The Cold War Essay Example for Free

The Cold War Essay Who was to Blame? Historians have changed their views about who was to blame for the cold war over the years. Soviet Historians: They blamed to the United States. The Traditionalits: They blamed to the USSR for the Cold War and its attempt to impose its ideology on the of the world Until the 1960s, most historians followed the official government line – that the Cold War was the direct result of Stalins aggressive Soviet expansionism. Allocation of blame was simple – the Soviets were to blame! This view of the Cold War has never really gone away, and there have always been people who have seen the Soviet Union as the cause of the confrontation. It is, by far, the most common opinion of people who post on the web. In the following collection, note that all the contributors seem to come either from America or Britain : An extract form Michael Hart’s Book: The 100: A ranking of the most infuencail persons in History which supports the idea of USSR being blamed for the Cold War. The Cold War was caused by the military expansionism of Stalin and his successors. The American response†¦ was basically a defensive reaction. As long as Soviet leaders clung to their dream of imposing Communism on the world, the West had no way (other than surrender) of ending the conflict. When a Soviet leader appeared who was willing to abandon that goal, the seemingly interminable Cold War soon melted away. Summary of Michael Hart’s argument justifying placing Mikhail Gorbachev in his top 100 most influential persons in history. Michael H Hart worked for NASA and is currently a professor of astronomy and physics at a US college. He holds degrees in physics, astronomy, and law and is author of: The 100: A Ranking of the Most Influential Persons in History (1986) The truth of the matter, Andrew insisted, responding to the statement of Dr James Leutze that US intellectual thought places blame for the Cold War equally between the US and the Soviet Union, is that the whole cost and  length of the Cold War rests almost completely with the men who led the Soviet Union to its ultimate implosion. â€Å"The Cold War was caused by the Soviet Union , was sustained by the Soviet Union , and was ended by the Soviet Union when it collapsed,† he said emphatically. â€Å"It was—and is—as simple as that.† Report of a QA session with Christopher Andrew (a Cambridge University don and expert on Cold War espionage) at the first Raleigh International Spy Conference, August 2003 The cold war was caused by the USSR s imperial appetite. US Naval War College Review of Eugene V Rostow, Violent peace and the management of power: dilemmas and choices in US policy (1988) Stalins bad behavior was the primary cause of the Cold War J.R. Nyquist styles himself ‘a WorldNetDaily contributing editor and a renowned expert in geopolitics and international relations. He is the author of Origins of the Fourth World War. The cause of the Cold War was the totalitarian nature of the Communist system itself. Posted by ‘Dangus’ on a webforum called @forumz, 11-06-2002 The Cold War happened because Stalin decided that he could not allow the Russians to be behind the US. He chose confrontation because he could not accept the cosquences of being behind †¦ The US is already supreme,why be provocative and upset it further? Posted by ‘PainRack’ on a webforum called Spacebattles.com, Jun 21st 2001, The Cold War was caused by the attempt of one state to impose its ideology on the rest of the world. That state was not the US , which demilitarized immediately after the war. That ideology was not democracy. Posted by Brian Grassie, United States of America on Thursday, December 12, 2002 The United Nations OnLine is a virtual model United Nations sponsored by a Non-Profit Organization from Texas . The UNOL Lobbying Area is for students from around the world to discuss topics concerning the work of the United Nations. The puppet governments [of Eastern Europe] were a huge source of anxiety for the West and were the main cause of the Cold War, the forty-five year long period of tension between the Soviets and the capitalists. thinkquest.org an international website-building competition, sponsored by the Oracle Education Foundation. The Cold War was caused by America s attempt to cooperate with Russia as a country that had common enemies rather than taking a firm stance against Russia from the beginning. posted by someone who calls himself ishalltriumph, 2004-03-16, on a web-forum called livejournal The Rivisionists: †¢ In 1959 the historian William Apple man Williams was the first to suggest that America was to blame. †¢ The revisionists said that America was engaged in a war to keep the countries open to capitalism and American trade. †¢ Rivisionists said that Truman’s use of atomic bomb without telling Stalin was the cause of the beginning of the Cold War. Canadian Ambassador arguing that The American atomic bomb was the main cause of the Cold War: The atomic bomb did help seed the Cold War. Lets face it, the bomb was not just meant to buckle Japan into surrender, it was also a political statement towards the Soviet Union . A statement of power towards a nation who practiced a political ideology different from America which was unacceptable to the free democractic United States†¦ posted by Michael Hughes, ‘Ambassador from Canada ’, on 11 Dec 2002 on the ONOL webforum The United Nations OnLine is a virtual model United Nations sponsored by a Non-Profit Organization from Texas . The UNOL Lobbying Area is for students from around the world to discuss topics concerning the work of the United Nations. The Pro-revisionists: John Lewis Gaddis first published this idea in 1972.The post-revisionists argues that neither Russai nor America was to blame both the sides wanted to keep the peace after the war..the Cold war was a cause of mutual misunderstanding and the failure to appreciate eachother’s ideas. | |P| |The Cold War was caused by the conflicting interests of the United States and the U.S.S.R., compounded by miscommunication and poor diplomacy. The |o| |differences in the cultures of the American political leaders and their moral and righteous justifications for diplomacy from Soviet leaders communist |s| |expansionist policies led to the unraveling of the new international order nearly established in Roosevelts wartime conferences with Churchill and |t| |Stalin. |-| |Analysis of President Truman’s ideas at a site called Innocents Abroad: Presidents and Foreign Policy |r| | |e| |The Cold War was caused by the social climate and tension in Europe at the end of World War II and by the increasing power struggles between the Soviet |v| |Union [and the United States]. Economic separation between the Soviets and the west also heightened tensions, along with the threat of nuclear war. |i| |A muddled free essay at: netessays.net |s| | |i| |The most important cause of the Cold War was the suspicion and rivalry between Truman and Stalin. |o| |Essay title at: coursework.info |n| | |i| |The Cold War occurred because defensive positions were viewed as aggression, |s| |Oakland School , US, Social Studies department essay title. |t| | |s| |The Cold War was caused by fear, not aggression | | |Statement from IB Standard Level History paper, May 2001 | | | | | | | | |and not forgetting some other, very strange conspiracy theories†¦ | | |   | | |In view of this reviewer†¦ much of the cold war was caused by these NAZI spooks who we hired to watch the Russians and that it was beyond comprehension | | |the number of NAZI officials who we illegally allowed to come here. America has always had a very strong German base and as one T.V. show observed the | | |NAZIS did not loose the war they simply had to relocate. | | |Statement made in a review of a book The Good German by John Acuff, ‘Country Lawyer’, | | |a Christian lawyer who writes reviews of the 3-books-a-week he reads. | | | | | |Its just a coincidence that the Cold War was caused by the Second World War which was caused by the First World War which was caused by a | | |dysfunctional trans-national banking system. | | |Jonathan P. Chance, Imperial Mammonism is Just a Coincidence on a pro-Palestinian site | | | | | | | | | | | After the Collapse of Communism:Post 1991 †¢ Russian historians such as Zabok and Pleshavok have been able to study the Soviet Union’s secret files for the first time. †¢ These files show the Soviet leaders during the cold war were genuinely trying to avoid conflict with the USA.This puts more of the blame on the US. †¢ Modern historians clash the cold war as the clash between capitalism and communism. Timothy White’s overview of the historiography of the cold war Despite the divergence of opinion concerning the origin and nature of the Cold War, there is an increasing consensus that shapes Cold War historiography. While scholars may have been blinded by loyalty and guilt in examining the evidence regarding the origins of the Cold War in the past, increasingly, scholars with greater access to archival evidence on all sides have come to the conclusion that the conflicting and unyielding ideological  ambitions were the source of the complicated and historic tale that was the Cold War. Timothy Whi te, Cold War Historiography: New Evidence Behind Traditional Typographies (2000) This is a difficult but very informative overview on the web of the historiography of the Cold War. Timothy White is on the faculty of Xavier University, Cincinnati, USA.

Case Analysis: Tescos Steering Wheel

Case Analysis: Tescos Steering Wheel In early 90s Tesco faced a stiff competition from various other retailers in the industry and thus its revenues showed a downfall. At that point Tesco could not differentiate itself from the other  competitors. Later under the leadership of then CEO Ian Mac Laurin it went through an image makeover, and acquired other retailing outlets like William Low; with which it reached just up to the sustenance mark. Later Terry took over as the CEO of the Company and aimed to make the company value driven Tesco in early 70s had acquired a lot of other  retailer companies but faced a problem of integrating them, more over Tesco stores were small and ill equipped. The company only focused on price where as  the goods available at the stores were perceived to be of mediocre quality, but with rising income customers looked forward to expensive and luxury merchandise.  Answering to this change Tesco closed some of its outlets to concentrate to give stores a better  facility. It also started off the revamp of its a product portfolio. It launched a price reduction campaigns so as to counter the threat from competitors. Also it centralized its distribution system and its own label  for food products.  Tesco developed its own brand labels targeted at different target sector. Tesco value for low income customers, Tesco brand for medium range products and Tesco finest for high end products. It also came up with special ranges like Tesco organics, Tesco whole foods and Tesco kids. The Tesco Way Tesco doesnt want one leader. We want thousands of leaders who take initiative to execute the strategy. ´ This is the statement made by Sir Terry Leahy, CEO of Tesco Tesco came up with the concept of The Tesco Way ´. They aimed at improving its competitive position in the market by becoming more customer focused and concentrated on differentiating itself from other retailers through the services it provided. Tesco had principles like  Better for Customers, Simpler for  Staff and Cheaper for  Operations. To make this goal a reality, in the early 1990s, Tesco went through a process to clarify its mission, values, and strategy. Tesco communicated its new strategy to its employees via a steering wheel, ´ a simple symbol and metaphor for a tool intended to drive performance and help employees navigate into the future. The Tesco steering wheel has four 90 degree arcs, representing the four BSC areas of focus: financial, customer, operations, and employee performance. With the community arc added recently. Every store gets a monthly steering wheel update, a summary of its metrics within each of the four arcs, so that all employees in Tescos mu ltiple regions and formats get feedback on their performance. Tesco supplements its steering wheel report with shopping lists ´ that capture key elements of the strategy in simple forms that employees can follow in their everyday activities. The steering wheel has helped the company stay focused on its strategy even as it experienced rapid growth over the past two decades. Balanced scorecard or in Tescos case the steering wheel provides the perfect base to the company for designing future strategies. It gives the current data and becomes the ideal predictors which is  important for  predicting future trends and thus formulate  strategies. It communicates strategy-aligned goals and manages strategic performance. It monitors progress and measures success. The organizations core purpose to create value for our  customers and to earn their lifetime loyalty ´ has been delivered on a clear and simple strategy of long-term growth. Tescos values and priorities (concerning customers, staff, business, and compliance issues) are embedded in the steering wheel through appropriate KPIs. These values pervade operations and are instrumental in securing staff commitment to the steering wheel. It is arguable that by embedding its values in the steering wheel, Tesco transformed its balanced scorecard from a management framework to a cohesive living strategy. The Tesco Steering Wheel evolves from, and is the route to fulfilling, the retailers core purpose to create value for customers to earn their lifetime loyalty and long-term goals. It organizes and defines the four core elements of Tescos business, those that together define the business. If faithfully adhered to, the  Tesco thinking goes, these elements will inevitably lead to the realization of the companys long-term goals and, through them, its core purpose. So it is that in each Tesco store, department and support facility is posted a corporate steering wheel, out of sight of the customers but in plain view of each staffer. Alongside each of the 15directions and admonitions within the circle  is a  coloured dot green for  acceptable performance, yellow for borderline performance, red for unacceptable performance which is updated, and can change, weekly. The scorecard is for the store, the job, and the individual. It gives one the ability, simply by  looking, to measure the performance of that  particular entity-and what aspects of that performance need to be improved. Some ways of calculating these basic factors are: Operations We try to get it right the first time- The difference between Predicted inventory and actual inventory. No excess stocks. We delivery  constantly  everyday- Regular deliveries and no miss. The stores receiving adequate and right stock in right condition. We always save time and money- Reduced wastage No repetition of steps in a process. People An interesting job- Retention (lowering of attrition) Absenteeism Audit and surveys focusing on indirect questions to know the employees interest levels.(using a 4 or 6  point scale to avoid average marking).   An opportunity to get on- Training levels achieved by the employees. Percentage of employees trained. No. of employees working loyally for how many years Customers I can get what I want- Regular customer surveys. Complain cells. Surprise checks. The prices are good- Competitor analysis Customer feedback Finance Maximization of profits- Calculating operating profit ratio, return on total assets, net profit ratio and return of capital employed and compare them with last year. Benefits of the balanced scorecard used at Tesco: Add to the Balanced Scorecards priority areas to reflect your organizations core aims and values. Converts strategy into an effective governance mechanism. Ensures alignment of all employees to the companys strategic vision. Provides holistic and balanced view of the health and performance of the organization.   Increased transparency and better communication   Simplify strategic aims by creating a visual summary and a shopping list of daily strategic to-dos. Make them applicable to peoples everyday work. Promotion from within then you have a deep understanding of strategy throughout the organization   Helps keep check on strategic aims against customer needs and preferences. Challenges:   Co ordination across multiple functions.

Opening Day :: essays research papers

The sun shines radiantly upon the towering stadium at the corners of Michigan and Trumball. Spring has arrived and erased the dreary, grey weather of winter. The old dilapidated stadium will come to life in a couple of hours to mark the beginning of an anticipated season.   Ã‚  Ã‚  Ã‚  Ã‚  Brringg! The bell signals the end of class and I anxiously wait for my mother to arrive. I find myself impatiently glancing at the clock every two minutes; finally the car pulls up. I jump into the back seat and throw off my heavy backpack. As my mom pulls away, the same old raspy voice can be heard over the radio. I try to block out the blaring AM station, but the word â€Å"opening day† grabs my attention. The weatherman forecasts a sunny day with a cool breeze. A smile erupts on my face, which my mom can’t help but notice through the reflection of the rearview mirror.   Ã‚  Ã‚  Ã‚  Ã‚  I arrive home and hurriedly run up the steps. Stacks of baseball cards and other memorabilia blanket the floor beneath me. I throw off my grade school uniform and find my clothes nicely folded on top of the dresser. I slip on a pair of jeans, but can’t figure out which shirt to wear. I take a seat on my bed and slowly contemplate which Tiger’s T-shirt I should wear. Looking at them brings back memories of past visits to Tiger games. I begin to reminisce, however my daydreaming is short-lived and terminated by the ringing chimes that signal the arrival of my other fifth-grade friends. I quickly grab any shirt and put on my broken-in baseball cap while running downstairs. My friends and I load the car and we pull away from my house. At last we’re on our way.   Ã‚  Ã‚  Ã‚  Ã‚  We arrive at the stadium among a frenzy of other fans. As I step out of the car, my body shakes with a chilling flash of excitement. I rub down the goose bumps that graze my arms and nervously reach into my pocket to find my ticket. It’s still there, but a light film of sweat still covers my palms. Even though we are a few blocks from the stadium, a buzz penetrates the air. Judging by the deafening cheers of the crowd, we know the game has already started. As I glance at the shaking stadium during each wild wave of applause, my steps increase ever so slightly in anticipation.

Hybrid Cars: The Slow Drive To Energy Security Essay -- Gasoline Elect

Hybrid Cars: The Slow Drive to Energy Security The hybrid car market is slowly ramping up. In the past five years the number of hybrid sales in the U.S. grew tenfold from 9,500 in 2000 to 100,000 in 2004. By the end of 2005, the number of hybrid cars on American roads will grow to 300,000, represented by about seven or eight hybrid models, including the two-door Honda Insight, which will have sales of about 2,000 in 2005. The increasing sales numbers are encouraging, but must be viewed in the context of the overall car market. The 100,000 hybrid car sales in 2004 represent about one-half of one percent of the 17 million new cars sold this year. If every new hybrid driver effectively (and optimistically) doubled fuel economy from 20 mpg to 40 mpg for 40 miles of daily driving, then a gallon per hybrid car would be saved every single day. That's a whopping 100,000 gallons per day chalked up to hybrid car drivers. But, we've only reduced our daily U.S. consumption from 360 million gallons to 359,900,000 gallons. Market forecasters predict a continued annual doubling of hybrid car sales for the next few years. We could reach the major milestone of one million hybrid cars on American roads somewhere in the 2007 or 2008 timeframe. Again, this is cause for celebration, until you consider that there are approximately 200 million cars in America today—and over 700 million vehicles worldwide. If car numbers keep increasing at the present rate, there will be more than a billion cars and trucks on the road across the world in 20 years. Vehicles are now driven two trillion miles each year in the U.S., and there are more cars than adults. Nevertheless, with the proven success of the Toyota Prius, which won every possible accolade... ...nsumers of hybrid cars have demonstrated, with their pocketbooks, their commitment to reducing oil dependency. In marketing lingo, they are considered â€Å"influencers† — the segment which is more educated, more affluent, and older — and which shapes the buying decisions of the rest of America. Hybrid owners sit behind the wheel of their hybrid everyday, and wonder what more they could do. Unfortunately, hybrid drivers and alternative energy supporters are now splintered and their efforts are diffuse. In order to put enough pressure on the automakers to stop resisting the change that must come, hybridcars.com is trying to galvanize hybrid drivers and develop partnerships with advocacy groups to develop the most effective strategies for promoting greater fuel efficiency in our cars and trucks. The environment, the economy, and our national security hang in the balance.

Life :: essays research papers

Life; A Work In Progress The average person has a grand total of 2 billion seconds to live out their existance. For those of us lucky enough to live out this time in relative health, or to exceed it, shouldn't we be trying for something more? It ends, people. Life ends. There is coming a time when your heart stops beating and you lie dead and cold on the floor somewhere--and that is it. No redo's, no timeouts, no second chances. Only the bittersweet what-ifs that you will have plagued yourself with for the remaining moments of life. 2 billion seconds doesn't seem nearly as long as my life feels, and I am still a kid. And yet we waste time bickering over the television, fighting over the computer, and resenting each-other over petty quarrels. A saying comes to mind when you consider how sad people can be; when you honestly consider that they would throw their time away on such things. It is a classic case of not being able to see the forest, through all the trees. When infact, those trees that you are so desperately trying to see around are the forest. You are trying to get past that next tree and then, then the forest will be in plain site. Only, it isn't there, and one more tree is in the way. First the tree of graduation is in your way and soon the tree of college jumps behind it. The tree of mediocre jobs blocks your view for years as you try and see around it it. The tree of midlife, or of retirement get in your way as you try and see the trees of contentment, happiness and fulfillment that affirm that 'yes, you have made a difference', and that when your two billionth second chimes to a close, and your eyes glaze over, you will not have been forgotten. That is all we want, people. That is it. One simple goal that will push every American until they die. That one goal of having meaning. Trying to hold on to the fact that, "if I make a difference in someone else's life, then mine will have mattered." So the question is, if making a difference to someone else's life is so important, and they are trying for the same goal you are, then why isn't making a difference in your own life just as important.

Emergency department patient satisfaction Essay

Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. The effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department and level 1 trauma center is investigated. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse and overall satisfaction. These results suggest that such training may offer a substantial competitive market advantage, as well as improve the patients’ perception of quality and outcome. A practitioner’s response to the case study is also included. Customer service initiatives in healthcare have become a popular way of attempting to improve patient satisfaction. The effect of clinically focused customer service training on patient satisfaction in the setting of a 62,000-visit emergency department a nd level 1 trauma center is investigated. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse and overall satisfaction. These results suggest that such training may offer a substantial competitive market advantage, as well as improve the patients’ perception of quality and outcome. A practitioner’s repsonse to the case study is also included. You  have requested â€Å"on-the-fly† machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated â€Å"AS IS† and â€Å"AS AVAILABLE† and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of th e translation functionality and any output derived there from. Hide full disclaimerTranslations powered by LEC. Translations powered by LEC. Headnote visit emergency department and level I trauma center. Analysis of patient complaints, patient compliments, and a statistically verified patient-satisfaction survey indicate that (1) all 14 key quality characteristics identified in the survey increased dramatically in the study period; (2) patient complaints decreased by over 70 percent from 2.6 per 1,000 emergency department (ED) visits to 0.6 per 1,000 ED visits following customer service training; and (3) patient compliments increased more than 100 percent from 1.1 per 1,000 ED visits to 2.3 per 1,000 ED visits. The most dramatic improvement in the patient satisfaction survey came in ratings of skill of the emergency physician, likelihood of returning, skill of the emergency department nurse, and overall satisfaction. These results show that clinically focused customer service training improves patient satisfaction and ratings of physician and nurse skill. They also suggest that such training may offer a substantial competitive mar ket advantage, as well as improve the patients’ perception of quality and outcome. INTRODUCTION Recent changes in healthcare have led to increasing competition and the perceived commercialization of the healthcare provided to patients. At the same time, a need for reaffirmation of the importance of the patient-physician relationship has been expressed in the midst of such powerful forces (Laine and Davidoff 1996; Glass 1996; Pellegrino and Thomasma 1989). One aspect of the patient-physician relationship deserving further study is the role of customer service training in healthcare. While numerous customer service training tools exist in business and industry, no studies have clearly delineated the efficacy of customer service training for patients in a clinical setting. This study examines the effect of a required customer service training program taught by healthcare professionals on patient and family complaints, compliments, and satisfaction in a high-volume high-acuity emergency department. METHODS Patient Base All patients presenting to the Emergency Department at Inova Fairfax Hospital, Falls Church, Virginia, between May 1, 1994 and April 30, 1995 formed the control group, representing the period prior to emergency department customer service training. Patients presenting to the emergency department between May 1, 1995 and April 30, 1996 formed the study group, representing the period following customer service training intervention. The mechanism of patient complaint/compliment analysis and the survey criteria were identical in the control and study periods. Patient acuity was assessed by three measures: the number and percentage of patients admitted to the hospital; the number and percentage of patients with Current Procedural Terminology 1996 (CPT) evaluation and management (E/M) codes 99281-99285, (Kirschner et al. 1996); and a nursing acuity rating scale (EMERGE, Medicus Systems, Evanston, Illinois). Inova Fairfax Hospital is a 656-bed not-for-profit institution that is a teaching h ospital, regional referral center, and level I trauma center. Customer Service Training All emergency department staff involved in patient contact (physicians,  nurses, ED technicians, registration personnel, core secretaries, social workers, ED radiology, and ED respiratory therapy) were required to attend an eight-hour customer service training program. The numbers and types of staff involved in training are listed in Table 1. Because of logistic limitations, emergency medicine residents attended a focused fourhour required training course. The eight-hour program consisted of the following modules: basic customer service principles, recognition of patients and customers (Are they patients or customers?), service industry benchmarking leaders, stress recognition and management, communication skills, negotiation skills, empowerment, customer service proactivity, service transitions, service fail-safes, change management, and specific customer service core competencies. (More detailed information on the content of these modules is listed in Appendix 1.) These core comp etencies follow: making the customer service diagnosis (in addition to the clinical diagnosis) and providing the right treatment; negotiating agreement resolution of patient expectations; and building moments of truth into the clinical encounter. Following the initial required training, new physicians or ED employees were required to attend identical customer service training within four months of their initial employment. Additional mandatory customer service training updates were offered three times per year and included modules of conflict resolution, customer service skill updates, advanced communication skills, and assertiveness training. Patient Satisfaction Data Patient satisfaction data in both the control and study groups consisted of patient complaints, patient compliments, and a telephone patientsatisfaction survey conducted by an independent research firm (Shugoll Associates, Rockville, Maryland) that was blinded to the study hypothesis and course content. Patient complaints and/or compliments were systematically identified from all available means, including verbal, written, telephone, or electronic mail sources. Sources of patient complaints, data analysis, and categorization of complaints were identical in the control and study groups, which was coordinated by hospital quality improvement analysts. ED  staff were instructed to report all potential complaints and concerns, regardless of how minor, to appropriate physician or nurse managers in both the control and study periods. Complaints were logged into a central office and were investigated initially by three authors (TM, RC, DR). In cases where classification of type of complaint differed, additional information and/or clarification was sought from staff, patients, and family. Any discrepancies were resolved by group-consensus techniques. All complaints and the classification thereof were independently reviewed and verified by quality-improvement analysts. Patient complaint and compliment letters were referred for comment or clarification to appropriate ED staff in both the control and study periods. Outpatient satisfaction surveys were conducted by an independent research firm (completely blinded to the study and its hypothesis) utilizing a 50-item questionnaire to identify key factors in customer satisfaction. This survey instrument was validated on a sample of more than 3,000 patients prior to implementation in either the control or study group. The study used a telephone survey on a randomized number table basis to 100 ED outpatients per quarter (Appendix 2). Logistic regression analysis performed on these data identified 14 areas of more important/key attributes in the ED (see Table 2). Patient compliment and complaint data, as well as acuity data, were subjected to a two-tailed ttest and the Fisher Exact test. Patient satisfaction surveys were subjected to a two-tailed t-test with a 95 percent confidence level. Patient Turnaround Times Patient turnaround times (TAT) were calculated from time of initial arrival in the ED to either discharge or transfer to an inpatient unit. Turnaround times were routinely calculated on each patient and on an aggregate basis by day, month, quarter, and year. RESULTS ED Volume/Acuity Neither ED volume nor acuity changed to a statistically significant degree between the control and study periods, based on both admission percentage and nursing acuity (see Table 3). Analysis of CPT 96 Evaluation and Management Codes showed a statistically significant increase in codes 99283 and 99285, with a similar decrease in codes 99281 and 99284. The number of pediatric patients did not change in a statistically significant fashion during the study period. The only payor mix category to rise in a statistically significant fashion was managed care (p < .01), with a nearly identical decrease in commercial insurance. Neither compliments nor complaints correlated with payor category. Patient Turnaround Time Mean patient turnaround time dropped from three hours and 24 minutes (204 minutes) to three hours and seven minutes (187 minutes), but this difference was not statistically significant, nor did the percent of patients at one and two standard deviations from the mean change in a statistically significant fashion. Patient Compliments The total number of patient compliments rose from 69 in the control period to 141 in the study period, an increase of more than 100 percent (p < .00001) (see Table 3). Patient compliment letters consistently mentioned warmth, compassion, and skill of the emergency care provider as the reason for contacting management to praise the ED staff. There was no statistical difference between males and females among patient compliments. Patient Complaints Patient complaints dropped from 153 in the control period (2.5 complaints per 1,000 ED visits) to 36 in the study period (0.6 complaints per 1,000 ED visits), (p < .00001) (see Table 3). Complaints about perceived rudeness, insensitivity, or lack of compassion on the part of ED staff dropped most dramatically. Two-thirds of complaints in the study period were a result of waiting times, billing, or delays in obtaining an inpatient bed, compared to 30 percent in the control period. Nevertheless, complaints regarding waiting times, billing, and wait time for an inpatient bed still decreased 50 percent in the study period (p < .001). There were no significant differences in patient complaints based on age or sex, confirming results of the study by Hall and Press (1996). Patient Satisfaction Survey Data Baseline survey data were subjected to logistical regression analysis that indicated that 14 surveyed areas formed a core group of key satisfaction attributes. All of these 14 attributes showed increases in the study period (p < .001, see Table 2). The largest increases were in the following areas: skill of the emergency physician, skill of the nurse, likelihood of returning, overall quality of medical care, doctor’s ability to explain condition, diagnosis, and treatment options, and triage nurse’s sensitivity to pain. DISCUSSION The patient-physician and patient-nurse relationships are arguably the oldest in the history of medicine. These relationships have recently been described as being under siege because of an increase in the tension between the art and science of medicine, as well as the strains attendant to changes in the economic structure of healthcare (Glass 1996). To this list may be added a third causative factor: the lack of rigorous, formal training for healthcare professionals in the customer service fundamentals of the patient-provider relationship. The fundamentals of such training are closely tied to what has traditionally been described as the art of medicine or the concept of beneficence (Pellegrino and Thomasma 1989). Physicians have for the most part learned appropriate patient interaction skills through observing their mentors and peers during the course of graduate medical education. However, there has only recently been substantial study of this important subject (Buller and Buller 1987; Aharony and Strasser 1993). While customer service has been emphasized in American business and industry in recent years (Zeithamal, Parasuraman, and Berry 1990; Jones and Sasser 1995; Reichheld 1996; Berry and Parasuraman 1991; Berry 1995), few training modules are specifically targeted toward physicians and healthcare professionals. For this reason, the authors created an eight-hour customer  service training course for their ED providers, based on principles of adult education, benchmarks from the customer service industry (Sanders 1995; Spectre and McCarthy 1995; Carlzon 1987; Connelan 1997), experience in the clinical setting, and the existing literature on patient satisfaction (Pelligrino and Thomasma 1989; Thompson and Yarnold 1995; Thompson et al. 1996; Bursh, Beezy, and Shaw 1993; Rhee and Bird 1996; Dansk and Miles 1997; Hall and Press 1996; Eisenberg 1997). This literature emphasizes the importance of communication skills, managing information flow, actual versus perceived waiting times, and the ex pressive quality of physicians and nurses. All of these concepts were built into the training modules, including practical clinical examples of behaviors reflecting these and other concepts. Our philosophy in designing this course was simple. Customer service is a skill for which we hold our staff accountable but in which they had never formally been trained. We believed that this dilemma required, at a minimum, two sentinel events to occur. First, the department needed to have a clearly articulated and easily understood cultural transformation to a solid commitment to customer service. Second, staff members needed education in a practical, pragmatic fashion regarding precisely how such customer service principles could be applied in the clinical setting. Just as advanced cardiac life support, advanced trauma life support, and pediatric advanced life support courses can be used to improve cardiac, trauma, and pediatric resuscitation, respectively, we believed customer service outcomes could be improved by well-designed, mandatory, rigorous application of customer service training. The training was provided by active clinicians involved in day-to-day patient care activities (TAM, RJC). We believe this clinical credibility may have played an important part in the customer service transformation, inasmuch as the staff knew the trainers were well aware of the inherent problems of applying pragmatic customer service skills in a busy emergency department. The data from this study strongly support the hypothesis that clinically based, formal customer service training grounded on these principles can  dramatically decrease patient complaints, increase patient compliments, and improve patient satisfaction, at least in a high-volume, high-acuity ED. Patient complaints dropped by over 70 percent and compliments more than doubled during the study period, such that patient compliments actually exceed complaints in our 62,000 patient visit emergency department and level I trauma center. National data indicate that ED complaints average between three to five per 1,000 emergency department patients, although no data are available regarding rates of patient compliments (Culhane and Harding 1994). Our emergency department was slightly below that national standard level even during the control period. Analysis of the patient satisfaction survey data revealed an extremely important trend. Specifically, patients rated skill of the emergency physician, overall quality of medical care, and skill of the ED nurse as three of the most improved areas during the study period compared to the control period, despite the fact that there were no changes in the ED physician staff during the study and there was very little turnover among ED nurses. This strongly implies that patients rate the quality of care and the skill of the physician and nurse based on elements of the customer service interaction. These data suggest an important causal relationship between the technical component of care and the patient caregiver interaction, which has not been previously demonstrated. It is important to recognize that both customer service and technical skills are competencies to which hospitals and healthcare systems should hold their staff accountable on a daily basis. Hospitals spend substantial dollars to ensure that their staffs are technically competent to deliver quality medical care (Herzlinger 1997). However, to ensure that customer service is effective, clinically based customer service training is essential to give staff the appropriate skills in the clinical setting to deliver service competently. This concept is indirectly supported by data from Mack and colleagues (1995), who found that satisfaction with interactive aspects of emergency medical care produced higher correlations with measures of future intention to use the service than did satisfaction with medical outcomes themselves. Their study, however, did not undertake interventions to improve the interactive,  communicative aspect of healthcare in that setting. Similarly, Smith and colleagues (1995) evaluated the effect of a four-week training program, focusing on patient interviewing, somatization, patient education, and self-awareness, that was taught to first year internal medicine and family practice residents. Their data were not conclusive, but suggested that some but not all aspects of patient satisfaction could be improved by such training. This study tends to confirm the work of Thompson and colleagues (1996) that demonstrated in a much smaller sample size that expressive quality and management of informatio n flow to the patient had an effect on patient satisfaction. However, their study did not assess the impact of strategies and techniques for ED staff to improve patient satisfaction by improving expressive quality. While several studies (Thompson et al. 1996; Thompson and Yarnold 1996; Dansk and Miles 1997; Hall and Press 1996) have emphasized the importance of waiting time and exceeding patient expectations regarding length of waiting time, our study demonstrates a dramatic improvement in patient satisfaction without a statistically significant reduction in patient turnaround time. This supports the work of Bursch and colleagues (1993), who found in a study of 258 patients that the five most important variables for patient satisfaction were the amount of time it took before being cared for in the ED, patient ratings of how caring the nurses were, how organized the ED staff was, how caring the physicians were, and the amount of information provided to the patient and family. However, the study did not assess strategies to improve satisfaction based on this knowledge. All of this information was built into the training modules to assist staff with practical strategies to manage waiting time effe ctively using information flow, queuing theory, and verbal skill training. The implications of the higher ratings of the skill of the emergency physicians and nurses are intriguing and could have a far-reaching impact on healthcare. Perhaps the strongest implication is that perceived skill stands as a marker for quality and/or outcome in the mind of patients and their families. It has been shown repeatedly that patient compliance increases with confidence in the physician (Frances, Korsch, and Morris 1969;  Sharfield et al. 1981; Waggoner, Jackson, and Kern 1981; Schmittdiel et al. 1997). While our study did not directly assess improvements in outcome, quality of care, or appropriateness of care, it certainly appears that patients rated the skill of the healthcare providers as a key quality characteristic in this survey. Furthermore, the fact that ratings of quality of medical care and likelihood of returning also increased dramatically speaks to the importance that effective customer service training may have in offering a competitive market advantage to hospitals and healthcare institutions. This is particularly important as the concept of customer loyalty is closely tied to the likelihood of a patient or their family returning to that healthcare institution. As the focus on outcomes management and evidence-based medicine increases, it is important to take into account the effect that customer service skills have on patients’ perceptions of quality and outcome. This study may be subject to several criticisms. First, while statistical data on patient compliments and complaints obtained substantial statistical significance, the number of patients contacted for the outpatient satisfaction telephone survey may have resulted in sampling bias. While a larger sampling is planned in the future, the patient satisfaction survey data trends were consistent throughout all quarters and appear to be a valid statistical tool, despite the number of patients sampled. Second, it was not possible to blind those responsible for investigating and classifying complaints and compliments. However, we did attempt to reduce or eliminate possible reporting or observer bias by identifying complaints from all sources and ensuring that all complaints and their classification were reviewed and approved by an author who was not involved in ED operations and by quality improvement analysts. Third, information is not available on national or regional trends of patient compl aints and/or satisfaction during the study period. It is possible that the data in this study may reflect local, regional, or national trends toward decreased complaints and increased satisfaction, either globally throughout healthcare or in ED patients specifically. However, this is highly unlikely as no such trends have been previously reported, nor would such trends fully explain the data from this study, even if they were present. The data on patient acuity  indicated an increase in CPT codes 99283 and 99285, suggesting a slight trend toward higher patient acuity. This could mean that patients with higher levels of acuity are more satisfied and less likely to complain. No data are available to either prove or disprove this possibility, but the trend toward higher acuity would not appear to completely explain the dramatic improvement seen in this study. Furthermore, the patient-satisfaction telephone survey excluded inpatients, who comprise a larger percentage of patients in the 99285 service code. Further study is needed to delineate the relationship of ED patient acuity to satisfaction. Despite these potential limitations, this study demonstrates that clinically based customer training for ED staff can decrease patient complaints and increase patient satisfaction in a large volume, high-acuity ED, and that satisfaction is independent of patient turnaround times. Furthermore, the data support the concept that patients rate the skill of the emergency physician, overall quality of medical care, and skill of the ED nurse significantly higher after such training is provided to the ED staff. Additional studies in ED with different volumes, acuities, and geographic locations are needed to demonstrate whether these results can be duplicated. Studies of the impact of customer service training in other healthcare settings would also be of benefit. Nonetheless, clinically focused customer service training has been shown in this study to improve patient satisfaction and ratings of the skill of physicians and nurses. If verified by other studies, customer service training should be considered an important part of graduate and undergraduate medical education to improve both the art and science of the patient-physician relationship. The clinically based customer service training described in this study is now a required part of competency based orientation for all physicians, nurses, residents, and support staff in the emergency department. All professional and non-professional staff interviewed for positions in the emergency department are advised of the institution’s strong commitment to customer service training and the necessity of attending the required training course. As healthcare increasingly emphasizes accountability for customer service in its staff, it is increasingly important that practical and effective customer service training is provided. While not directly addressed in this study, the data on ratings of quality of medical care, skill of the physician and nurses, and likelihood of returning strongly suggest that effectively completing the customer service transition offers a competitive market advantage to hospitals and healthcare systems. References Aharony, L., and S. Strasser. 1993. â€Å"Patient Satisfaction: What We Know About and What We Still Need to Explore.† Medical Care Review 50 (1): 49-79. Berry, L. L. 1995. On Great Service: A Framework for Action. New York: Free Press. Berry, L. L., and A. Parasuraman. 1991. Marketing Services: Competing Through Quality. New York: Free Press. Butler, M. K., and D. B. Buller. 1987. â€Å"Physician’s Communication Style and Patient Satisfaction.† Journal of Health and Social Behavior 28 (4): 375-88. Bursh, B., J. Beezy, and R. Shaw. 1993. â€Å"Emergency Department Satisfaction: What Matters Most?† Annals of Emergency Medicine 22: 586-91. Carlzon, J. 1987. Moments of Truth: New Strategies for Today’s Customer-Driven Economy. New York: Ballinger Publishing. Connelan, T. 1997. Inside the Magic Kingdom. Austin, TX: Bard Press. Culhane, D. E., and P. J. Harding. 1994. â€Å"Quality in Customers: Great Expectations.† Presented to the American College of Emergency Physicians Management Academy, Boston, Massachusetts, May 19, 1994. Dansk, K. H., and J. Miles. 1997. â€Å"Patient Satisfaction with Ambulatory Healthcare Services: Waiting Time and Follow-up Time.† Hospitals and Health Services Administration 42 (2): 165-77. Eisenberg, B. 1997. â€Å"Customer Service in Healthcare.† Hospitals and Healthcare Services Administration 42 ( 1 ): 17-32. Frances, V, B. M. Korsch, and M. J. Morris. 1969. â€Å"Gaps in Doctor-Patient Communication. Patient’s Response to Medical Advice.† New England Journal of Medicine. 280: 535-49. Glass, R. M. 1996. â€Å"The Patient-Physician Relationship: JAMA Focuses on the Center of Medicine.† Journal of the American Medical Association 275: 147-48. Hall, M. F., and I. Press. 1996. â€Å"Keys to Patient Satisfaction in the Emergency Department: Results of a Multiple Facility Study.† Hospitals and Healthcare Administration 41 (4): 515-32. Herzlinger, R. 1997. Market-Driven Health Care. New York: Free Press. Inova Health System. 1997. â€Å"Outpatient Satisfaction Research.† Shugoll Research. Rockville, MD. Jones, T. O., and W. E. Sasser, Jr. 1995. â€Å"Why Satisfied Customers Defect.† Harvard Business Review 73: 88-99. Kirschner, C. G., R. C. Burkett, G. M. Kotowicz, et al. 1996. Physicians’ Current Procedural Terminology-CPT 96, ed 5. Chicago: American Medical Association. Laine, C., and F. Davidoff. 1996. â€Å"PatientCentered Medicine: A Professional Evolution† lournal of the American Medical Association 275: 152-56. Mack, J. L., K. M. File, J. E. Horwitz, and R. A. Prince. 1995. â€Å"The Effect of Urgency on Patient Satisfaction and Future Emergency Department Choice.† Health Care Management Review 20: 7-15. Pellegrino, E. D., and D. C. Thomasma. 1989. For the Patient’s Good: The Restoration of Beneficence in Health Care. New York: Oxford University Press. Rhee, K., and J. Bird. 1996. â€Å"Perceptions in Satisfaction with Emergency Department Care.† Journal of Emergency Medicine 14: 679-83. Reichheld, E E 1996. â€Å"Learning from Customer Defections.† Harvard Business Review 74: 56-69. Sanders, B. 1995. Fabled Service: Ordinary Acts, Extraordinary Outcomes. San Diego: Pfeiffer and Company. Schmittdiel, J., J. V. Selby, K. Grumbach, and C. P. Quesenberry. 1997. â€Å"Choice of a Personal Physician and Patient Satisfaction in a Health Maintenance Organization.† Journal of the American Medical Association 278 (19): 1596-1612. Sharfield, B., C. Wray, K. Hess, and E. M. Smith. 1981. â€Å"The Influence of Patient-Practitioner Agreement on Outcome of Care.† American Journal of Public Health 71: 127-31. Smith, R. C., J. S. Lyles, J. A. Mettler, et al. 1995. â€Å"A Strategy for Improving Patient Satisfaction by the Intensive Training of Residents in Psychosocial Medicine: A Controlled, Randomized Study† Academic Medicine 70: 729-32. Spectre, R., and P. D. McCarthy. 1995. The Nordstrom Way: The Inside Story of America’s #1 Customer Service Co mpany. New York: John Wiley and Sons. Thompson, D. A., P. R. Yarnold, D. R. Williams, and S. L. Adams. 1996. â€Å"Effects of Actual Waiting Time, Perceived Waiting Time, Information Delivery, and Expressive Quality on Patient Satisfaction in the Emergency Department† Annals of Emergency Medicine 28: 657-65. Thompson, D. A., and P. R. Yarnold. 1995. â€Å"Relating Patient Satisfaction to Waiting Time Perceptions and Expectations: The Disconfirmation Paradigm.† Academic Emergency Medicine 2: 1057-62. Thompson, D. A., P. R. Yarnold, S. L. Adams, and A. B. Spaccone. 1996. â€Å"How Accurate Are Waiting Time Perceptions of Patients in the Emergency Department?† Annals of Emergency Medicine 28: 652-56. Waggoner, D. M., E. B. Jackson, and D. E. Kern. 1981. â€Å"Physician Influence on Patient Compliance: A Clinical Trial.† Annals of Emergency Medicine 10: 348-52. Zeithamal, V. A., A. Parasuraman, and L. L. Berry. 1990. Delivering Quality Service: Balancing Customer Perceptions and Expectations. New York: Free Press. You have requested â€Å"on-the-fly† machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated â€Å"AS IS† and â€Å"AS AVAILABLE† and are not retained in our systems. 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China especially Essay

â€Å"River Town: Two years on the Yangtze† is a book written by Peter Hessler describing how his life was in China. This is a book he wrote during his years in rural China when he was an English teacher. During this period, he was working for the Peace Corps in Fuling, a remote town located along Yangtze River. This was even before westerners became common in mainland China. In fact during this time, Hessler was one among the only four westerners in the whole rural town full of hundreds of thousands of people. He provides an account on his everyday struggles with the culture and language of the Chinese people. He tells how he teaches his English students on Shakespeare using the Chinese twist and the way communist party bureaucracy sometimes becomes a hurdle to some developments. Of much interest is the manner in which the education system in china is described as one of the most standardized. According to Hessler (34), students had the responsibility of cleaning the classroom. As explained, there are a lot of responsibilities for Chinese students in their system as they had to wash the blackboards between classes. Moreover, they had to clean the windows and the floor twice a week. Students are required to obey and accomplish their obligations and if for example the cleaning of the classroom was not adequate, they would be fined (Hessler 34). Here, students are fined if they miss morning exercises, if they skipped classes, returned late to the dormitories during the night and if they failed in the examinations. This is an education system that looks very different from that of America since students here have very little extra cash to spend and it was thus possible for the classrooms to be thoroughly and diligently cleaned. The education system has a place for exercises which is mandatory for all in the morning. Some of the exercises involved pressing two fingers on one’s eyes, cheeks or nose. Typically, children go to school as from 7:00am to 4:00pm. However, the elementary schools start as early as 7:30am. Common subjects here include propaganda, writing, reading and studying mathematics. It is during recess when children are expected to attend relaxation exercises and calisthenics. The schools seem to be overcrowded as there were around forty-five in every classroom pressed together seated on old wooden desks. Children here are accustomed to rote learning and this according to Hessler meant that they had to always follow models even to the point of plagiarism (Hessler 100). Students in this system are inveterate copiers and thus it is possible to get an exactly the same paper from a group of students. In this case, copying is not wrong in the Chinese education system as in their whole school life they are taught to imitate models, accept what they have been told by their teacher without questioning, copy things and this is what they often do (Hessler 100). In this education system, books used were mostly published in China and they had political intent overstated. For example, Hessler cites the example of â€Å"A Handbook of Writing† that he was using during his writing class that had model essay titled â€Å"The Three Gorges Project Is Beneficial† which was in the â€Å"Argumentation† chapter (Hessler 99). There is an explanation on the chapter on benefits and risks associated with the project that had made some to be against it. But in the end there was a transition that summed up everything that the worries of those against the project were justified â€Å"But we should not give up eating for fear of choking. † Thus the writer of the handbook had to focus more on the benefits of the project and thus gave examples of improved transport, more electricity and better control of flood. The conclusion was that the Three Gorges Project had more advantages than disadvantages. This is what the students are supposed to be taught and to write. When they are given a composition, they end up writing the same phrase â€Å"But we should not give up eating for fear of choking. † Thus, in short this means that the system stresses to give students literature that would make them to be more patriotic to the administration. Students are supposed to appreciate the ancient poetry as this is taken to be the strongest part in Chinese literary tradition. In comparison to American schools, the environment in Chinese schools is harsh for any writer due to culture. It is actually very difficult for any Chinese to write on what is happening at the present and especially if that writer wants to use fiction. Most of the outstanding fiction writers in China are exiles and since they had that status for a long time, it is quite difficult for them to write about what happened in the recent past in accuracy. It is actually difficult for writers in China especially due to censorship and political issues. Even the cultural elements make it really hard for them as those who are educated in this society usually look down on the working class and the farmers and they seem to have very little interest in that world. Educated Chinese are more preoccupied on ideas than on stories and individuals (Miller 1). In American schools, the structure involves set questions, worksheets and group activities. Children are required to perform most activities as a group and ample time is awarded for individual work. Moreover, more flexibility is seen in the American education system. The Chinese education system however is more relentless on group mentality. In most cases writers are individuals but unfortunately this is an instinct that is commonly broken in a Chinese classroom. Teaching writing in China has no emphasis on character, narrative voice or perspective. The focus is on getting the kids copy poetic phrases day in day out. Children are taught that they must spout off any set opinions instead of generating something unexpected. They also deal with so much handwriting. This is traditional Chinese education system that focuses purely on other values and skills. Communist system establishes funded film-schools which impart vital technical skills (Miller 1). American education system strives to teach the students on how they can think independently as opposed to the Chinese system that aims to teach the students on imitation. Educators in China teach their students to learn via rote. An American student is given room to ask questions. On the contrary, a Chinese student is not supposed to ask any question but should expect to be taught without his/her contribution. Traditionally, children are taught via rote learning, memorizing all material with no space for asking questions. In addition, there are so many topics that are banned and great amount of time spent to learn numerous Chinese characters that are supposed to be memorized. A classroom in China carries between 40 and 50 students and in some cases this may go up to 60. This number encourages rote learning instead of using discussions and other student-driven activities. American students however have more time to engage in self-driven activities and important discussions that encourage thinking (Hays 1). Works cited Hays, Jeffrey. School Life in China, 2008. Retrieved from http://factsanddetails. com/china. php? itemid=1094&catid=13&subcatid=82 Hessler, Peter. River Town: Two Years on the Yangtze, London: HarperCollins Publishers, 2006. Miller, JFK. Why I Write: Peter Hessler, 2010. Retrieved from http://www. urbanatomy. com/index. php/arts/why-i-write/2770-why-i-write-peter-hessler