Integrated Occupational Therapy Practice Case Study

Integrated Occupational Therapy Practice Case Study Introduction This report will focus on the occupational therapy (OT) process for Meera (Appendix A), a 56-year-old woman with a left cerebral vascular accident (CVA). Stroke is the death of brain cells due to the lack of oxygen (Bartels et al. 2016).It can either present as haemorrhagic or ischaemic in nature. Risk factors of CVA include hypertension and hypercholesterolemia which Meera has. Stroke may lead to neurological, psychological, speech and musculoskeletal complications. Meeras symptoms of right hemiplegia, right sided neglect and speech difficulties can be attributed to the occlusion of her left middle cerebral artery (Mtui et al. 2016). A multidisciplinary inpatient stroke rehabilitation unit was involved with Meeras post-stroke rehabilitation. Stroke patients who underwent treatment inpatient stroke care were found to have improved independence (Stroke Unit Trialists Collaboration 2013). Treatment was aimed at managing vital problems through restorative and compensatory approaches in order to prepare her for discharge (Edmans 2010). Thus, this service was most appropriate for Meera due to her recent onset of stroke. The OT process was guided by recommendations from the College of Occupational Therapist, National Institute for Health and Care Excellence (NICE)(2013) and Intercollegiate Stroke Working Party (ISWP)(2016)(Edmans 2010). Assessments and Problems Identified An initial assessment was gathered through an interview using the Kawa Model. It portrays a persons life as a river and various objects such as rocks, river banks and driftwood depict circumstances experienced by a person (Teoh and Iwama 2015). Younger stroke patients such as Meera may require services which cater particularly to their needs which most stroke units were found not to do so (ISWP 2016). As Kawa focuses on the view of the client, it allows the therapist to know what is important to Meera in order to formulate priorities for intervention. The assessment is shown below: Life flow and priorities (river) Past Medical History: Hypertension Hypercholesterolemia Roles and Occupations: Independent in self-care Proud Stay at home mother Took charge of matters at home such as: Cleaning Shopping Gardening Laundry Enjoys cooking for family Present Medical History: Stroke Roles and Occupations: Patient Needs assistance in most self-care tasks Loss of previous role and not engaging in occupations meaningful to her Future Meera felt afraid and pointless to talk about the future, worrying that she may have another stroke if she engaged in activity. Obstacle and Challenges (rocks) Occupational performance challenges: Right hemiplegia with increased spasticity in right arm and leg, causing difficulty in: Sitting Coordination of movement Tasks that require her hands due to being right handed Unable to feel sensations on right hand Feels she cannot remember things as easily and may not know the time and place she is at Right sided neglect with visual agnosia, resulting in difficulty : washing right side awareness of people approaching from affected side interacting with others Expressive dysphagia hinders communication with others. Feeling low mostly Feels useless Embarrassed that people are taking care of her Fatigues easily Concerns Family unable to function as she is unable to manage the household A burden to family, especially her husband who needs to manage the household together with the pressure at work now that she is in hospital Childrens studies and social life may be affected as they may be concerned about Meera and visiting her in hospital may affect their daily life Physical and Social Environment (river banks) Physical (Home) 3 room semi-detached Bathroom, toilet and bedroom on the upper storey Kitchen, combined living and dining room on ground floor Nearest bus stop and convenience store 10 minutes walk away Social Close knit family Meera usually supports family members as they will confide her during difficulties Looks forward to dinner every day where family will gather together Family is most vital source of support for Meera Frequent interaction with neighbours and will help each other with chores if needed Occasionally communicates with extended family overseas on phone Personal resources (driftwood) Personality Hardworking Afraid of trying new things Kind and caring Responsible With information from the initial assessment, the problem list was formulated in a client-centred manner (ISWP 2016). Stroke survivors felt more engaged in the therapeutic process when their perspectives were taken into account (Peoples et al. 2011). Interventions were based on Meeras perceived problems in order to increase her motivation in therapy which she lacked. However the Kawa model only shows the problems perceived by Meera but not the therapists views. In order to gather a clinical and therapeutic point of view, standardized assessments were conducted as well. The table below depicts the various assessment conducted, reasons for use, limitations and results. Assessment Reasons for use and limitations Results Assessment of Motor and Process Skills (AMPS) (Fisher and Jones 2010) AMPS evaluates motor and processing skills of clients through observation of appropriate tasks (Fisher and Jones 2010). Self-care, specifically showering, dressing and cooking tasks which was important to Meera, were used to assess. This allowed the OT to break the tasks down and acknowledge the challenges Meera faced in order to formulate an appropriate intervention. AMPS was found to be valid, reliable and standardized among cultures but results has to be computer generated in order to be valid which may make the process tedious (Fisher and Jones 2010). Less than 1 for both motor (Moderate increase in physical effort) and process (Moderate inefficiency and disorganization) skills. Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) (Itzkovich et al. 2000) LOTCA evaluates the orientation, visual and spatial perception, visual-motor organization and thinking operations through the use of various activities included in the kit (Itzkovich et al. 2000). This allowed the OT to assess Meeras right sided neglect and to discover any underlying cognitive deficits. The LOTCA is reliable and valid for use in people with stroke but needed to be conducted in more than one sitting as assessments were long and tedious for Meera who experience fatigue (Katz et al. 2000). Meera was able to sequence tasks but was unable to complete tasks involving her right field of vision. She needed prompts to complete orientation tasks. Activities involving memory were also a challenge for her. Rivermead Motor Assessment (RMA) (Lincoln and Leadbitter 1979) The RMA consists of tests evaluating the gross, leg, trunk and arm function of a stroke patient (Lincoln and Leadbitter 1979). This was conducted together with the physiotherapist. The RMA allowed the team to know which movements Meera had difficulties in order to formulate appropriate interventions. This assessment was found to be reliable and valid but due to being strenuous and long, it had to be conducted in a few sessions due to Meera showing signs of fatigue (Kurtais 2009) Meera was not independent in transfers and mobility, she required assistance of one for transfers and used a wheelchair for mobility. She also had minimum trunk and leg control at her affected side and require assistance for movement. However, she is able to hold objects using her affected arm but cannot reach for an object far away due to scapular instability. Â  From these assessments, 3 problems Meera faced, in order of significance was developed: 1. Loss of independence in self-care affected Meera the most. From the assessments conducted, it was found that challenges in motor, cognition and perception affected her performance in self-care. Managing self-care would focus on these domains as well (NICE 2013). It was hoped that Meera would be more engaged in therapy by focusing on an issue she perceived as critical. This was evidenced by a study where patients were more motivated and engaged more in interventions when treatment was catered to their perceived needs (Combs et al. 2010). This would also help Meera to elevate her mood as low involvement in self-care was found to be a factor for post-stroke depression (Jiang et al. 2014). The psychologist in the team would be managing Meeras low mood as well (ISWP 2016). By working with Meera on her self-care would also remove some burden from Sanjay, who was assumed to be her main carer when she is discharged from hospital. 2. Problems with visual perception, specifically right side neglect and agnosia, were targeted as it was found to have an influence on self-care (Barker-Collo et. al 2010). This would help Meera in performing self-care tasks. Her visual deficits also affected her social life and transfers. Managing her perceptual problems would allow her to interact more with other patients in the ward which could provide her with social support. 3. Meeras motor challenges, specifically right side weakness and spasticity were addressed as it was one of the major challenges faced during self-care. It was hoped that through the management of motor deficits, Meera would increase her engagement in occupations. This would also have a positive effect for Meera in future as it was shown that physical function affected quality of life in stroke patients (Ellis et al. 2013). Motor challenges faced by Meera would be managed in conjunction with the physiotherapist (ISWP 2016). Skills in managing motor challenges can also be transferred to other aspects such as cooking and reinstating her role as a homemaker. Treatment Plan Client Aims: Meera wants to be more engaged in her personal care. Therapist Aims: To increase Meeras engagement in her self-care tasks. To manage Meeras right sided neglect and agnosia. To manage Meeras weakness and spasticity in her right arm, leg and trunk. Objectives: Meera should be able take charge of her own shower and dressing every morning for an hour, with assistance of one, in 4 weeks. Meera should be able to independently identify items required on her right field of vision for washing and dressing every morning in 4 weeks. Meera should be able to go from lying to sitting, and pivot transfer from bed to wheelchair as well as from wheelchair to shower chair, every morning with assistance of one in 4 weeks. Intervention Washing and dressing assessment was conducted through the use of AMPS. This allowed the OT to formulate an appropriate wash and dress plan for multi-disciplinary use through identified difficulties in motor and processing skills (Fisher and Jones 2010). Using a meaningful occupation as a basis for intervention was beneficial for Meera. This can be supported by a study where occupation based intervention was shown to be critical in improving occupational performance (Wolf et al. 2015). The intensity of the intervention would be higher than the recommended minimum frequency of 45 minutes, 5 days a week as it was included in Meeras daily routine (NICE 2013). The washing and dressing plan was adapted from Salisbury District Hospitals (2013) assessment form. The OT conducted the first session in order to teach Meera the relevant compensatory and visual scanning skills. Other sessions could be conducted by other staff with guidance from the plan. A further review after every few days would also be required in accordance to recommendations (ISWP 2016). Washing and dressing plan for Meera Transfers Bed Mobility: Meera is able to roll to her right side independently. She requires assistance from lying to sitting. Bed to wheelchair: Require assistance of one for pivot transfer Standing: Require assistance of one and grab rail in the bathroom Wheelchair to shower chair: Require assistance of one for pivot transfer Allow Meera to navigate to bathroom Washing Notes: Require the use of a shower chair in the shower Allow Meera to initiate and sequence task independently Only give Meera assistance when she asks for it Place items necessary for shower on Meeras right side If Meera seems to be searching for something, prompt her to look for it by turning her head Encourage use of right hand to wash herself Meera may require assistance to release her grip on objects Provide assistance if Meera feel fatigue Upper body: Meera is able to wash her right side independently Meera require assistance to wash above her elbows on her left side Assistance may be needed to wash hair and back thoroughly Lower Body: Meera should be able to wash her genitals and front upper thighs independently Assist Meera in standing with the grab rail with one person supporting at all times Another person will assist Meera in cleaning her bottom and her rear upper thigh Encourage Meera to wash her lower thighs but prevent her from falling from the shower chair Assist in cleaning the rest of the lower thighs Dressing Upper Body: Encourage Meera to put on the bra independently using the one arm method. Allow Meera to use the one hand method to wear her t-shirt. Prompt her by reminding her of the steps if she is struggling Lower Body: Meera requires assistance to put on her trousers while assisted in standing. Both the restorative and adaptive approach was used to guide the intervention. Restorative approach is grounded upon neuroplasticity where relearning takes place when new neural connections form in the brain during constant exposure to various stimulus (Gillen 2016). By practising various movements of her affected side during self-care, Meera should have a reduction in her impairments. This is supported by a study where patients who went through functional motor relearning therapy were found to have improved balance and performance in self-care (Chan et al. 2006). The compensatory approach is where tasks are modified to be easier for the clients to achieve (Edmans 2010). Even though this approach has been criticized for hindering motor recovery in people with stroke, it is still appropriate for Meera (Jones 2017). The compensatory method of using the one hand dressing method served as a feedback mechanism which could improve motivation as supported by Popovic et al. (2014). This would thus encourage Meera to engage in therapy. Risk Management Plan Meera might be fatigue and may not be able to do some of the tasks required. The staff in charge will assist when required and allow Meera to rest when needed. Due to the intimate nature of a wash and dress, Meera might feel embarrassed and down during the process. In order to preserve her dignity, sensitive areas would be covered whenever necessary and observation would be subtle. Environmental hazards would be checked before commencing any transfers or wash and dress in order to prevent falls. Relapse prevention In the hospital setting, encouragement for frequent engagement in occupation and usage of relevant motor and cognitive skills would prevent Meeras occupational performance from deteriorating (Brainin et al. 2015; Ullberg et al. 2015). According to NICE (2013), long-term health and social support should include education on symptoms and dysfunction relating to stroke, services available and participation in meaningful occupation. As such, Meera and her family would be briefed on these strategies. Outcome Measures Evaluation of treatment outcomes is important to conclude if the intervention was successful and used to change the treatment plan according (Mew and Ivey 2010). The outcomes were evaluated by using goals and comparing standardized assessment at baseline and outcome. Firstly, intervention was evaluated through the achievement of goals. Goal achievement was linked to client satisfaction and a significant client-centred outcome (Custer et al. 2013). Meera was able to achieve the objectives as expected. Secondly, the AMPS was conducted again, using the task of showering and dressing (Fisher and Jones 2010). Meera scored higher in these tasks but still required some assistance in achieving them. Thirdly, Meera improved on the LOTCA tasks which involved visual scanning, little to no improvement was seen on the orientation and memory tasks (Itzkovich et al. 2000). Lastly, the RMA was conducted again (Lincoln and Leadbitter 1979). Meera improved in the trunk, leg and upper limb function but there were still signs of weakness and instability involved. Further plans Other domains of concern would be managed as according to initial assessment and outcome measures. Further interventions would include management of cognitive function such as memory and orientation through cooking. Including Meera in a social group such as breakfast club in the ward would be beneficial to her as well (Venna et al. 2014). To prepare for discharge, Meera would be referred to the Early Supported Discharge team. The team would help Meera and her family by introducing appropriate adaptations at home and relevant education on stroke (ISWP 2016). A smooth transition from hospital to home was found to improve patients function in activities of daily living and service satisfaction (Fearon et al. 2012). This would thus be beneficial for both Meera and her family. References Bartels MN, Duffy CA and Beland HE (2016) Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors IN: Gillen G (ed) Stroke Rehabilitation: A Function-Based Approach (4th Edition). Missouri: Elsevier 2-45 Brainin M, Tuomilehto J, Heiss WD, Bornstein NM, Bath PMW, Teuschi Y, Richard E, Guekht A and Quinn T (2015) Post-stroke cognitive decline: an update and perspectives for clinical research. European Journal of Neurology 22(2):299-e16 Chan DYL, Chan CCH and Au DKS (2006) Motor relearning programme for stroke patients: A randomized controlled trial. Clinical Rehabilitation 30(3):191-200 Combs SA, Kelly SP, Barton R, Ivaska M and Nowak K (2010) Effects of an intensive, task-specific rehabilitation program for individuals with chronic stroke: A case series. Disability and Rehabilitation 32(8):669-678 Custer MG, Huebner RA, Freudenberger L, Nichols LR (2013) Client-chosen goals in occupational therapy: Strategy and instrument pilot. Occupational Therapy in Health Care 27(1):58-70 Edmans J (ed) (2010) Occupational Therapy and Stroke (2nd Edition). Chichester: Wiley-Blackwell Ellis C, Grubaugh AL and Egede LE (2013) Factors associated with SF-12 physical and mental health quality of life scores in adults with stroke. Journal of Stroke and Cerebrovascular Diseases 22(4):309-317 Fearon P, Langhorne P and Early Supported Discharge Trailists (2012) Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 7: CD000443 Fisher AG and Jones KB (2010) Assessment of Motor and Process Skills Vol. 1: Development, Standardization and Administration Manual (7th Edition). Fort Collins: Three Star Press Gillen G (2016) Stroke Rehabilitation: A Functional-Based Approach (4th Edition). Missouri: Elsevier Intercollegiate Stroke Working Party (2016) National Clinical Guideline for Stroke. Royal College of Physicians. Available from: https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx [Accessed 28 March 2016] Itzkovich M, Averbuch S, Elazar B and Katz N (2000) Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) Battery (2nd Edition). New Jersey: Maddak Inc. Jiang XG, Lin Y and Li YS (2014) Correlative study on risk factor of depression among acute stroke patients. European Review for Medical and Pharmacological Sciences 18(9):1315-1323 Jones TA (2017) Motor compensation and its effects on neural reorganization after stroke. Nature Reviews Neuroscience doi:10.1038. Available from: https://www.nature.com/nrn/journal/vaop/ncurrent/pdf/nrn.2017.26.pdf [Accessed 28 March 2017] Katz N, Hartman-Maeir A, Ring H and Soroker N (2000) Relationships of cognitive performance and daily function of clients following right hemisphere stroke: Predictive and ecological validity of the LOTCA battery. Occupation, Participation and Health 20(1):3-17 Kurtais Y, Kucukdeveci A, Elhan A, Yilmaz A, Kalli T, Tur BS and Tennant A (2009) Psychometric properties of the Rivermead Motor Assessment: Its utility in stroke. Journal of Rehabilitation Medicine 41(13):1055-1061 Lincoln N and Leadbitter D (1979) Assessment of motor function in stroke patients. Physiotherapy 65(2): 48-51 Mew M and Ivey J (2010) The Occupational Therapy Process IN: Edmans J (ed) Occupational Therapy and Stroke (2nd Edition). Chichester: Wiley-Blackwell 49-63 Mtui M, Gruener G and Docker P (2016) Fitzgeralds Clinical Neuroanatomy and Neuroscience (7th Edition). Philadelphia: Elsevier National Institute for Health and Care Excellence (2013) Stroke Rehabilitation in Adults. Available from: https://www.nice.org.uk/guidance/cg162/resources/stroke-rehabilitation-in-adults-35109688408261 [Accessed 28 March 2016] Peoples H, Satink T and Steultjens (2011) Stroke surviors experiences of rehabilitation: A systematic review of qualitative studies. Scandinavian Journal of Occupational Therapy 18(3):163-171 Popovic MD, Kostic MD, Rodic SZ and Konstantinovic LM (2014) Feedback-mediated upper extremities exercise: Increasing patient motivation in poststroke rehabilitation. BioMed Research International 2014(2014): Article ID 520374. Available from: https://www.hindawi.com/journals/bmri/2014/520374/ [Accessed 28 March 2017] Salisbury District Hospital (2013) Occupational Therapy Washing and Dressing Assessment. Salisbury NHS Foundation Trust. Available from: http://www.icid.salisbury.nhs.uk/ClinicalManagement/RecordsAndForms/Documents/12e3053a7be542cabff277c26634947aAcuteOTWashDressAssv1007091.doc [Accessed 28 March 2017] Stroke Unit Trialists Collaboration (2013). Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 9:CD000197 Toeh JY and Iwama MK (2015) The Kawa Model Made Easy: A Guide to Applying the Kawa Model in Occupational Therapy Practice (2nd Edition). Available from: http://www.kawamodel.com/download/KawaMadeEasy2015.pdf [Accessed 28 March 2017] Ullberg T, Zia E, Petersson J and Norrving B (2015) Changes in functional outcome over the first year after stroke: An observational study from the Swedish Stroke Register. Stroke 46(2):389-394 Venna VR, Xu Y, Doran SJ, Patrizz A and McCullough LD (2014) Social interaction plays a critical role in neurogenesis and recovery after stroke. Translational Psychiatry 4(1):e351 Appendix A Meera CVA Meera is a 56-year-old woman who was recently admitted with a left Cerebral Vascular Accident affecting the middle cerebral artery. She has a history of hypertension and hypercholesterolemia. She was admitted via A E after being found by her husband. Her husband reports that she felt unwell and made her way upstairs to have a lie down. He went out to walk the dog and on his return found her on the floor in the bathroom. Meera presents with a right hemiplegia with increased spasticity in her right arm and leg. As a result, she has difficult with sitting balance and co-ordinating her movements in order to engage in activities such as washing and dressing. Meera also presents with right sided neglect, which results in her failing to identify objects on her right side, difficulty washing her right side and responding to others who approach her from her right. She has difficulty in articulating in a meaningful way to get her needs met and is very tearful. The Occupational Therapist under took an initial assessment with Meera, the report is detailed below. Initial assessment summary Meera appears low in mood and is reluctant to talk about the future. She is worried that she may have another stroke and consequently is reluctant to engage in activity. Meera is embarrassed that she needs help in personal activities of daily living and is reluctant to talk about activities that she finds difficult. Family Meera is married to Sanjay, a 58-year-old man who works as a plumber. They have two children, Anni aged 18 years who has just completed her A levels and will be attending a local university in one months time, and Sam aged 17 who is at secondary school. Social situation The family live in a privately owned three bedroomed semi-detached property in a small town. Sanjay describes Meera as a stay at home mum who prides herself on her family and her cookery skills. Posture Meera has a right- sided hemiplegia; her scapular is unstable and she finds it difficult to flex her arm above 90 degrees. Elbow extension is uncontrolled and there is stiffness in her forearm making supination difficult. She is able to grasp objects but finds release very difficult. Sensory assessment Meera has poor deep and light sensation in her right hand, which has a profound effect on a range of performance areas. Cognition and perception Meera has a right sided neglect which interfers with washing and dressing, and transfers. She also has difficulty socialising with other patients on the ward due to to this. Meera has some cognitive impairment which presents as poor memory and disorientation. These features are more prominent at the end of the day when Meera is tired. Mobility Meera currently uses a wheelchair but can manage a controlled transfer with one person assisting.

Light and Dark in Joseph Conrads Heart of Darkness Essays -- Heart Da

Light and Dark in Heart of Darkness   Ã‚   Every story has a plot, but not every story has a deeper meaning. When viewed superficially, Joseph Conrad's Heart of Darkness is a tragic tale of the white man's journey into the African jungle. When we peel away the layers, however, a different journey is revealed - we venture into the soul of man, complete with the warts as well as the wonderful. Conrad uses this theme of light and darkness to contrast the civilized European world with the savage African world in Heart of Darkness.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     In Heart of Darkness, Conrad uses light and dark to symbolize good and evil, respectively. "It is whiteness that is truly sinister and evil, for it symbolizes the immoral scramble for loot by the unscrupulous and unfeeling Belgian traders in ivory and human flesh; the whiteness of ivory is also contrasted with the blackness of the natives whose lives must be destroyed for its sake" (Gillon 25).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Two central themes occur in Conrad's Heart of Darkness. The first is the struggle between the white people and the native tribes, which plays in... ...ok and also provides its title. In Heart of Darkness, there is a real contrast between what is light and what is dark. These contrasts work within a reality of civilized and savage. It appears that light represents the civilized, and dark represents the uncivilized, but truly, white is evil, and the dark is innocent and virtuous. Works Cited Conrad, Joseph. Heart of Darkness. Middlesex, England: Penguin Publishers, 1983. Gillon, Adam. (1982). Joseph Conrad. Twayne's English Author Series: Number 333. Kinley E. Roby, ed. Boston: Twayne.  

Process Design Matrix and Summary Essay

We’ll begin by defining processes development. According to (Chase & Jacobs) process is defined as common manufactured products that describe the necessary essential steps for the design of a product. These methods represent a basic sequence of steps or activities that an organization uses to create or modify a product. Many of these tasks involve more intellectual knowledge than physical activity. Some companies define and follow an accurate and detailed development process, while others may not even be able to describe their processes. Every company uses a different process from any other company; in fact, the same organization may follow a different process for each of its products or markets. The purpose of this strategy process is to design a process that meets the customers needs and to product details within the cost and other administrative constraints. Note that the selected process will have a long term effect on competition and the flexibility of the production, as well as on the cost and quality of goods produced. Therefore, much of the procedures strategy is provided at the time of the decision making. I work at Humana Healthcare Insurer Company. It is a Kentucky based Company with 45 years in the market, a leader in consumer-centric health benefits and a Fortune 100 company with revenues of more than $ 30 billion, ranking 79 in our evolving approach to well-being. To help people achieve lifelong well-being, the elements of purpose, belonging, security and health all work together to produce true well-being and we make our contribution to bigger than balance through core strength of our health. Taking into considering the service offered, which is a health insurance plan, Humana has a call center that uses an advanced technology platform that allows access to multiple platforms at the same time to focus on solving the resolution of the call. Calls are answered by highly trained personnel to meet the highest standards of quality and customer  satisfaction. We answer calls in a time of 20-80 seconds allowing each call to be a good experience for our customers. This will allow flows and processes designed to meet and comply with operational requirements and customer needs. To reach the highest levels of satisfaction our Call Center Workforce Management area has to forecast calls volume, agent requirement calculation, compare results and build sc hedule workforce. Our results of the survey conducted to our customers exceed the standards of 98 percent satisfaction. Another service that Humana offers are programs directed to health care. Prevention is one of the main approaches for optimal health. Humana adds value promoting programs such as Humana Beginning for pregnant women, asthma prevention program and nutrition programs where our nutritionists coordinate health programs to guide and promote an optimal health that would result in healthier employees and lower utilization costs. With this vision a 30 percent reduction of your bill for medical claims is expected. The technology used for the call distribution it’s an ACD which allows equitable distribution. Humana provides a dedicated unit called SBU / VIP Area which is a dedicated area of integrated services for our customers. The objective of this area is to manage VIP customer calls through this dedicated area, offering them an exclusive and unique service. Our product is intangible, where each of our programming methods is directed to the contact with the customer, the response time is short, and our markets are local and international. Another of our features is the simultaneous production and consumption with re sponse; duty cycles that are closed after each call and systems technology for call log inquiries to document the call resolution. The main objective is to improve quality, associates productivity and timely response. References Boothroyd, G.,P. Dewhurst and W. Knight. Product Design for Manufacture and Assembly. 2nd ed New York Marcel Dekker 2002 Cooper, R. G Winning at New Products: Accelerating the Process from Idea to Launch Reading MA Perseus Books. 2001 Morgan James M., and Jeffrey K. Liker: The Toyota Product Development System: Integratimg People, Process, and Technology. New York Productivity Press, 2006 Ulrich, Karl T., and Steven D Eppinger. Product Design an Development 3rd ed. New York: McGraw-Hill/Irwin, 2004 Un diagrama de flujo està ¡ diseà ±ado para representar un proceso, ya sea en negocios o en lo personal, para mostrar la forma mà ¡s eficaz de completar un proceso. Un diagrama de flujo puede ayudar a visualizar lo que està ¡ pasando y ayudar a la persona o personas que està ¡n buscando en ellas para entender el proceso que se describe, y si es necesario, la forma de mejorarlo. Cada dà ­a, las personas realizan diferentes tareas que consumen una gran parte de su rutina diaria. En el siguiente artà ­culo, de un proceso especà ­fico ha sido identificado y, a continuacià ³n un diagrama de flujo ha sido diseà ±ado para mostrar los diferentes factores que pueden afectar el proceso, asà ­ como la mà ©trica especà ­fica que identifica el proceso. En el diseà ±o de un diagrama de flujo, los resultados muestran cà ³mo la cantidad de tiempo podrà ­a ser minimizado y que hacer para que el proceso sea mà ¡s eficiente. Hay diferentes tipos de diagramas de flujo, y cada uno tiene diferentes cuadros que representan distintas etapas en el proceso que se discute. Tambià ©n pueden incluir distintos niveles de detalle, segà ºn sea necesario y se muestra la estructura general del sistema. Diagramas de flujo suelen utilizar sà ­mbolos especiales, como los diamantes o rectà ¡ngulos. Un rectà ¡ngulo de bordes redondos representa las actividades de inicio y finalizacià ³n. Un rectà ¡ngulo regular representa una actividad o un solo paso. Un diamante representa el punto de decisià ³n. Las là ­neas de flujo muestran la progresià ³n de una etapa a la siguiente. Los factores que afectan el proceso de diseà ±o de tiempo dedicado a prepararse para el dà ­a serà ¡n los siguientes: 1.  ¿Por quà © me levanto de inmediato o no oprimà ­ el botà ³n de la alarma? 2.  ¿Està ¡ mi ropa planchada para el dà ­a o tienen que ser planchada? 3.  ¿Mis hijos preparan sus bultos para sus prà ¡cticas de volleyball en la noche o lo hacen en la ma à ±ana? 4.  ¿Mi hijo de 11 aà ±os tienen practica o va a quedarse en casa? Si tiene prà ¡ctica, el tiempo debe ser aà ±adido en vestirse, lavarse la cara, cepillarse los dientes, desayunar. Todos y cada uno de estos factores puede afectar el tiempo de proceso, ya que potencialmente pueden afectar la cantidad de tiempo dedicado a cada tarea. Algunas otras medidas que podrà ­an incluirse en la rutina de la maà ±ana son los siguientes: 1) Lavarse los dientes 2) Ducha 3) Secarse el cabello 4) Aplicar el maquillaje La mà ©trica que se ha identificado para medir este proceso serà ¡ el tiempo. Estoy buscando una manera mà ¡s eficiente para agilizar el trà ¡fico de la maà ±ana con mis hijos a partir del tercer grado en dos semanas y un bebà © recià ©n nacido en casa. El diagrama de flujo incorporarà ¡ la mà ©trica del tiempo para cada dà ­a de la semana que se està ¡ estudiando, en un plazo de cinco dà ­as. El tiempo es un componente crà ­tico en la maà ±ana si me les pido a mis hijos preparar los bultos para las prà ¡cticas de volleyball a tiempo o salir por la puerta para el nombramiento de un mà ©dico u otra actividad programada. Los tiempos que se enumeran a incluir la colecta de datos durante cinco dà ­as de la semana del 3 de octubre de 2011. Lunes, 10/03/11 tiempo de preparacià ³n: 32 minutos Martes, 10/04/11 tiempo de preparacià ³n: 20 minutos Mià ©rcoles, 10//05/11 tiempos para prepararse: 33 minutos Jueves, 10/06/11 tiempo para prepararse: 15 minutos Viernes, 10/07/11 tiempo de preparacià ³n: 19 minutos El tiempo total gastado en el transcurso de cinco dà ­as: 119 minutos Un diagrama de flujo puede ayudar a una persona a decidir quà © medidas tomar para agilizar un proceso en el trabajo o en su vida personal. El diagrama de flujo que diseà ±Ãƒ © muestra claramente que el fin de agilizar la rutina de la maà ±ana, es necesario cuidar al mà ¡ximo la noche anterior. Esto incluye el planchado de la ropa, preparar los bultos, y tener a mi hijo ducha. El diseà ±o del diagrama de flujo muestra el tiempo extra que serà ¡ necesaria si cada paso que no se toma el cuidado de la noche anterior, o AM si me decido a golpear el botà ³n del despertador a las 6:00 a.m. CERTIFICATE OF ORIGINALITY I certify that the attached paper is my original work. I am familiar with, and acknowledge my responsibilities which are part of, the University of Phoenix Student Code of Academic Integrity. I affirm that any section of the paper which has been submitted previously is attributed and cited as such, and that this paper has not been submitted by anyone else. I have identified the sources of all information whether quoted verbatim or paraphrased, all images, and all quotations with citations and reference listings. Along with  citations and reference listings, I have used quotation marks to identify quotations of fewer than 40 words and have used block indentation for quotations of 40 or more words. Nothing in this assignment violates copyright, trademark, or other intellectual property laws. I further agree that my name typed on the line below is intended to have, and shall have, the same validity as my handwritten signature

Buddhism is the Solution to Our Current Environmental...

Buddhism is the Solution to Our Current Environmental Problems The destruction of the environment is a major problem in the world today. The exploitation of natural resources, over population, pollution and the spread of human’s impact has negatively affected the quality of the Earth. All life is suffering from the environmental degradation. Air and water quality in cities and surrounding areas is poor. Greenhouse gas emissions are causing a global climate change that is displacing many species out of their natural habitat. The root cause of these issues is that human action negatively effects the environment. Western culture exploits the Earth as a resource for materialist growth. We are driven to develop without fully†¦show more content†¦I will show how the principal teachings of Buddhism create a connection to the Earth, thereby helping preserving it. I have focused of four concepts of Buddhism that connect to environmental prosperity. These four ideas are central to Buddhism and very influential in a Buddhist’s life. The first principal is the simple yet very profound concept of having compassion for all sentient beings. This idea, when taken to heart, connects all life into a harmonious relationship which each other. The second Buddhist practice that I will connect to environmental prosperity is the everyday practice of meditation. Meditation can have many effects that help promote the environment by connecting to the Earth on a personal level. The Middle Way is the third Buddhist concept that is discussed. The Middle Way is a life of non-extremes in every aspect. This leads to proper relationships with people, the land, material goods, and the self that creates a life in balance with nature. My forth topic is the connection between Buddhism and environmental activism. Buddhist teachings foster a motivation and selflessness to the Earth that creates environmental activists. Sentient Beings A sentient being is a living animal with consciousness, allowing it to feel emotions like suffering and happiness. All sentient beings experience some kind of suffering since that is the nature of life.Show MoreRelatedThe Application of Traditional Disciplines to Solve the Ecological Crisis1359 Words   |  6 PagesIt was a misfortune for the world that an omnivorous primate and not some more compassionate form of animal made the sentient breakthrough. Our species retains hereditary traits that add immensely to our destructive impact. Instinctively, we are tribal and aggressively territorial, intent on the acquisition of resources with complete disregard for other organisms, and oriented by selfish sexual and reproductive drives. 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