. Malaysia What Malaysia lacks in manpower (its population is significantly smaller than India or China and thereby cannot meet the same economies of scale) it makes up for in advanced infrastructure. Malaysia is second only to Singapore in IT competitiveness rankings between countries in Southeast Asia. Strong government support is apparent in efforts such as the Multimedia Super Corridor project, which includes the development of infrastructure in what they have called â€Å"intelligent cities† such as Cyberjaya and Penang Cybercity, where major IT leaders such as IBM and Motorola have already located their regional offshore service centers. Latin American Countries Latin American countries such as Brazil, Chile and Mexico enjoy the advantage of being â€Å"near-shore† destinations, or offshore servicing countries close to the served country, this being the United States. Near-shore destinations are in the same time-zone as most customers, thereby lessening the need to arrange multiple 8-hour shifts in the day as well as the need to invest in additional expenses for hazard pay, safety insurance and the like. The A.T. Kearney study found Brazil has the best labor skills in the region, Argentina has the cost advantage, while Chile has the best business environment (e.g. it has, for instance, supplemented agreements with US and European companies with IP infringement penalty clauses). Nonetheless, perhaps the primary advantage of the region in general is the vast availability and incomparable quality of its bilingual (English and Spanish) call centers, much in demand in the United States. Eastern European Countries Eastern European countries such as the Czech Republic, Poland, Romania and Hungary are possible choices for Weste rn European countries as a near-shore destination. Eastern European call centers provide cost, language skill, and time-zone advantages. Multilingual call centers for the multilingual European market can be easily and efficiently set up in Eastern Europe more so than in Latin America or Asia. Customers from Germany and the United Kingdom moreover may prefer Eastern European call centers most particularly for its bilingual workforce: citizens in most Eastern European countries can speak both German and English. Reportedly, however, Eastern European countries, most particularly Russia, need to upgrade telecommunications infrastructure to compete with the other regions as well as to comply with European Union requirements. 14 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS V. CONCLUSION The factors affecting firm strategy, structure and rivalry involve the services offered by local firms, and how competitive locally provided services are against those provided by other countries. Primarily, this involves why the Philippines is chosen by call center companies when making the call center location decision. The factors involving demand conditions involve the evolving needs of the global market for call center services, ranging from the basic service of answering inquiries based on predefined scripts to the more complex service of providing technical assistance and support. The sufficiency of related supporting industries will involve the state of local educational institutions, real estate, transportation and retail sectors and how these sectors contribute to sustain the growth of the local call center industry. Finally the conditions affecting the key factors of production, such as local skilled labor and mission-critical technology, will also be discuss ed. Firm Strategy, Structure and Rivalry Figure 11 Factors Affecting the Call Center Location Decision As earlier mentioned, the first factor affecting competitiveness is firm strategy, structure and rivalry, which primarily contributes to why the Philippines is chosen by call center companies when making the call center location decision. The offshore location decision is influenced by a number of factors and it is against these criteria that India, China, the Philippines and other countries are evaluated. It follows that it is in these attributes that the Philippines should perform for a distinct competitive advantage over the others. These factors include the following: quality and cost of labor (including technical competency and language skills), connectivity (i.e., telecommunications bandwidth) cost and reliability, mature business, regulatory and technological environments for outsourcing operations, political stability, and cultural alignment between the offshore outsourcer, the outsourcing company, and the customers to be served by the call center. Decision Criteria in Selecting an Offshore Call Center Political Stability Reliability and Cost of Connectivity Quality and Cost of Labor Cultural Alignment Mature Business Environment Among these success factors, the Philippines competes strongest in (1) quality and cost of labor, and (2) cultural alignment. It is in these two factors that exponential growth in 2003 and 2004 can be attributed. The challenge of sustaining the Philippines’ advantage in the industry can be discussed from two vantage points: first from the view of creating a distinct AILEEN S. ALAVA 15 competitive advantage and second from the view of ensuring the distinct advantage created is impervious to erosion. Threats arise from deliberate attempts by competing entities to undermine it and from developments in call center operations and technology that will shift the bases of competition. The benefit of lower cost is the Philippines’ most substantial value offering to call center investors and customers. The results of the AT Kearney survey have shown that while other factors are also significant, the global competition in the call center sector continues to be driven by cost at the present: it remains to be the most important factor in the perception of the â€Å"attractiveness† of an outsourcing location. In this regard, the country’s low infrastructure and compensation costs, as well as the provision of special tax concessions within specific zones have contributed significantly to making the country a preferred choice among investors. In addition, the results of the study also emphasized that in the Philippines, call centers were given most emphasis among the outsourcing sectors and likewise highlighted the efforts of the government to promote these services by establishing special economic zones that provide investors with freeport privileges, tax shields and holidays. Among the participants in the global call center industry, India outperforms all other countries with a combination of advantages: low-cost labor as well as a progressive educational system ensuring a continuous supply of highly-skilled employees, reliable low-cost infrastructure, supportive business government, and a wealth of management experience in the call center industry, as well as in other outsourcing services. The Philippines directly competes against India by providing labor and infrastructure at comparable rates and furthermore provides the advantage of a Westernized culture and better performance in conversational English to appeal to US-and UKbased c ustomers. Singapore has the highest compensation rates but has the advantage of good government reflected in lower costs of bureaucracy and corruption. China’s major advantage is its massive pool of available lowcost talent—only China can directly compete with India in size of available labor—however labor skills are still limited in language proficiency and management experience in the industry. What makes India a success story is the combination of multiple sources of advantage available to the call center investor. The Philippines’ current competitive advantage meanwhile is in the combination of low compensation cost and high English proficiency, and while this advantage continues to bring additional revenues and employment to the sector, growth rates have also been observed to be decreasing, apparently due to two observable trends: low acceptance rates and high attrition rates. Both low acceptance and high attrition threaten the advantages of labor availability, cost and quality of Philippine call centers. The advantage of cost over other factors, i.e., people and environment, affecting the offshore location decision is n onetheless not a perpetual one. The leveling of technical competency between the different countries through globalization and convergence of technologies as well as the homogenization of social conditions between different economies may affect the importance of cost as a success factor. The ubiquity of information available through advanced mass media and telecommunications have also brought about less cultural heterogeneity between the countries competing as call center locations. The advantage of cultural alignment is therefore not exclusive to the Philippines and, further, is one that erodes with the passage of time and the availability of communications technology. Demand Conditions Despite the low-cost labor advantage offered by offshore call centers, companies continue to look for ways to gain even more cost savings, if not from a more efficient and thereby cheaper workforce, then from automation technology. Meta Group’s technology research services group reported an increasing number of clients 16 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS choosing to implement voice-automation technology systems to handle standard, routine inquiries, e.g., account balances, product and service, payment offices, etc., instead of contracting the services of an outsourcer in a low-cost country or establishing their own call center operations offshore. The eventual outcome of this development is that, with the existence of automation technology, only customer calls requiring more complicated assistance will be routed to offshore call centers, perhaps from the Philippines or India. This direction means that customers will have higher expectations from call center agents in offshore countries. Agents will no longer be able to rely on simplified question-and-answer instructions or â€Å"scripts† to answer more complex questions that will be asked them. Industry analysts observe that, out of 100 applicants, only three to five are hired given existing skill requirements. Support services for more complex inquiries, perhaps requiring tec hnical information or instruction, will consequently require higher technical competency, as well as more than adequate communication and problem-resolution skills. Should such requirements be made necessary, it is expected that the hiring rate will be lower in the years to come, unless initiatives are implemented to enhance the skills and capabilities of existing as well as future workers in this sector. Sufficiency of Related Industries The Philippines’ weakness in information technology infrastructure threatens the ability of the country to compete where value-added services require a higher telecommunications bandwidth. Despite being one of the top offshore location choices in the world, the Philippines ranks, and has always ranked poorly in network readiness surveys, seen by most investors as measures of the competitiveness of a country in information technology. In both the 2004 and 2005 Network Readiness Index (NRI) listing compiled by the World Economic Forum (WEF), t he Philippines ranked in the lower levels: 67th in a group of 100 in 2004 and even lower in 2005 (70th place). Other outsourcing destinations fare similarly: India, the top location for offshore outsourcing is at 40th place while China, 2nd in the AT Kearney Index, is at 50th place. The WEF NRI is a measure of relative performance in the following areas: a) aspects of the environment of a given nation for development in information and communications technology (ICT) such as the regulatory regime and legal framework for ICT, and the available infrastructure; b) networked readiness of individuals, businesses and governments; and c) ICT usage by individuals, businesses and governments. The apparent inconsistency between networked readiness and other IT competency ratings for the Philippines and the remarkable growth of IT-based services, made plain by records of investment, revenue, and employment actually generated by the sector, is attributed by industry analysts to the observation that indices and rankings comparing countries with each other consider all the regio ns in the country, from the most advanced areas to the undeveloped ones. Developed countries such as the United States, Japan, and Germany have progressed to a point where the availability of telecommunications technologies and other related services in the less urbanized regions are virtually at par with that of the most industrialized areas. Developing countries are characterized by a marked difference in infrastructure and economic activity between the centers of business and the rural, residential areas. Such is the case of India, China and the Philippines where the small portion of the population living and working in the centers of business enjoy advanced technology while the rest have very limited access to even the most basic computing technology, e.g., internet access, if at all access is given them. Nonetheless, call centers in developing countries choose to locate only in the industrialized, AILEEN S. ALAVA 17 technology-enabled centers of business. Thus, they are able to employ, and at a cost advantage, the network infrastructure, hardware equipment, software and consulting services at a comparable technological level to those used by call centers in more developed countries. While it is valid that network-readiness surveys include locales in the Philippines which call centers are not considering to locate in, and that these call centers are eventually established in the industrialized, technology-enabled centers of business, it is still worthwhile considering that this shortcoming significantly limits the range of options for call center sites in the Philippines. Low infrastructure development in areas outside Metro Manila also threaten the cost advantage as call centers are constrained with only a few places to locate their operations since the location options are limited, the cost of real estate in these areas increases. While on the one hand the rise in real estate prices is seen as contributing to the trickle-effects of revenue growth in the call center sectors, on the other hand it can be seen as a threat to the country’s cost advantage as far as real estate and infrastructure costs are concerned. Factor Conditions The 2006 Asian Contact Center Industry Benchmarketing Report ranks human resource management, particularly the areas of recruitment and agent turnover, as the greatest challenge faced by Asian contact centers. In the Philippines, the consistency of supply of qualified call center personnel is threatened—as reflected in a very low 3% acceptance rate—by apparent degradation of the quality of primary and secondary education in both private and public schools. Although it has been reported that the average 10-year-and-above literacy rate in the Philippines is above 93%, literacy is not enough to ensure a position for a call center applicant. Basic English proficiency, for that matter, is considered a minimum requirement, enough for the agent to be considered for a position, but still insufficient to match the higher levels of conversational and even colloquial proficiency required for hiring. While low cost labor still works to the country’s advantage, labor on the average making up 46% of the total budget of operating call centers, such an advantage will not be sustainable if the country is not able to supply as much as is needed by steadily growing demand. While hiring is becoming more and more stringent, English proficiency in the formative levels of education remains below average. English language skills tend to diminish over time, as shown by statistics reported by the Department of Education, e.g., Grade 4 public school students show national average of 42% in English, while high school students show 30%. As English and communication subjects are required less in college, it may be expected that the level of proficiency will deteriorate more in the tertiary levels of education. Although English continues to be widely used in business, in government (at least in the high levels), and in school, programs in local mass media and entertainment are dominated by Tagalog films, making mastery of English a more difficult task for the average call center applicant. The current state is reflected in the low acceptance rate among applicants in call centers and other BPO companies. Out of every 100 new college graduates applying, only three are hired. High attrition rates and the increase in â€Å"poaching† and â€Å"piracy† of agents on the other hand threaten the low cost of labor as companies invest in benefits and compensation packages to ensure agents will not move to a competitor. In 2006, the labor attrition rate in the Philippines is reported to be 18% for full-time agents and 24% for part-time agents. India has significantly higher attrition rates, as follows: 18 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS Table 2 Comparative Mean Attrition Percentage for Full-Time and Part-Time Call Center Agents in China, India, Malaysia, the Philippines, Singapore and Thailand Mean Attrition (FullTime) 17% 38% 18% 18% 16% 15% China India Malaysia The Philippines Singapore Mean Attrition (Part-Time) 29% 32% 24% 24% 21% 16% Thailand Source: callcentres.net At this rate, a job in a call center is already considered as a career in the Philippines, and not looked upon as merely a â€Å"temp† position as in the United States. Nonetheless, â€Å"poaching† or â€Å"pirating† of employees between call centers has already been observed because of the limited talent pool. Call centers are challenged to implement best practices in curbing employee attrition in the call center industry such as a flexible and conducive environment, high incentives, and training schemes, and more importantly, a career path development plan to convince college graduates that being a call center agent is not a â€Å"dead-end† type of job. The Challenge of Moving Forward The question remains as to who will bear the cost of improvements required to strengthen all factors necessary to ensure the sustainability of the Philippines’ competitive advantage in the call center industry. Some call centers have shouldered the cost themselves, o ffering free inhouse training for new hires. Still others have established joint efforts with existing universities and the Technical Education and Skills Development Authority (TESDA) to incorporate call center-oriented training requirements in their curricula and courses. Call centers have established personnel development initiatives, e.g., in-house training and evaluation, to enhance skill, and compensation and benefits initiatives, e.g., higher allowances, all-expense paid holidays and vacations, career development planning, etc., to curb attrition rates, ensure greater stability of the workforce size, and lessen the â€Å"poaching† of call center agents. More call centers are also contributing to the development of the countryside, more specifically the locations outside Metro Manila such as Laguna, Baguio, La Union, Cebu, Davao, Cagayan de Oro, Iloilo, etc. Geographical diversification, i.e., expanding call center operations to provinces, will provide more labor supply, and breathing room to answer to the intense scrambling for office space in Metro Manila. Call center operations will also encourage infrastructure development in other metro cities, with the possibility of replicating the development in the cities of Metro Manila in infrastructure and skill to the countryside areas. Another opportunity available to the sector is value diversification. India’s move towards strengthening non-voice services was not lost on Philippine ears. In its forecast towards 2010, the Department of Trade and Industry (DTI) expressed its target to increase the share of other BPO services in the total BPO revenue pie while decreasing dependence on call centers, which might now be showing signs of decline. The semiconductor industry in its peak of growth during the mid-1980’s also prompted recommendations toward diversification towards higher-value processes. At the time, the sector primarily consisted of low-level technologysupported processes, mainly automated simple assembly of semiconductor devices and product testing. Even now, industry activity in high-level AILEEN S. ALAVA 19 technology-supported activities such as wafer production and device design are still yet to reach the growth stage. The Philippines’ competitive advantage in the call center industry may be sustained through the enhancement of supply conditions, strengthening of related industries, and geographical diversification. Whether these efforts will work will be determined by two developments industry participants should take care to observe at the close of the year: first, how the market will respond to the industry’s efforts, i.e., whether the growth in demand will be sustained by continuous inflow of new contracts and whether forecasted increases in employment, facility expansion and investment will be attained or exceeded; second, how the industry will answer the demands of the market, i.e., whether the total operational capacity (as to labor supply, connectivity, technology, facility and real estate) of the call center sector will be sufficient to respond to the rise in demand. These developments will indicate whether the call center industry can reverse the tide and halt impending decline. However, the industry should be prepared should the slowdown in growth rates persist in the coming years, indicating that the country’s advantage has been weakened by the supply strength of other countries such as India or China. In this case, a prudent response that call centers should consider is to diversify into other BPO sectors such as high-value, non-voice-based services to compensate for the effects of decline in the call center industry. REFERENCES A. T. Kearney (2007 & 2005). Global services location index. Balfour, F. (2003, February 3). The way,way back office. Business Week. Bharadwaj, G., Varadarajan, P. & Fahy, J. (1993). Sustainable competitive advantage in service industries: a conceptual model and research propositions. Journal of Marketing, 57(4), p. 83. Business Process Association of the Philippines, http://bpap.com.ph Board of Investments, http://boi.gov.ph Call Center Directory, http://callcenterdirectory.net Callcentres.net. 2006 Asian contact center industry benchmarking report. Contact Center World. http://contactcenterworld.com Cruz, Dennis H. (1981, October) A review of international subcontracting arrangements in the Philippine electronics (semiconductor) industry, October 1981. Department of Trade and Industry. http://dti.gov.pg Domingo, G. (2005, April 11). BOI, BPAP, CICT: What roles they play. Computer World. Domingo, G. (2005, March 7). Why we rate poorly in technology in global competitive surveys. Com puter World. 20 INDUSTRY REPORT: THE PROBLEM OF SUSTAINABLE COMPETITIVE ADVANTAGE IN PHILIPPINE CALL CENTERS Frost & Sullivan (2005, December 20). Assessment of the Asia Pacific contact center markets. Hookway, J. (2004, October 7). The services spin-off. Far Eastern Economic Review. IBON Databank Phil, Inc. (1990). The semiconductor industry. Institute for Developmental and Econometric Analysis, Inc. Call center industry and the Philippine economy. Lecture delivered at the UP School of Economics. March 2006. International Customer Management Institute. http://www.incoming.com IT Matters. http://itmatters.com.ph McDougall, P. (2004, January 26). Automation takes toll on offshore workers. Information Week. NOTES 1 Selection of the ten top call center companies is arbitrary and not based on an objective ranking of financial performance. The subset was intended to illustrate industry concentration: how a small minority of ten call centers have contributed significantly more revenues to the sector than the other 138.

Ethics of Peer to Peer downloading and Sharing Essay

Abstract In the short time that computers and internet have existed in the modern era, the world has seen a complete 360 degree turn and in the various forms of electronic entertainment that people all over the world are now using. In the days before CD’s, DVD’s and the internet, not much was said if a vinyl album (remember these?), VHS cassette (or these?) or an audio cassette was loaned to a friend for their listening / viewing pleasure, but today with the availability of sending an email with three or four megabytes (mb) of information, one can enjoy a borrowed song but is assumed that it is piracy or stealing. Is this a fair assumption? This Author will not give his opinion but rather discuss both sides of the Peer to Peer (P2P) downloading and sharing issues and let the reader form their own opinions. Peer downloading and Sharing: Definition and History â€Å"Peer-to-Peer† technology, what is meant when this phrase is mentioned in the world of electronic entertainment or computers? Usually in today’s environment, this phrase has a negative connotation assigned to it, but this phrase deserves a deeper investigation into all aspects of the concept. Peer-to-Peer technology is defined by the textbook of this class as â€Å"technology which permits easy transfer of files over the Internet by large numbers of strangers without a centralized system or service.† (Baase, 2008) When this definition is read, does it imply an impartial connotation or is the definition insinuating that this technology is wrong without some form of centralized system or service? Who knows? This is up to the reader to decide, but much probably depends on the readers personal opinion on the matter. With the textbook’s definition stated, what is actually meant by P2P technology? In Basic English, P2P technology is the ability share / loan / give an electronic file of any sort, be it music, software, video or documents, with anyone that is logged onto to the same server or network as the person in possession of the file. Another important definition that needs to be stated is that of â€Å"Copyrights.† Copyrights are defined by the Merriam-Webster online dictionary as â€Å": the exclusive legal right to reproduce, publish, sell, or distribute the matter and form of something (as a literary, musical, or artistic work)† (Merriam-Webster 2011) Again in Basic English this translates to that the original owner of a product has all rights to make profits from their product or service. But, there is always a but, as this definition does not state, do these legal rights apply to the sharing of a product or service and thereby not making a profit from the product? There seems to be two main questions that need to be answered and they are: 1) What is the legal definition of â€Å"sharing?† and 2) What is the legal definition of â€Å"making a profit?† It would seem that until someone legally defines these, this will be the never ending question that will continue plague the electronic world of entertainment. These two questions will be discussed later in this document. As with many things in life and technology, when these ideas and concepts were initially invented or designed, apparently these people did not look to the future and what may become of these ideas or designs. When the initial copyright law was passed in 1790, computers, MP3’s and various other forms of electronic technology did not exist and this law only covered books, maps and charts and protected them for 14 years. (Baas, 2008) It wasn’t for almost 130 years that the US Congress updated the law to include photos, sound recording, and movies but again nothing is done to define profit or sharing as it relates to this topic of conversation. As time has passed, various countries, including the USA, have passed and enforced stricter laws, mostly in favor of the entertainment industry. i.e. copyright infringement, illegal sharing of copyrighted material, and profiting from copyrighted material. All of these examples seem very similar but in reality they have some very fine differences that if you ask any judge to define, you may end up with as many different answers from each different judge asked. This is where the dilemma starts. As time has passed and technologies have become available to the average people of the world, including those with lesser amounts of disposable money, the ability to â€Å"share or loan† electronic material has become increasingly popular. The question still remains in the mind of this author; what is the difference between sharing and audio cassette with a friend and sharing an MP3 that has been legally copied from disk or downloaded from Itunes? In the eyes of many people, there is not a difference in these two concepts. In the eyes of many, the concept of sharing a MP3 is that same as sharing a cassette but has followed the theory of evolution and grown from the era of physical items, like cassettes, and evolved to the electronic media market. This sharing concept brings forth another question. Why did music industry and other various media companies not try to enforce the existing laws when it was only video and audio cassettes? Could it be that â€Å"back in the day†, the number of cassettes / albums being shared were not near the numbers of electronic media being shared today? This seems to be the probable answer because to share a cassette or album there needs to be some form of physical contact between the two participants and to share electronic media the two participants can be miles apart and only need a computer with internet or email access. Back in the day, the amounts of profits lost were not worth the legal fees to fight the practice of â€Å"Sharing.† Present Day Operations So now let’s jump to the present day and discuss the practice of Sharing as it is being practiced today. By present day, it is to include the modern era of computers and the Internet. With the invention of the Internet, CD’S, DVD’s and other forms of electronic technologies came to associated people that would eventually try to use these inventions to their fullest extent. This too included the sharing of files, music and software. Napster was one of the first agencies to openly advertise that you could â€Å"share† files with their P2P software. What happened? According to History.com, Napster began operation in 2000 and by later in the year, some 60 million users were freely â€Å"sharing electronic media of various forms. This is where the modern practice of enforcing the existing versions of copyright laws was being challenged in court. Napster, as it originally operated, only lasted for about a year and a half before the legal eagles of the media industry came at them with a vengeance and essentially shut them down. These lawyers, representing just about all aspects of the music industry, â€Å"filed suit against the company, alleging â€Å"vicarious copyright infringement† under the U.S. Digital Millennium Copyright Act of 1996.† (history.com) Although Napster continued to exist in various forms since 2000, after going legit, they just have not had the same impact on the P2P world that they had back then. As of 30 Nov 2011 Napster, who was owned by Best Buy, has been sold to Rhapsody in an effort to increase Rhapsody leading music subscriber database. (cnnmoney.com. 2011) Along the same time as the Napster rise and fall, other P2P companies were trying to find every legal loop hole to be able to continue operating without worry of legal action from these media moguls. These companies included, but were not limited to Grokster, Kazaa and the nearly legal Limewire. Throughout the years that followed, these companies tried every possible exception to the laws to circumvent the laws but in the end even Limewire was shut down by the US Gov’t. In the past, when you loaded Limewire’s website, their page was loaded with ads, software download links and various other stuff, but now all you get is the official seal of the US Justice department and a warning that you are trying to access a seized webpage and/or to stop distributing their P2P software. What is interesting now is that the P2P software industry and music / movie are not the only ones trying to stop the use of computers and the internet to share files, now TV moguls are also trying to jump on this bandwagon. In recent years, websites and various users have been streaming live sporting events to the internet via their personal paid cable TV services such as Comcast or DirectTV. The websites included rojadirecta and ahdte, but again if you visit these sites you will be met with the justice department seal and a disclaimer saying they have been seized and shutdown for illegal operations such as copyright infringement. The question now is what is considered ownership of the pay per view service? For example, if customer A uses the pay per view option on his/her cable box, does he/she now own the program and therefore has the right to reproduce the item as they see fit? Or, do they still have to obey the original reproduction laws. Another concept is this. If Customer A purchases the right to view a program and then puts said program available for viewing by friends that visit his/her house, is this copyright infringement? The list of questions goes on and on. If customer A purchases the right to view the program and then chooses to stream the program to a free and public website, can others log onto this website, view the program and not be guilty of breaking any laws. Although there may be some ethical and moral questions to answer for, these do not affect the legality of this arena. Customer A did not make a profit by streaming the program to a free website. Customer A did allow friends to view a program that by legal intention of the law was for the viewing of customer A only. Viewing live streaming is not the exact same as that of P2P sharing of files but does have the same implications. Someone is receiving a product or service that was not paid for, At least this is what the media industry would like the legal system to believe. In the 2011 it would appear that the media industry is winning the legal battles, albeit they are having much more success within the USA than other parts of the world. This is especially true in the more disadvantaged countries. This author will use his current country of Colombia, South America as an example. Here it is very common place to purchase or download shared versions of music, movies and computer software. Why is this? Quite frankly this is a poor country and without these shared versions of these products, people here could not afford any of these products at regular corporate pricing. After experiencing the technological environment here, one can understand why the â€Å"shared† file industry is so important. Ethical Questions So! Many views and examples have been shown for both sides of the P2P and file sharing argument. Now the questions need to be presented as to what laws are actually being violated. The media industry would have you believe that by sending a legally purchased MP3, for example, to a friend for their listening pleasure, that both parties are now breaking the copyright laws for that artist. Furthermore, the media industry wants you to think that if you would not have shared this MP3 with your friend, then this friend would have to go to a store and purchase this same song on a disk. The general public counters these arguments with these answers. The persons sharing the MP3, would argue that they are not violating the law because they are only sharing the music with each other and neither party is making a profit off the item and that by sharing the item first, one can make an informed decision on whether to spend more money for the entire disk or possibly only purchase the single. These same arguments apply to almost all portions of the P2P file sharing industry and live streaming of television events as well. Conclusion Basically it comes down to this. The media industries want to continue receiving and growing their profits and the general public would things for the lowest possible price. Whether or not to use P2P file sharing technology or view live event streaming on computers will always be a moral and ethical question that only one person can answer. That person is, the person that is deciding whether to use the P2P technology or not and will always be a personal issue that each and every one that uses these technologies will have live with. Everyone will have to answer this for themselves. References Baase, S. (2008). A gift of fire. (3rd ed.). Upper Saddle River, NJ: Prentice Hall.Microsoft Server and Cloud Platform (N.D.). Windows Server 2008 R2, Retrieved Merriam-webster online dictionary (2011) Definition of copyright. Retrieved from http://www.merriam-webster.com/dictionary/copyright History channel (N. D.). The death spiral of Napster begins Retrieved from http://www.history.com/this-day-in-history/the-death-spiral-of-napster-begins CNN Money(N.D.), Today is Napster’s last day of existence, Retrieved from http://money.cnn.com/2011/11/30/technology/napster_rhapsody/index.htm

Providing Feedback to the Community-based Care Transitions Program Research Paper

Providing Feedback to the Community-based Care Transitions Program - Research Paper Example The CCTP is connected with the Partnership for Patients, whose focus is on improving patient experience and reducing the costs of hospital readmissions by 20 percent (Partnership, 2014). Those included in the partnership are the Hospital Engagement Networks there are 26 states, regional and national hospital system organizations that help identify solutions for protecting against hospital-acquired conditions; the Community-based Care Transition Program (CCTP) which seeks to incorporate social service providers, pharmacies, primary care practices, nursing homes and home health agencies to provide patients with care; and the Patient and Family Engagement (PFE) system which connects relationships between patients, their families and the health care system, so that outside care can continue, rather than returning to the hospital (Partnership, 2014). The New York Methodist Hospital provides a coordinator who assists each patient during the first 30 days to assist patient needs, decipher discharge paperwork and care instructions, oversees follow-up medical appointments for the patient, along with prescription fillings, and will also connect the patient with community services, such as Meals on Wheels (NYM, 2014). As this whole process is still relatively new, it is a work in progress, particularly as the ACA moves into gear in this past year. Obviously, hospitals want to reduce costs, but it should never be at the expense of the public’s health, particularly when concerning older people. As of January 2013, New York State’s Medicare Quality Improvement Organization (QIO) showed reduction rates for Medicare patients in re-admissions within the first 30 days of implementing the program (PR, 2013). Those rates were compared to those from an intervention pilot program during 2009 to 2010, as part of the CMS 9th Scope of Work (SOW) Care Transitions initiative, covering 14 communities nationwide.  Ã‚  

Brief Case Study For The Requirements Specification Document

Brief For The Requirements Specification Document - Case Study Example The main assumption of this model will be The systems used will concentrate on serving one customer at a time as opposed to handling orders from multiple customer. The main objective of this approach will involve serving multiple users at the same time (Connolly and Begg, 2007).. A database containing the details of orders made by all customers, their prices, due dates and status of the orders will be created. It is assumed that all multiple orders will be processed at the same time. However,the rate of processing the orders will be different as this will be dependent with he agreements made between the company and each individual user. The best approach among the two will be the combined approach because it allows for the increased efficiency of serving customers. It will enable the company to process multiple orders concurrently, thus contributing to the achievement of increased revenues (Stephens,

International Dimensions Of Business Essay Example | Topics and Well Written Essays - 2500 words

International Dimensions Of Business - Essay Example Briefly, the Haier Company came in existence by the year 1984 in a Qingdao, in the Shandong province. Following this, the company specifically does manufacture home appliances over 15,100 products. Consequently, the above data did basis on 96 categories of different specifications. Back in 2006 April, the Haier firm had come to 6,189 mark of original technology products that they had manufactured. To add on that the company did acquire software certificates of about 589 from intellectual property rights. Essentially, the Haier products in marketed their products in over 100 different countries. Apparently, the Haier Company sponsored the Beijing 2008 Olympics games (Nancy & Allison, 2008, p.90). In summary, the company has its headquarters in the Shandong province at a place known as Qingdoa in the republic of china. Additionally, the company has almost 50,000 employees worldwide and has over 240 subsidiaries. Concerning the financial status, the company has revenue of about 103.4 bi llion RMB that is global. Consequently, this averages to 68% annual growth between the year of 1984 and 2005.Haier Company is the most profound company that has undergone dynamic changes. Furthermore, it is now the most successful company globally. Therefore, it is important for one study the company. The company gathers a range of issues that are comprehensive for one to learn. Some of the subsidiaries that came to be on the list were Qingdao Haier Company, limited on the stock exchange of the Shanghai as well as the Haier electronic group limited that was listed in the Hong Kong stock exchange. As most companies, the Haier had to have business tock as follows: manufacturing and product development, trade, research on technology and lastly the finance services. Notably, the company did stick on its line of production for several issues namely; freezers, microwave ovens, washing machines, televisions, computers, mobile phones and lastly commercial air conditioners. In the summary of the introduction Haier Company came into existence in the year 1984, in the Qingdao city in the province of Shandong, and lastly, it is in china. It was the first white goods company of the china republic and eventually, it did distribute its products in five continents, which are 160 countries. The company had over 70 thousand employees over the world. Ranking Subsequently, during the year of 2006, Haier Company was in 86th position out of 500 of most prominent brands. Notably one of its achievements was that this is the only company that came to top 100 positions consecutively for three years. It is noteworthy that the company improved its reputation in that it was the first among the Chinese brands to acquire appropriate recommendations in its financial reports globally by the year 2006. The reports came in generation by the Canada state and in addition, the group got world climate rewards from the U.S.in summery, this is few achievements of the Haier Company. The productions of the Haier Company Following this, the Haier Company did manufacture a wide range of products from refrigerating cabinets, air conditioners, computers, water heaters, and home theater, televisions, and mobiles phones among the many that have not been in mention. Furthermore, Haier is leading in the technology domains of home furniture that are integrated by intelligence, digitization, and extensive integration of circuits. Haier’ global branding deal Company did aim at getting to a position of local brand in several markets worldwide in concurrence with the superior competitiveness of the product in relation to tough corporate operation. International business structure comprises of the universal design network, production, distribution and as far as procurement of after sale services (Shaw & Onkvisit, 2008).

Video Observation and Reflection Movie Review Example | Topics and Well Written Essays - 1000 words

Video Observation and Reflection - Movie Review Example She explains that it is vital they work in that manner because the girls may not participate well when they partner with the boys. Completing the task required that the students partner so that they share and discuss how the connections worked. They also managed to walk around and ask the other students how they managed to work on their experiments successfully (Completing the Circuit: A Conversation About Teaching, 1999). Engagement Questionnaires were given to the students by Ms. Block to allow her know about the encounters of students with electricity. Posters about various uses of electricity and the applications were made by the students. Engagement can spring from two different conditions: experience and dialogue (Bilica, 2007). Experience has been used by Ms. Block through the classroom experiments she has administered. The students in the learning have been assigned the duty of carrying out experiments using the materials they have been given and making precise observations a bout the circuits. Through dialogue, the students purposefully discuss the unit content with their experiences in relation. They write down the class notes and the discussion details. The students thus become the creators and users of knowledge and not passively the recipients of it. Communication Ms. Block herself allowed the students to talk about their observations. This she does by first taking them through the step-by-step process of discussing with them the things she will look for during the learning session. She asks the students questions regarding what their thoughts about sharing and working in groups. It is a process of question asking and letting the students give out their thoughts on the topic (Bilica, 2007). Ms. Block explains that she will be interested in the way the students will be sharing the materials she will give out. Additionally, she will be interested in how the students themselves will share with others the observations and ideas as the experiments contin ues. While giving out the instructions on how the discussions and experiments should be carried out, Ms. Block was standing in front of the class. The students communicated with each other by: 1. Discussing with their individual partners about the connection details and the observations. 2. Moving from their individual groups to other tables to check, ask and help others on their experiments. 3. Giving out their observations to the whole class as they answered the questions asked by the instructor later on when they had finished different phases of the experiment. Direct instruction Ms. Block directly instructed the students about what she looked for during the lesson. She explained-before she gave out the materials for the experiment-that the students will work in groups. The atmosphere in the classroom The groups had different encounters and views during the experiments. This helped to bring out seriousness and involvement in the learning environment (Barton & Haydn, 2006). Studen ts could reveal their excitements when their connections were a success. Others, however, could be seen to be a bit nervous considering that they had difficulties completing their circuits. Ms. Block did her best by also engaging in the experiment process by checking on the groups that were not working out their connections properly. The classroom atmosphere was fun, and the students mood was jovial. We could finally say that the classroom

Home work Assignment Example | Topics and Well Written Essays - 250 words

Home work - Assignment Example Technical writing has several characteristics, including having a specific purpose for writing, the audience written for, providing accurate information, and logical and linear organization (â€Å"Characteristics†). The mentioned characteristics are found in the given prose. The purpose of the prose is to inform readers in a matter-of-fact manner the characteristics and causes of fog, most probably written for academically-engaged individuals like science students. The prose provides scientific information necessary for the audience and not consisting opinions, as in technical writing. It is arranged in an organized manner, initially introducing fog, then progressing to its types and occurrences, finally concluding to how fog poses hazards to vehicle drivers’ ways to disperse fog. The presence of such technical writing features in the prose thus supports that the characteristics of the former can be applied to the latter. Reference Characteristics of technical writing. (n.d.).

Characteristic of the U.S. health care delivery system Essay

Characteristic of the U.S. health care delivery system - Essay Example 9). These characteristics hinder the delivery of healthcare in the US because they pose problems of delays and legal complications. These characteristics reflect that the US healthcare system is highly fragmented and has immense political, economic, and cultural influences. People belonging to certain ethnicities and age groups e.g. older African Americans receive poor access to effective healthcare treatment. In the researches controlling for insurance of health, the older African Americans have been found to have gotten lesser eye examinations, screening for breast cancer, and various other kinds of treatments (Yeo, 2009, p. 1279).The US healthcare system also reflects lack of a central governing agency in the US. The current system of US healthcare poses many emotional, cultural, and political challenges for the health care administrators. However, support for the model of universal health coverage in the US has increased in the recent years and this is seemingly the best way to make the healthcare system unbiased, cost effective, and of high quality (Pushman and Chung,

Merketing research strategy for a case study Paper

Merketing strategy for a case study - Research Paper Example This matter has been made worse by a section of the media, which has published derogatory article showing that the event should not be sponsored by the government. Another section of the public argues that the event benefits commercial businesses in the Gold Coast, and hence it is not worth government sponsorship. The following report is prepared with the aim of justifying the current financial commitment for the event. Table of Contents Problem statement 4 Background 4 Management Decision Problems 4 Marketing Research Problem (MRP) questions/statement 5 Research objectives 5 Proposed mixed method to address MRP 5 The proposed Research design 5 Data collection instruments – questionnaire 7 Sampling plan, data collection procedures and data analysis 8 Key limitation of the study design 10 Independent-samples t-tests 10 Analysis of variance (ANOVA) 12 Bivariate correlation coefficient matrix 14 References 15 PART A Problem statement Background ‘Schoolies’ week is a major tourism attraction event, which takes place annually at the Gold Coast, Australia. The event, which attracts many sponsors and participants, is usually attended by students who have completed their Year 12 (the final year at high school). ... 4. How can the negative perception of the members of the community against ‘Schoolies’ be changed? 5. What actions can be taken to curb the media’s negative publicity of the ‘Schoolies’? 6. What information can be gathered to justify the financial commitments of ‘Schoolies’? 7. What actions can be taken to show the locals that ‘Schoolies’ is a worthy public project? Justification Since the ‘Schoolies’ events were started in 1975, many negative behaviors have resulted in the events’ negative publicity, and actions needs to be taken to address this problem, if the event is going to get public good will. This negative publicity has been as a result of negative behaviors, such as drunkenness, which cause civil disturbances in the main street. As such, the actions that should be undertaken to rescue the good name of this project, should focus on changing the behavior of the students who participate, because thi s is the root cause of problems. Despite its perceived social economic benefits, the role of the state government as a financier of the event has faced many hurdles because some groups, including the members of the opposition have argued that the event is largely benefiting the private sector such as the hotels along the beach, hence not worth the sponsorship. This calls for a deliberate action by the government to ensure that the real benefit of the event to the members of the public is evident, to justify its financial commitment. Marketing Research Problem (MRP) questions/statement 1. Why do the media and the public consider ‘Schoolies’ as a negative project that is not worthy commitment of public resources? 2. Why do the youth who attend the

Organisational Behavior Research Report Assignment

Organisational Behavior Research Report - Assignment Example This part of the paper will highlight the workforce changes of the recent time and the possible implications for organizational policies to cater to these trends. Increased globalization and the minority population in the key developing world bring us to the first trend of diversity. Skilled labor from different parts of the world isattractedtowards thedeveloped world for employment as they offer a better environment for them to grow professionally as well as financially. With greater workforce equality and empowered employees, it has become almost necessary to take into account workplace diversity, whether it is females, blacks, handicapped or other ethnocentric groups, at the time of employment. A healthy organization boasts of a diverse workforce that treats all its employees equally(Dol.gov 2014). With trends like feminism, racial equality and minority rights groups, organizations have to keep an out for possible accusations that may lead to a bad name. Narrowing gaps between minorities and an increase in the number of female employees stepping into the professional world has made it imperative that they are made to feel equally welcome and acknowledged. Gone are the days when men were the sole bread earners in the family and women were responsible about family. With women stepping out and equally contributing to the financials of a family, it has become a responsibility of both the men and the women to take care of the family and kids. Thus, it has become important for both the sexes to have job flexibility that allows them to give reasonable time at home and meet family challenges that are now equally shared by the parents. With the advent of technology, workplaces have become more automated. Thus, the most sought after skill is web and computer orientation, making manual labor obsolete. In order to keep up with the pace of change in

Gender Role and Sexuality Essay Example for Free

Gender Role and Sexuality Essay I can fortunately and happily say that I personally have not experienced unequal treatment in regards to my chosen career, educational path or previously held jobs. What I do still see currently being stereotyped are gender roles and the way they are allowed or not allowed to sexually express themselves in the public eye. From my experience it is more acceptable for men to compose music about sex, be in main stream media selling sex, have successful careers in sex, and everyday unequal expectations in dating, sex and relationships. Men have more sexual freedom in the world today. Men are encouraged and in most cases applauded on the discussion of how many partners they have had in the past and the specifics of each experience, yet woman are still expected to hide their sex from the world in fear of ridicule and isolation. In our society today woman who are overly sexual or dress in form fitting clothes or lack thereof are automatically stereotyped as the promiscuous type. Why the double standard? I don’t agree at all with displaying private sexual acts to the general public to gain fame and wealth and in by doing such corrupting children and destroying the beauty of sex but I don’t believe that we should have to hide that women are as much sexual beings equally as men. I feel religion and culture play major roles in the history of sexual repression of woman. Even dating back to the Puritan who believed that anything resulting in pleasure was a sin, women’s freedom to express their sexuality has been suppressed in fear of domination because we are just as powerful as men. Growing up in a strict catholic home I was always taught to act like a lady in public. Exactly what was meant by that I wasn’t fully sure but I knew its underlying symbolism was repressing my sexuality. I wasn’t allowed to wear spaghetti straps, mid drift shirts, shorts above my knees, or make up till I was 18 years old. Sex was not spoken of in my household at all, and if it happened to be seen in a movie or on television I was instructed to cover my eyes because sex was forbidden. Being a sexy woman was seen as vulgar. If I had male friends I could not talk on the phone with them or play outside of school with them without a parent or chaperone. On that contrary my younger brother was encouraged to dress well, wear cologne and have many female friends. It was a symbol of popularity. In my father’s Hispanic culture the young men were pampered and treated as kings with double standards. The women were there to serve them. We are not allowed to be sexy or let alone discuss sex in anyway shape or form. As an adult now I can understand why I completely rebelled against the stereotypes created by my religion and culture. It’s not fair to make women feel less than human than men. We are sexual creatures who share the same desires and needs. I now embrace my sexuality. I’m not afraid to be who I am, and say how I feel. Being a single mother in society today puts me in another stereotype as well. Having a child out of wedlock is still looked down upon, and more so with the mother. We are labeled as â€Å"promiscuous†, â€Å"unholy†, and â€Å"irresponsible†, but to me I loved a man for 8 years and wanted to create a life with him. Unfortunately the abuse I endured was too great to allow after the child was born, so I chose to leave. On the other hand the single father is praised and labeled as â€Å"hard working†, and â€Å"honorable†. In news and media woman are portrayed as sex objects in order to entice society. It draws women in because they either want to be like them or look like them and it draws men in because they love the visual stimulation. Sexuality is used as a shock value for ratings. Are sexy woman who love their bodies and the way it makes them feel really that shocking? Instead of conditioning our young woman to hide their sexuality we should be teaching them healthy ways to explore and express their human desires of sexuality in a safe, healthy way.

Exam Topics Home Ownership, Neighborhood Essay Example for Free

Exam Topics Home Ownership, Neighborhood Essay Home ownership Home ownership is one of the definitions of success in America. Generally people are judged by the houses they live in. It is not only the size and architecture of the house but also the type of neighborhood and the distance from different amenities. The progress in buying a house of ones own was steady from the 1930s right up to 2000. By 2000 69,8 million Americans lived in their own homes. But then the steady growth stopped and started falling back. By the end of the eighties the home-ownership rate had declined to 63,4 percent. Why did this happen? The basic reason for the turnaround is simply that home ownership, which was never cheap, has gotten more and more expensive. The reasons are follows. Ownership costs are increasing more than income. Cash down payments are out of any proportion as compared to what they were twenty years ago. Monthly principal (mortgage) and interes payments for a medium house are soared. Prices for homes are so inflated, particularly in good and safe neighborhoods, that tthey are beyond most peoples budget. Life-style changes are also influencing the home-ownership rate. There are more singles and childless couples who are unwilling to commit themselves to a mortgage. Steady home prices and a strong market formerly contributed to mobility, but owners can now find themselves immobilized by deflated but still expensive housing that can take a year or more to sell. Home ownership is becoming a thing of the past. Some experts predict that builders will eventually move toward smaller, more moderately priced housing demanded by many people. Owning is still far less risky than renting, since costs can be fixed with a long-term mortgage. Besides, the underlying desire to be your own boss is deeply ingrained in the American consciousness. Neighborhood Neighborhoods are an important element of the setting for a house. They may be steady or not, friendly or not, clean or not, safe or not. The list of qualifying adjectives can be endless. And still you must live with it if you have a house in this neighborhood. The ethnic origin and economic status of the people who live in the neighborhood often define it. Few neighborhoods today are static. They are constantly changing: people of different ethnic groups and economic status are beginning to live together in the same  neighborhoods. Many young professionals (doctors, lawyers, academics, etc.) move into traditionally poor neighborhoods because they can find larger and less expensive housing there. These young professionals often have money and power and they cause changes in the character of the neighborhood. This process is called gentrification. It then becomes too expensive for the poor residents and they move on. This is a way a poor, unfashionable inner city neighborhood may change into a very expensive area in the course of several years. The atmosphere of neighborhoods is also changing. Formerly one could always borrow a couple of eggs or a ladder from the friend next door. But their family has moved, and the people in there now are strangers. Some of the old sentimentality of neighborhoodliness has receded. There is no reason to have friendly ties with the people who live next door to you just because they happened to wander into a real estate office that listed the place next door to yours. The only thing neighbors have in common to begin with is proximity, and unless something more develops, that isnt reason enough to be best friends. It sometimes happens naturally, but the chances are very small that you neighbors will be your choice as friends. The best relationship with neighbors is one of friendly distance. You say hello, you make small-talk if you see them in the yard, you help each other in emergency. It is easier to produce nostalgia about a neighborhood than about a community, but a community is probably a better unit. A neighborhood is just a bunch of individuals who live in proximity, but a community is a group of people who rise above their individual limitations to get some things done for the public. The American Civil War The American Civil War, also known as the War between the States or simply the Civil War, was a civil war fought from 1861 to 1865 between the United States (the Union or the North) and several Southern slave states that had declared their secession and formed the Confederate States of America (the Confederacy or the South). The war had its origin in the fractious issue of slavery, and, after four years of bloody combat (mostly in the South), the Confederacy was defeated, slavery was abolished, and the difficult Reconstruction process of restoring unity and guaranteeing rights to the freed slaves began. In the presidential election of 1860, Republicans  led by Abraham Lincoln opposed expanding slavery into the territories. Lincoln won but before his inauguration on March 4, 1861, seven cotton-based slave states formed the Confederacy. Outgoing Democrat James Buchanan and the incoming Republicans rejected the legality of secession. Lincoln’s inaugural address insisted his adm inistration would not initiate civil war, leading eight remaining slave states to reject immediate calls for secession. A Peace Conference failed to find a compromise. Both sides prepared for war. The Confederates assumed that Europe was so dependent on King Cotton for its industry that they would intervene; none did and none recognized the new Confederate States of America. Hostilities began on April 12, 1861, when Confederate forces fired upon Fort Sumter, a key fort held by Union troops in South Carolina. Lincoln called for the creation of an army to retake it; meanwhile, four border slave states joined the Confederacy, bringing their total to eleven. The Union soon controlled the Border States and established a naval blockade that crippled the southern economy. The Eastern Theater was inconclusive in 1861–62. The fall 1862 Confederate campaign into Maryland ended at the Battle of Antietam, dissuading British intervention. Lincoln issued the Emancipation Proclamation, which made ending slavery a war goal. To the west, by summer 1862 the Union destroyed the Confederate river navy, then much of their western armies, and the Union at Vicksburg split the Confederacy in two at the Mississippi River. In 1863, Robert E. Lee’s Confederate incursion north ended at the Battle of Gettysburg. Western successes led to Ulysses S. Grant command of all Union armies in 1864. In the Western Theater William T. Sherman drove east to capture Atlanta and marched to the sea, destroying Confederate infrastructure along the way. The Union marshaled the resources and manpower to attack the Confederacy from all directions, and could afford to fight battles of attrition through the Overland Campaign towards Richmond. The defending Confederate army failed leading to Lees surrender to Grant at Appomattox Court House on April 9, 1865. The American Civil War was one of the earliest true industrial wars. Railroads, the telegraph, steamships, and mass-produced weapons were employed extensively. The mobilization of civilian factories, mines, shipyards, banks, transportation and food supplies all foreshadowed World War I. It remains the deadliest war in American history, resulting in the deaths of an estimated 750,000 soldiers  and an undetermined number of civilian casualties. Historian John Huddleston estimates the death toll at ten percent of all Northern males 20–45 years old, and 30 percent of all Southern white males aged 18–40. Reconstruction. Ku-Klux-Klan Reconstruction of the Union held many promises. Black men and women in the South could move to their new home in Florida. Black refugees quickly poured into these lands. By 1865 40 thousand freedmen were living in their new home. But the opposition to the Reconstruction in the South steadily grew. In 1869 the Ku-Klux-Klan added organized violence to the whites resistance. Despite federal efforts to protect them, black people were intimidated at the polls, robbed of their earnings, beaten or murdered. By the early 1870s the failure of the Reconstruction was apparent. The Military Reconstruction Act of 1867 called for new governments in the South; it barred from political office those Confederate leaders who were listed in the Fourteenth Amendment. But the law required no redistribution of land and guaranteed no basic changes in southern social standards. Terrorism against blacks was widening. Nighttime visits, whippings, beatings, and murder became common. In time, however, the Klans purpose became not only economic (to keep the slaves) but also openly political and social. Klansmen also attacked white Republicans and school teachers who were aiding the freemen. Then in 1871 the actions of KKK moved Congress to pass two acts directed against the KKKs violence. These acts permitted the use of martial law, but they were unsuccessful in combatting the Klans activities. The Klans terror frightened many voters and weakened local party organization, but it did not stop Reconstruction. Throughout the South conventions met and drafted new constitutions. New governments were set up, and Republicans won majorities nearly everywhere. After 1877 thousands of blacks gathered up their possessions and migrated to Kansas. They were disappointed people who were searching for their share in the American Dream.

Using gentamicin in the management of sepsis

Using gentamicin in the management of sepsis Sepsis is defined as the inflammatory response toward an infection (1). It is either simple or severe sepsis depending on the organ dysfunction involved as a result of the infection and other factors (2). In terms of the pathophysiology of severe sepsis, a cascade of inflammation and activation of the coagulation system associated with impaired fibrinolysis causes changes in microvascular circulation associated with organ dysfunction, severe sepsis, multiple organ dysfunction syndrome, and death (3). In terms of definitions of other sepsis-associated symptoms, it was generally agreed at the International Sepsis Definitions Conference which was convened in 2001 and the following definitions of sepsis syndromes were published in order to clarify the terminology used to describe the spectrum of disease that results from severe infection. Sepsis is the presence of infection in association with meeting the Systemic inflammatory response syndrome (SIRS) criteria (Box 1 (2)). The clinical significance of meeting SIRS criteria in the absence of organ dysfunction or shock is still unclear. Severe sepsis is defined as evidence of end-organ dysfunction such as altered mental status, episode of hypotension, elevated creatinine, or evidence of disseminated intravascular coagulopathy. Septic shock is defined as persistent hypotension despite adequate fluid resuscitation or tissue hypoperfusion manifested by a lactate greater than 4 mg/dL. Bacteremia is defined as the presence of viable bacteri a within the liquid component of blood (1). Acute pyelonephritis is defined as an acute infection of one or both kidneys; usually, the lower urinary tract is also involved (4). Antibiotic regimen of choice for Sepsis that is associated with urinary tract infection is Co-amoxiclav 1.2g 8 hourly intravenously together with Gentamicin IV dose of 5mg/kg once daily (5). Although that is controversial whether to use the ideal body weight (IBW) or to obtain blood samples indicating Gentamicin level to get the optimal dosing regimen for Gentamicin in obese patient due to risk of accumulation with Aminoglycoside and the fear of oto- and nephrotoxicity (6). Other supportive measures depend on the patients status; table 1 (1) contains helpful measures that indicate markers of organ dysfunction. Case Summary Our patient, C.M., is a 56 years old female who was admitted to the Accident and Emergency department (AE) due to an increased urinary frequency and a high temperature of 40.5 °C. Other complaints were back pain and shortness of breath (SOB). Also, the patient had reported a fall the night before admission. Moreover, the patient had vomited the night before and in the morning of admission. C.M. is a previous smoker who had stopped smoking several years ago and she lives with a partner. She is clinically obese weighing 100kg and her height is 152.4cm. Giving this, her ideal body weight (IBW) comes to 49kg. The only known allergy for this patient is microspores tapes. The patients past medical history (PMH) included asthma, non-insulin dependent diabetes mellitus (NIDDM) and fibromyalgia. She was on one puff daily of each Symbicort Turbohaler 200/6  µg and Ventolin Accuhaler for the management of her stage 3 asthma. Metformin 1g daily was prescribed for her diabetes control; however, its formulation was not mentioned (whether it is a sustained release tablet or a normal release one!). For her fibromyalgia, she was taking 300mg of Quinine sulphate daily together with 150mg of Amitriptyline daily (which is a very high dose; low dose of tricyclic antidepressant (T CA) is recommended i.e. 20-30mg of Amitriptyline). For her pain, the patient was on Co-codamol tablet as required (strength, dose and frequency were not mentioned). Having that she is a diabetic patient over 40 years old, a dose of Simvastatin 40mg daily was prescribed as a primary cardiovascular disease (CVD) protection measure. In addition, Omeprazole 20mg daily was one of her regular m edications with unclear indication. Investigations On admission, an Electrocardiography (ECG) was performed and indicated sinus tachycardia; which could be related to the high temperature, pain or sepsis. The patients vital signs were abnormal having a respiratory rate (RR) of 22 breaths per minute (normal is ~ 12bpm), a heart rate (HR) of 117 beat per minute (normal is ~ 70bpm) and a blood pressure (BP) of 142/65 mmHg (target for diabetic patients is Her laboratory investigations were almost normal except for some parameters. The Sodium level was a bit low which could be a result of the frequent urination or an Amitriptyline hyponatremic effect. Glucose and C-reactive protein (CRP) levels were high which might indicate the presence of infection. Thrombocytopenia may be caused by Quinine or Simvastatin administration! Impression and related Management Plan The patient was diagnosed as a pyelonephritis and sepsis case; so empirical antibiotic regimen was initiated with 1g Amoxicillin intravenously six hourly and 500mg ciprofloxacin orally once daily. Also, 1g Paracetamol intravenously six hourly and one liter Normal Saline intravenously over 24hours was started. Urinalysis on the first day indicated the presence of leucocytes, nitrites, glucose, ketones and blood which means a presence of infection. On the second day, blood culture showed a growth of E. coli which is sensitive to Gentamicin, therefore, 400mg Gentamicin intravenously every 24 hour was prescribed and ciprofloxacin was discontinued. Gentamicin plasma level was requested 6-14 hours after administration of the first dose. In addition to the patients regular medications, 50 mg of Cyclizine eight hourly and 20mg of Citalopram once daily were added, paracetamol IV was switched to orally in the second day and 30mg of oral codeine as required was prescribed ; but the patients Salbutamol Inhaler had been stopped for unclear reason. Discussion Revising the management plan for this patient and in comparison to the local guidelines for the management of pyelonephritis and sepsis patients, we would notice that 1.2g intravenous Co-Amoxiclav is the first-line choice of Penicillins, not Amoxicillin, together with Gentamicin. However, if the ideal body weight is required to obtain the appropriate dosing of Gentamicin for obese patients, so in this case, 245mg of Gentamicin supposed to be prescribed instead of 400mg which is the maximum daily dose (Although that some infectious diseases specialist would recommend going to the maximum dose to make sure that we get the maximum benefit; but we must consider patient status and severity of infection!). Also, it is essential to check the optimal timing for monitoring each drug plasma level, in our case, Gentamicin therapeutic drug monitoring (TDM) has not deviated from the local guidelines recommendation for the once daily dosing of Gentamicin i.e 6-14 hours after giving first dose. Having a patient with increased urination and vomiting, we must consider fluid replacement. Replacing with one liter Normal Saline (NS) might have not met the patients requirement! So it is recommended to check patients need to ensure appropriate replacement i.e. at least 2.5-3 liter daily. We could have recommended giving 2 liter NS each over 8 hours plus the addition of 500ml 5% Dextrose to ensure calories intake if the patient cannot tolerate oral intake. Considering the patients asthma control, we must confirm that Salbutamol inhaler was not mistakenly missed after admission. Since that SOB was one of the patients complaints, we must ensure that it was relieved, if not, consider 5mg of Salbutamol nebulizer four times daily to be added to the regimen and if nebulizer is not necessary, ask for Salbutamol inhaler to be charted as if required basis (6). Also, blood gases were not mentioned so it is probably safer to ask for the oxygen and carbon dioxide saturations to consider if oxygen therapy is needed! Confirm that the patient and nursing staff are aware of inhalers techniques. The patient is on Amitriptyline 150mg orally daily which is considered an old practice for the treatment of fibromyalgia (high dose TCA) and the current recommendation states 20-30mg of Amitriptyline daily for 8 weeks (6) so it is better to re-consider dosing or to change regimen. Low dose Sertraline or high dose Venlafaxine therapy may be effective (6) so consider changing if no further benefit of the use of Amitriptyline. For the associated pain, Paracetamol with Tramadol has better efficacy than Co-codamol. Pregabalin (150-300mg every 12 hours) may improve pain especially if combined with Tramadol; it also improves sleep and morning stiffness (6). So, knowing the patients control with the current medication would be helpful to consider treatment change or modeling to get the most of pharmacologic treatment. Suggesting alternative ways to manage symptoms is also recommended, e.g. spa therapy, physiotherapy, stress management, acupuncture or diet (6). NICE guidelines for the management of type II diabetes mellitus state that Metformin is the first line choice for obese patients. Choosing appropriate formulation that suits the patients lifestyle is essential to ensure patients compliance. Once daily dosing of sustained release formula could provide 24 hour control over glucose, but in this case the present of infection interfered with having accurate reading so it is logical to check the HbA1c to check the glycemic control over the last 8 weeks to consider any therapy modification. Also, pre- and post-prandial glucose level monitoring is required to avoid both hyper- and hypoglycemia using the current regimen. Statins must be prescribed for all diabetic patients who are over 40 years old (6) and having any risk factor of Coronary Vascular Diseases (CVD). The patient was on Simvastatin 40mg daily but no Cholesterol level obtained (consider Ezetimibe if high Cholesterol). Monitoring liver function tests (LFTs) and any muscular side effect is important. Also, having a high BP on admission, checking that BP is normal after sepsis reveals is vital. If persistent high BP, consider adding ACE inhibitors, having the benefit of BP control and protecting the heart in patients susceptible to Vascular Diseases. Weight loss in this patient is advisable so consider dietitian and physiotherapist review to consider going on diet and exercise. Also, annual eye check is recommended to control retinopathy due to DM. Cyclizine was prescribed on regular basis, so we better check if the patient is really on need of a regular anti-emetic, otherwise, consider changing it to as required basis. Regarding Paracetamol, it was prescribed on as needed basis but it was not put clear not to exceed the maximum daily dose, so it is recommended to clarify that to not give the patient more than 4g per day. It is safer to contact the patients GP to confirm the indication of Omeprazole and to consider discontinuation if no clear indication was obtained. Additionally, the patient was thrombocytopenic, which could be a side effect of administration either Quinine or Simvastatin, so monitoring the platelets count is highly recommended to prevent any complication, although DVT prophylaxis is not needed as long as the patient is mobile. Conclusion In conclusion, the overall patient management had no much deviation from the current guidelines recommendation except for some practice that need to be reviewed considering the current patients status. Therapeutic monitoring should be carried on because the patient is under risk of many complications or side effects. Lastly, patients awareness of her clinical condition and treatment requirement for each problem is helpful to prevent or reduce future health problems. Appendix 1: PATIENT MEDICATION PROFILE Patient details Name C.M. Consultant General Practitioner Address Gender Female Weight 100 kg Height 152.4 cm Community Pharmacist Date of Birth (Age) 56 y.o. Known Sensitivities Micropores tapes Social History Previous smoker, lives with partner Patient hospital stay Presenting complaint in primary care / reason for admission Admission date 2008 Increased urinary frequency Back pain Shortness of breath Vomiting Fall (the night before) Fever (40.5 °C) Discharge Date Discharged to Relevant medical history Relevant drug history Date Problem Description Date Medication Comments Asthma Symbicort 200/6 Turbohaler 1 puff daily Ventolin Accuhaler 1 puff daily Non-insulin dependent diabetes mellitus Metformin 1g daily Formulation? Fibromyalgia Co-codamol PRN Strength? Amitriptyline 150mg daily Too high! Quinine sulphate 300mg daily Duration? Simvastatin 40mg daily 1ry CVD prevention Omeprazole 20mg daily Indication? Relevant non drug treatment Prescribed Medication Start Stop Clinical/Laboratory Tests Result 1 Paracetamol 1g IV 6 hourly Day 1 Day 2 ECG Sinus tachycardia 2 0.9% sodium chloride 1000ml IV over 24 hours Day 1 HR 117 bpm 3 Amoxicillin 1g IV 6 hourly Day 1 BP 142/65 4 Ciprofloxacin 500mg PO OD Day 1 Day 2 RR 22 bpm 5 Metformin 1g PO OD Day 1 Urine analysis Leucocytes, nitrites. Glucose, ketones, blood +ve 6 Omeprazole 20mg PO OD Day 1 Blood culture E. coli 7 Quinine sulphate 300mg PO OD Day 1 Na 134 (135-145) 8 Simvastatin 40mg PO OD Day 1 CrCl 145.3 (78-120) 9 Amitriptyline 150mg PO OD Day 1 Glucose 8.9 (3.9-5) 10 Symbicort 200/6 inhaler 1 puff daily Day 1 CRP 180 ( 11 Codeine phosphate 30mg PO PRN Day 1 Bilirubin 35 (3-16) 12 Citalopram 20mg PO OD Day 1 PT 17 (12-15) 13 Cyclizine 50mg PO 8 hourly Day 1 APTT 39 (20-30) 14 Gentamicin 400mg IV 24 hourly Day 2 Platelets 70 (150-400) 15 Paracetamol 1g PO PRN Day 2 Clinical management Diagnosis Pharmaceutical Need Pyelonephritis Evidence-based treatment Sepsis Treatment according to guidelines Care Issue/Desired Output Action Output Confirm drug history + reconcile drug history Ask patient how and when she takes her medication and the indication for each medicine. Compare with GPs DHx + Phone GP for indications for amitrip., omep. and quinine, and when they were initiated. All regular meds have been charted except prn salbutamol. Patient is SOB; advise Dr to chart it prn. Confirm antibiotic regimen for pyelonephritis/sepsis in addition to TDM Check the local guidelines that amoxicillin is first-line for the indication (culture sens. to gent.).Calc. her ideal body weight and CrCl.Calc. gent. dose based on ideal body weight and compare to 400mg iv od (max dose).Check local guidelines whether 6-14 post dose gent. level is correct procedure. Chase level. Monitor BP, Temp, Pulse, RR for signs of resolving sepsis whilst on current regimen. Co-amox 1.2g iv tds is first-line with gent 5mg/kg (max 400mg, ideal body wt 49kg, CrCl 71ml/min). Recommend switch to co-amox because she needs 7/7 iv + oral. Recommend 245mg gent iv od Obtain level before 2nd dose is given+TDM for gent is correct. Review need for gent in 48h Fluid requirements possibly not being met by 1L N. saline in 24hours Request a running fluid balance chart due to vomiting + increased urinary frequency. Ask patient if she can tolerate oral liq. or if feels thirsty. Assess if iv is necessary (2.5L daily + replace losses) Advise doctor to amend first bag to 8 hours and chart 1L N.saline over 8hours + 500ml glucose 5% over 8 hours if patient cant tolerate oral liq. Is her current SOB being treated appropriately? If patient is still wheezy, ask for PaCO2 + PaO2. Request salbutamol nebs 5mg qds + O2 60% to be charted. If not currently SOB, ask for accuhaler to be charted prn. Assess inhaler technique for both inhalers when breathing ok Is her fibromyalgia regimen in-line with current evidence? Check Brit. Soc. Rheum for current guidance on fibromyalgia. Check that citalopram is the SSRI of choice in fibromyalgia since it has been started on admin. Review quinine; if has been in use for 3 months with no benefit consider stopping it High dose TCA is an old practice; current evidence states 25mg/day for 8 weeks. Advise a review of Amitrip. Low dose sertraline has better evidence for use in Fibro. Advise switch + show evidence to prescriber. Tramadol with paracetamol has better efficacy than co-codamol. Suggest trial switch and monitor for dizziness due to recent unexplained fall. Consider pregabalin. Lifestyle advice: stress management, diet, physiotherapy/massage, etc. Is her type II diabetes under control? Check SIGN guidelines on diabetes for current management. Request HbA1c test to determine control over last 2-3/12 Monitor glucose pre/post-prandial and random. Ask patient how she takes the metformin and how regularly Metformin is first-line in obese type II. From lab results, assist endocrinologist in determining whether metformin dose should be increased + which preparation suits patients lifestyle. Is her CVD primary prevention needs being met? Check SIGN guidelines on CVD primary prevention. Check BP + Cholesterol. Next UEs ask for urine albumin + protein levels. Ask patient about current diet and exercise plan (obese) + last eye test. Simvastatin 40mg charted. Check cholesterol. If it is high, may need ezetimibe 10mg od. LFTs ok BP 142/65, upon resolving sepsis recheck BP and initiate ACEi if appropriate. Advise dietician review (obese) + physiotherapy review (or GP) for plan (30mins exercise 5/7). Advise eye test once a year Regular cyclizine may be unnecessary Endorse chart for paracetamols maximum daily dose Reassess patients need for a regular anti-emetic and re-chart cyclizine as prn instead of regular if required Max 4g in 24 hours (e.g. 1g QDS) Highlight patients thrombocytopenia No need for DVT prophylaxis if patient is mobile. Mention that quinine or simvastatin could be the cause of low platelets. Suggest trial withdrawal of quinine if not planning on stopping anyway. Monitor Platelets level if continued. Indication for omeprazole Determine indication from GP and patient. Consider trial withdrawal if indication unknown. Appendix 2: Box 1. Consensus Conference of the American College of Chest Physicians and Society of Critical Care Medicine definitions for the various manifestations of infection.   Ãƒ ¢Ã¢â€š ¬Ã‚ ¢ Systemic Inflammatory Response Syndrome (SIRS): Manifest by two or more of the following conditions: 1. A temperature >38oC or 2. A heart rate >90 beats per minute 3. A respiratory rate >20 breaths per minute or a PaCO2 4. A white blood cell count >12,000/mm3 or 10% immature forms. à ¢Ã¢â€š ¬Ã‚ ¢ Infection:Microbial phenomenon characterised by an inflammatory response to the presence of microorganisms or the invasion of normally sterile host tissue by these organisms. à ¢Ã¢â€š ¬Ã‚ ¢ Bacteraemia: The presence of viable bacteria in the blood. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis (Simple): The systemic response to infection, manifested by two or more of the SIRS criteria pus an infection. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis (Severe): Sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Hypoperfusion and perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status. à ¢Ã¢â€š ¬Ã‚ ¢ Septic shock: Sepsis-induced hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include, but are not limited to lactic acidosis, oliguria or an acute alteration in mental status. Patients who are receiving inotropic or vasopressor agents may not be hypotensive at the time that the perfusion abnormalities are measured. This is a subset of severe sepsis. à ¢Ã¢â€š ¬Ã‚ ¢ Sepsis-induced hypotension: A systolic blood pressure 40 mmHg from baseline in the absence of other causes for hypotension. Adapted from Bone RC et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992; 101: 1644-1655. Appendix 3: Table 1. Clinical and laboratory markers of organ dysfunction. Organ System Clinical Laboratory Cardiovascular Tachycardia Hypotension Cardiac arrest Arrhythmias Haemodynamic support Altered CVP, PCWP Reduced cardiac output Endocrine Weight loss Hyperglycaemia Hypoalbuminaemia Haematological Bleeding Thrombocytopenia Increased D-dimers Abnormal white cell count Abnormal clotting profile Gastrointestinal Ileus GI bleeding Acute pancreatitis Acalculous cholecystitis Decreased intestinal pH Elevated amylase Hepatic Jaundice Hyperbilirubinaemia Increased PT Elevated LFTs Hypoalbuminaemia Neurological Delirium Confusion Altered consciousness Altered EEG Renal Oliguria Anuria Renal replacement therapy Elevated creatinine Elevated urea Respiratory Tachypnoea Cyanosis Mechanical ventilation PaO2 SaO2 PaO2/FiO2 Immune Pyrexia Nosocomial infection Altered white cell count Impaired white cell function Adapted from Balk RA. Pathogenesis and management of multiple organ dysfunction or failure in severe sepsis and septic shock. Crit Care Clin 2000; 16: 337-352.