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By P. Topork. Northern Kentucky University. 2018.

Building on their experience in public relations and communications safe seroquel 100 mg medications bad for kidneys, healthcare organizations expanded their range of mar- keting techniques to encompass a variety of different approaches purchase seroquel 100 mg without prescription medications errors. Early in this process, marketing was often equated with advertising, and, beginning in the 1980s, many healthcare organizations initiated major advertising campaigns. The limitations (and costs) of traditional advertis- ing were eventually realized, and healthcare organizations began develop- ing a more balanced approach to marketing. Over time, direct sales capabilities were added and technology-based marketing techniques were adopted. A new generation of health professionals offered a more mature approach to marketing as the twentieth century drew to a close. Once marketing became accepted as an essential business function, healthcare organizations allowed marketers an expanded role. During this period of growth and development, marketing moved from the periphery of the corporation (and its status as a necessary evil) to a core function for determining the direction of the corporation. Marketers were given high- level administrative positions and the opportunity to sit in the corporate boardroom. By the beginning of the twenty-first century, marketing was poised to have a major impact on the future direction of healthcare. Discussion Questions • Why was marketing not considered important by healthcare profes- sionals until the 1980s? Ann Fyfe was an aggressive 28-year-old owner of a small advertising agency in Colorado. Her clients included a western clothing manufacturer, an irrigation system company, and an international food dis- tributor. Fyfe subscribed to Philip Kotler’s marketing formula based on the four Ps—product, price, place, and promotion (see Box 4. In 1978, Fyfe was enticed by a visionary CEO at a major hospital in San Francisco to bring her marketing formula and suitcase of imple- mentation strategies to a hospital setting. Fyfe jumped at the opportunity to bring what appeared to be a virtually bulletproof system for generating revenue into a field that seemed to be rich with possibility and amazingly untouched by the whole notion of marketing. They established among others an executive physicals program called Vital, an urgent care center in the hospital called CliniCare, and one of the first sports-medicine programs in the United States. A sales force was established, and a major ad agency was engaged to develop clever collateral materials and radio spots. They used direct mail and radio for both public service announcements and paid advertising. They also implemented a full program of community services, from dinners for seniors to wellness pro- grams at health clubs to educational seminars. The marketing initiative was so impressive that it could boast Charles Schwab as the chair of the board’s marketing committee and was considered newsworthy enough to be fea- tured on the Today Show. Corporations were eager to offer a suite of health services to their executives, consumers loved the urgent care clinic, and sports medicine boomed along with the wellness craze of the 1970s. Despite the apparent success of the hospital’s aggressive marketing program, the process soon experienced an ironic twist. Within two years of pulling off this marketing miracle, one that nearly every other U. As a fledgling healthcare marketer, no one had said anything to Fyfe about physicians. To some physicians, the hospital represented direct competition in that physical exams and urgent care patients were being diverted away from their practices. Most staff doctors, however, expe- rienced a more visceral reaction: this slick marketing approach felt sleazy, commercial, and inappropriate, and the culture of medicine was simply not ready for it. Meanwhile, hospitals everywhere were lining up to learn how to replicate this organization’s dubious success. In response to overwhelm- ing demand, Fyfe assisted the American Marketing Association in the for- mation of a healthcare section.

But in addition to her exhaustion and anxiety cheap 100 mg seroquel amex medications rapid atrial fibrillation, she was furious with Charles for not being able to work or help out more with the demands of family life order 300 mg seroquel otc medications j-tube. He struggled to do all he could between seizures to maintain the household, but his efforts seemed, if anything, to only increase her anger and disgust. Emily’s re- sponse to her husband was puzzling and distressing at first, until she shared her history. Her father was alcoholic and abusive of their mother, although not to the children. Her mother had become severely depressed and anxious, and largely unable to function around the house. From an early age, Emily had found that taking the role of housekeeper and caretaker of the younger children had lessened her mother’s depression and given Emily some sense of safety and value in an otherwise bleak situation. Because chronic illness can have such a profound impact on the life of the patient and his or her family, it is easy to forget that emotional factors un- related to the illness can have an equally profound impact on how the cou- ple manages the illness and the changes it requires. In the case of Charles and Emily, it was clear that the emotional reactions to the situation were being fueled by factors external to the illness and the stress and isolation it brings. It is not always so clear, however, how emotional reactivity is con- tributing to the difficulties couples face in dealing with illness. The term emotional reactivity refers to the tendency to get caught up in emotional reactions, which then drive behavior, in contrast to being able to be aware of when one’s responses are out of proportion to the situation and limit the extent to which these responses drive behavior. Indications that emotional reactivity is complicating adjustment to ill- ness include reactions that appear especially intrusive and out of proportion to the situation, problems that do not respond to the couples’ usual coping strategies, or conflicts or concerns that have a sticky quality—that repeat endlessly and with a level of anxiety or intensity that is not easily calmed or soothed, even temporarily. When these signs are present, it is helpful to ex- plore what else might be going on internally that is driving the response, in addition to the real challenges presented by the illness. STEP 3: REDIRECT ATTENTION FROM THE OUTER REALITY OF THE ILLNESS TO THE INNER RESPONSE AND MEANING OF THE ILLNESS Having determined which areas of concern are most likely to be colored by emotional reactivity, it can then be useful to explore the underlying mean- ings associated with those areas of concern. The goal is to begin to clarify 264 SPECIAL ISSUES FACED BY COUPLES the sources of the emotional reactivity. The first step in the process is to highlight the emotions or reactions that are elicited by the particular cir- cumstance or conflict. As a first approach, each member of the couple can be asked why he or she imagines he or she is having such a reaction: To the healthy spouse: "Of course this illness is devastating, but do you have any idea about the reasons for the depth of your frustration about your hus- band’s illness? Having begun this process in the previous step, each individual is now asked to further describe his or her reactions. In the process of description, the speakers elaborate on their internal processes. The therapist responds empathically, underlining the emotions or attitudes hinted at in the speaker’s statement and asking ques- tions to help the speaker continue to elaborate, subtly directing attention to his or her inner experience. As this process continues, the focus shifts from the external difficulty to the speaker’s reaction to it. For example: • The patient begins with an external focus: PATIENT: "This endless treadmill of doctor’s appointments is running us into the ground. STEP 5: CONNECT THESE EMOTIONS TO EACH PERSON’S PARTICULAR VULNERABILITIES AND PREVIOUS INJURIES With the speaker now more clearly in contact with the internal feeling state elicited by the external conflict or challenge, the therapist can ask when, under what circumstances, or with whom he or she may have felt such feel- ings before. Was there ever a time when you were younger that anyone interacted with you in a way that left you feeling like your feelings don’t matter and you just have to do what’s demanded of you? My mother was so control- ling, I wasn’t even allowed to have an opinion about what flavor ice cream I wanted. The spouse often jumps in at this point with a revealing comment about the speaker’s childhood experiences. The husband in one couple I (WHW) saw would feel enraged when his wife asked him questions about the man- agement of the house when she was laid up with her illness. His wife convincingly explained that he had this reaction to the most innocent and gentle of questions she might ask. I asked him if he had ever had a similar feeling or reaction before with anyone else.

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Statics in which r and v denote trusted 100mg seroquel symptoms in early pregnancy, respectively cheap seroquel 200 mg with visa medicine 3604, the position and the velocity of the mass element dm, and the integration is over the mass of body B. The acceleration of the center of mass a body is equal to zero when the body is at rest or in constant motion. The balance of ex- ternal forces acting on an object may in certain cases be sufficient to en- sure static equilibrium. For example, the weight of an elevator hanging from a cable is supported by the pull of the cable. If two boys can pull on a rope with the same intensity, they and the rope remain in static equilib- rium. An object, however, is not necessarily in static equilibrium even if the resultant force acting on the object is equal to zero. That is because if there is a resultant moment acting on the object, it will, in accordance with Eqn. Moment of momentum of an object with respect to a fixed point O must be equal to zero as long as the object remains at rest. To assure static equilibrium we must also satisfy the following condition: SMo 5 0 (5. Thus, if the moment of forces acting on an object can be shown to be zero with respect to one point, then it is zero for any other point fixed in an inertial reference frame. When the forces and the moments acting on an object are three-dimensional, the vector equations, Eqns. According to the equations of static equilibrium, if only two forces act on an object, not only that the forces must be equal in magnitude and op- posite in direction but also they must have the same line of action (Fig. The condition of force balance is satisfied when the two forces are equal in magnitude but in opposite direction. The condition of balance of moment of momentum requires that they must have the same line of ac- tion. For this object to be in equi- librium, forces involved must be of same magnitude, opposite sense of direction, and must also share the same line of action. This re- sult has implications on the forces carried by the long bones of the hu- man body. The weight of a bone acts at its center of mass but may be neg- ligible in comparison with the forces acting on the joints. When the tensions in the two strings are large enough, the rod aligns along the tension line as if it were weightless and all the forces acting on it were at its endpoints. Note, however, that in the case of a long bone, muscle forces do not act right at the ends of the bone but have small lever arms. Thus, the assumption that the bone transmits force along the direction of its long axis may not be reasonable under a vari- ety of loading conditions. Another simple result directly derived from the equations of static equi- librium concerns objects under the application of three forces (Fig. If the lines of action of two of these forces intersect each other at some point in space, then the line of action of the third force must also pass through that point. The only way the resulting moment on the object will be equal to zero is if the line of action of the third force also passes through this point. Investigation of static equilibrium requires computations of moments created by external forces. As we have already demonstrated, the mo- ment of a force with respect to point A is defined as MA 5 rP/A 3 F (5. We could determine moment MA by going through the formal procedures of vector multiplication. However, some- times it is easier to adopt an approach that employs only scalar algebra. The direction of the strings specifies the directions of the forces acting at the ends of the rod. Note that when the tensions in the strings are comparable to the weight of the A rod, then the rod and the string C forces are not aligned. However, as the string connecting the rod to the B hook D is pulled with increasing D force, the rod acts as if it is under C the influence of just two forces. The weight of the rod can then be ne- glected in the condition of force bal- ance.

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However 200 mg seroquel amex symptoms 4 weeks, an agreed-upon mechanism should be estab- lished for regular communications among the team members for strategic thinking seroquel 200 mg with mastercard medications look up, troubleshooting, and assessment of progress. Chapter Five IMPLEMENTATION ACTIONS BY THE DEMONSTRATION SITES The low back pain guideline demonstration tested an implementa- tion approach that included actions at both the corporate (MEDCOM) and local (MTF) levels. MEDCOM defined the desired clinical practices (as specified in the DoD/VA practice guideline) and key metrics to measure attainment of those practices, and it also provided several tools to assist the MTFs as they introduced new practices in response to the guideline. The practice changes were carried out by the MTFs, as the health care delivery organizations, and the MTFs were offered the flexibility to define strategies and clinical process changes within the context of their respective mis- sions, populations, and administrative and clinical assets. Because these characteristics differed across facilities, we expected to observe differences among the MTFs’ implementation strategies and the pace at which they introduced practice changes. We assessed the merits of this flexible approach in the evaluation, looking at how it affected the MTFs’ ability to achieve best practices and progress to- ward consistent practices across facilities. We report in this chapter the findings of the process evaluation with respect to the strategies and actions undertaken by the MTFs to im- plement best practices for management of low back pain patients. First, we summarize what we learned about the environment and climate for guideline implementation at the participating MTFs, which represent the settings within which the MTF teams were carry- ing out actions to modify the way the MTFs provide care to low back pain patients. Then we describe the strategies and actions the MTF teams identified in their implementation action plans and the 53 54 Evaluation of the Low Back Pain Practice Guideline Implementation progress they made in achieving desired practice changes. Finally, we summarize the lessons learned from the experiences of the MTFs participating in this demonstration. THE MTF ENVIRONMENT The four demonstration MTFs varied in their sizes and clinical ca- pabilities as well as in their previous experience with quality im- provement strategies and use of clinical practice guidelines. These features influenced the strategies chosen by the MTF teams for im- plementing the low back pain guideline and the actions they under- took to carry out the strategies. They are also taken into account in our assessment of implementa- tion progress by the various sites. MTF Service Capabilities All the sites had the basic clinical capabilities for the treatment of low back pain including primary care clinics and physical therapy ser- vices. For three of the sites, primary care services were reasonably centralized at either hospital-based clinics or TMCs that were located separately. Two of these sites had two clinics and one TMC, and the other had two clinics and three TMCs. The fourth site had two clinics at the hospital and a network of seven TMCs located remotely across the post. All the MTFs had a mixture of contract and military physi- cians providing primary care services, but one of them reported be- ing particularly dependent on contract providers. All sites indicated they had low ratios of ancillary support staff to providers, typically not exceeding one-to-one. Support staff limitations were a constraint on the MTFs’ ability to take on new workload for implementing new practices. The MTFs differed in the on-site availability of other relevant ser- vices, including relevant specialty clinics—physical medicine and re- habilitation, orthopedics, neurology, and neurosurgery. For specialty services they did not provide, the MTFs had access to the services from other MTFs or from community providers. Two sites offered back classes (for back pain management) at their wellness centers. In addition, two sites were participating in the Army chiropractic Implementation Actions by the Demonstration Sites 55 demonstration, and so chiropractic services were also available for low back pain patients. Inherent to the Army environment are annual rotations and deploy- ments of active duty personnel, including medical personnel. The sites varied in the frequency of deployments that took place during the demonstration. These sites experienced their typically high pace of deployments during the low back pain demonstration, including loss of some MTF providers to deployments. Climate for Guideline Implementation Among the factors that influence the extent to which a treatment facility achieves lasting improvements in its clinical care processes is the conduciveness of the organizational climate for guideline im- plementation. Relevant factors include the attitudes of key stake- holders regarding practice guidelines, their motivation for using guidelines, the nature of corporate cultures, and the priority that has been placed on quality improvement activities.

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