Race and Your Community Personal Statement Example | Topics and Well Written Essays - 1250 words

Race and Your Community - Personal Statement Example Admittedly, my community, that is Dallas, is notorious for the existence of racism. It seems that the issue of racism is much higher in this city because of the special nature of the demography here. In this area, all the racial groups are almost equal in size. According to the 2000 statistics, Hispanics are the largest group which constitutes nearly 35.55 % of the population followed by 34.56 percent whites. The presence of blacks is estimated at nearly 25.65%. Asians and other races are the minority, which together contribute less than 5% of the total population. Evidently, this mix of population has a specific role in amplifying racial issues. Due to the almost equal proportion of various groups, both politicians and media are eager to utilize racism as a tool for campaign and publicity. In fact, my neighborhood too is a mix of a variety of races, and the difference is visible in the look of people too. There are people who are black in complexion, some who are rather brown in complexion, and there are whites. The fact is that my society is more mixed than many other cities in the US. The difference is visible in communication too. For example the Hispanics, the Whites, and the Asians are easily distinguished for the way they use language. I have come to know that people like the Asians who first reach the place face serious problems communicating, and this situation leads to poor access to vital social services like medicine and other governmental grants. Admittedly, the leaders within my community are highly aware about the situation, and often, it seems as if they intentionally try to use the matter for easy public attention. Though most people and leaders try to avoid hurting other people by avoiding racial comments, some just make the comments publically. An exa mple is the recent statement made by a Dallas County commissioner to an attorney that â€Å"All of you are white. You can go to hell† (Piggy, 2011). The commissioner claims that he got angry because he found the statement of the attorney racial in nature. Though there are allegations of racism every now and then, from my observation, it seems that the leaders try to avoid any racial discrimination in their dealings. And most of the time, the term ‘racism’ does not arise in public offices and services. However, when there are issues involving people from two different races, the first allegation is racial profiling or racial discrimination. When a black child is punished by a white teacher, the situation is often given the color of racism. Similarly, when a black youth is arrested for drug or looting, the media shows the tendency to present the situation in the light of racism. The frequently made claim by the media is that, or what they try to make people believe is that, blacks are antisocial creatures who live on violence, theft and drugs. Another area where racism is highly visible is peer groups. Admittedly, the youth prefer to remain within groups of their own race. Within such groups, often comments of racial content take birth, and most of the time, it seems that such groups are behind racial attacks and abuses. I feel that the youth, if alone, will not resort to such activities of racism. As White and Perrone (2001) point out, it is the collective identity and the feeling of security within the group that makes them engage in such rare activities of racism. Though it is not always so, there are many whites who prefer to remain within white groups and blacks who prefer to be with blacks, and the main reason behind this situation is not hatred, but fear of getting maltreated by the other that is injected by the society and the media. Thus, though the administration cries ‘no racism’, there is racism in the air, and everyt hing in the society is first analyzed in the light of racism. A catalyst of racism, as already said, is media. It seems to me that media is bent on crating stereotypes and formulas in the social relations. As Rickford (2011) states, while

Marketing report Essay Example | Topics and Well Written Essays - 2500 words

Marketing report - Essay Example Unequivocally, firms have greater emphasis on marketing research to generate useful information that in turn facilitates in modifying business strategies, in decision-making and problem-solving. For instance, the emergence of mass media has greatly affected / influenced the attitudes, perceptions, behaviours, beliefs and lifestyles of people all across the globe, thereby creating new challenges for a firm to thrive in contemporary environment. Marketing research (exploratory, descriptive and causal) is also beneficial in analysing the business potential and viability of products. In addition, it enables the firm to gain insight over underlying factors and critical risks after which firms could amend their strategic objectives and product lines. Nevertheless, the research enables the firms to identify gaps in consumer markets, to innovate and differentiate their procedures and products followed by attainment of cost leadership. An important advantage of marketing research is that it f acilitates change management initiatives. In other words, it helps replacing the old workplace rules, regulations, requirements and criteria by new workplace standards and roles so that the organisations could flourish in an absolutely uncertain, unpredictable, unclear, unstructured and unexpected business environment. A professional or private sports / fitness club initiates marketing research after problem identification (for example – when sales decline because customers are switching to other centres, when top facilities in centre unable to attract maximum customers due to flaws in marketing strategy, when competition increased after inauguration of new clubs at nearby locations and other issues, when customers all across the city are unaware of the club’s product offerings etc.). In simple words, the research enables a sports / fitness club to draw useful inferences regarding external environment and to compare differences in their actual and perceived strengths. Having assessed the aforementioned, the club could then implement more ‘effective’ marketing and advertising strategies that can be utilised to enhance the profitability and long-term monetary gains. This paper will demonstrate the marketing strategies adopted by Lifestyle Aquatic Fitness Centre - a UK based sporting, exercising and gyming centre that provides premium quality fitness services to public across Liverpool. Nonetheless, Lifestyle Fitness has always focused towards brand recognition, innovation, differentiation and value proposition because these aforementioned are the foundations of success and sustainability of any group or business organisation. Indeed, the strategic planners pay special attention to maintain and improve service quality through induction of new equipment, training courses, facilities and sporting activities because it enhances market reputation and goodwill among stakeholders and customers. Total Quality Management principles such as benc hmarking, continuous learning and experimentation etc. are adopted for value creation, which then lead to improvement in sales and profitability. Without any doubt, the aforementioned provides Lifestyle a competitive edge over rivals such as Greens Health, Hercules Health & Fitness Centre, Novotel Liverpool, Absolutions Health Clud and others etc. in fitness and sporting industry .

Investigation of Effectiveness of Clozapine

Investigation of Effectiveness of Clozapine Catarina Scott-Beaulieu Abstract: (250) Background: Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. It is effective in treating the positive and negative symptoms of schizophrenia with a reduced chance of extrapyramidal side effects compared with other typical antipsychotics. Clozapine is known to have cardiac side effects including, but not limited to, myocarditis and cardiomyopathy. Approximately 75% of cases, of clozapine-induced myocarditis, occur within the first month of titration, highlighting the need for monitoring. Objectives: To assess the extent to which the monitoring guidelines for myocarditis, at a London mental health trust, are being followed. Method: Patients who were registered with ZTAS from June 2014 to October 2016, at the trust,  Ã‚   were identified. Data was collected based on the audit tool created from the guidelines. Using the patient notes and laboratory data, found using the trusts operating systems, data was collected and stored in the audit tool. Key findings: The monitoring standards were met for full blood count in the week prior to initiation and in week 3. No other standards were met. Conclusion: Introduction: (500-1000) Clozapine is the first atypical antipsychotic created and is used in treatment-resistant schizophrenia, which is defined as a lack of or an inadequate response to at least two antipsychotics.[1] It is a dibenzodiazepine derivative antipsychotic and interferes with dopamine binding with a strong affinity for D4-dopaminergic receptors   and 5-HT2a serotonergic receptor affinity [2], in addition it has an anticholinergic effect and antagonizes histaminergic receptors. [3, 4] Clozapine is useful in treating both the positive and negative symptoms of schizophrenia [4] and is less likely to cause extrapyramidal side effects when compared to first generation typical antipsychotics such as haloperidol[5, 6]. It has also been shown to significantly reduce the suicidal behaviors in schizophrenic patients [1, 7]. However, it is not used as a first line treatment due to its extensive side effect profile, most recognized being agranulocytosis which occurs in approximately 1% of patients in the first year of treatment [8, 9], explaining the need for regular, mandatory hematological tests for the duration of clozapine treatment. Other side effects include fever [4], metabolic effects and seizures.[4, 6, 10] Agranulocytosis, however, is not the only potentially fatal side effect of clozapine use. There is an increasing number of clozapine-related cardiac complaints reported in the literature, resulting in cardiac effects from clozapine treatment having become more recognized over the past few years. [5, 7] Whilst tachycardia is a common side effect it can be indicative of other, potentially more serious, cardiac effects such as cardiomyopathy and myocarditis. [9] Myocarditis is an inflammatory process of the myocardium, which is often of viral aetiology but may also include bacterial, fungal and drug-induced.[11, 12] The condition presents with a wide range of symptoms such as chest discomfort, flu-like symptoms and abnormal vital signs [9] and most are non-specific.[2] Reported cases of clozapine-induced myocarditis range from 0.15% to 1.2%,[5, 8, 13-15] with the highest incidence being reported in Australia, >1%. [16] Time to onset varies, but over 75% of cases occur within the first month of treatment. [12, 16-18] Endomyocardial biopsy was the gold standard for diagnosing myocarditis, but the procedure has only limited sensitivity and specificity. It was by proposed Ronaldson et al.[18] in 2011 that combining C-reactive protein (CRP) and troponin T/I would give a sensitivity for clozapine-induced myocarditis of 100%. This is a less invasive method of diagnosis, with a higher specificity and sensitivity for myocarditis and has led to the current guidelines that are in place for the monitoring of clozapine treatment. Whilst clozapine-induced myocarditis is still rare, the need for consistent monitoring within the first month of treatment is needed to ensure any possible cases are detected early, allowing for prompt treatment, increasing the chances of a better outcome for the patient.[1] This audit aims to assess the extent to which the monitoring guidelines for myocarditis, at a London mental health trust, are being followed. Assessments will explore the extent to which the recommended additional blood tests, CRP and troponin, are being completed and the extent to which the advised echocardiogram (ECG) are being followed. Additionally, it will aim to check to see if a clinician is checking the above objectives and assess the extent to which the nursing staff are asking the patients about signs and symptoms of myocarditis. Method: (500-1000) This audit was designed to investigate the extent to which the monitoring requirements, in regards to clozapine initiation and titration within the first four weeks of treatment, at a London mental health trust had been completed. The monitoring requirements audited were specific to the detection and diagnosis of myocarditis. Data collection occurred between October 2016 and February 2017. It is a baseline, retrospective audit of case notes and laboratory data. As per the Health Research Authority regulations, this audit did not require ethical approval. Audit standards and audit tool The standards used in this audit were taken from the trusts clozapine guideline, which can be found in table 3. The monitoring requirements for the detection of myocarditis involve an ECG, vital sign monitoring (pulse, blood pressure, temperature) and CRP and troponin T blood tests. These had to be completed prior to initiation and weekly for the first four weeks after initiation. It is also necessary for clinicians to verify the results of the CRP and troponin T tests, and for the nurses or clinicians to check if the patient has had any signs or symptoms of myocarditis. For the purpose of this audit, criterion 1 and 3 (table 3) will be met if the results of the investigations were documented. Criterion 2 (table 3) will be met if the clinician has made specific reference to CRP and troponin T tests in the patient notes, criterion 4 (table 3) will be met if there is specific reference to questions being asked about myocarditis symptoms. An audit tool was created using the specified mo nitoring requirements mentioned in the clozapine guideline, a template of the audit tool can be found in table x. Identifying patients to be involved in the audit Clozapine patients require regular and frequent prophylactic blood tests in order to initiate and continue treatment. As such, there is a mandatory need for patients to be registered to a clozapine monitoring service database, which collects and stores the results from the weekly blood tests. Zaponex Treatment Access System (ZTAS) is the monitoring company that was used by the trust. ZTAS provided a list of patients who were registered with them whilst under the care of the trust, from June 2014 to October 2016. This resulted in a total of n=57 patients. The patients were selected to be used in the audit after they adhered to the inclusion criteria, which are shown below. Data Collection Data was collected using various information sources at the hospital. Data on haematological tests were collected systematically from ZTAS, bloodresults.co.uk, and the trust clinical portal. ZTAS and bloodresults.co.uk offered information on the standard full blood count (FBC) monitoring that takes place weekly. The trusts clinical portal was used to collect information on other heamatological tests, CRP and troponin T; this source was also used to check any other available FBC test results. RiO, the trusts operating system, was used to collect information on the other standards being measured in this audit (criterion 2, 3 and 4)(table 3). The data collected was stored in the audit tool. ( table x) Inclusion and exclusion criteria The inclusion of the patients in the audit required them to have been registered with ZTAS at the trust between June 2014 and October 2016. It was also necessary for the patient to have started some (at least two) of the required monitoring standards prior to initiation. Prior monitoring requirements included an ECG within a maximum of 3 months prior to initiation and  Ã‚   FBC, CRP and troponin T within 10 days of the initiation date.   Vital sign monitoring such as pulse, blood pressure and temperature were included if they had been completed a maximum of 7 days before initiation. Patients were excluded from the audit if they had been transferred from another trust and were already on a controlled clozapine treatment regime. Method of data analysis Data analysis and statistical analysis was completed using Microsoft Excel 2013. Overview As stated previously, clozapine is associated with an increased risk of myocarditis, which has been fatal in some cases. Preventative monitoring measures for myocarditis are advised at this trust. Baseline troponin T, CRP and ECG should be done prior to beginning treatment and then weekly for the following first four weeks after initiation. These measures are specific in identifying myocarditis, but should also be done in concordance with standard monitoring during treatment. The standard monitoring procedures include pulse, blood pressure and temperature to be completed every other day and FBC weekly. These monitoring procedures are necessary in helping to diagnose myocarditis; symptoms of myocarditis are non-specific, but tend to indicate the presence of an infection (fever) or simulate myocardial infarction (chest pain). Nurses and practitioners are advised to question patients on the appearance of any side effects similar to myocardial infarction to help ascertain if they could h ave myocarditis. Patient demographics and study data In total, n=57 patients were reviewed. Of those, n=3 patients were excluded based upon the inclusion and exclusion criteria described in the method. Of the remaining n=54 patients, n= 6   (11.11%) patients did not initiate clozapine treatment, but n=5 were included in the audit as they had started the monitoring required prior to initiating treatment. Reasons for not initiating treatment are outlined in table 1. A total of n= 3 patients ceased clozapine treatment in week one (n=2) and during week three (n=1); one patient was persistently tachycardic, one patient refused to continue treatment and one patient was severely hypotensive. The patient group (n=53) was predominantly male 66% (n=35), 34% (n=18) were female. The mean age of patients who initiated treatment (n=48) was 34.42 years old, with the youngest patient age being 16.92 years old and the oldest being 65.21 years old. Length of treatment was calculated as the time between a patient commencing clozapine treatment and either ceasing clozapine or the end of the audit period. A total of n=10 patients were excluded from the calculation, as they either did not start treatment or the end of treatment time was not able to be calculated; reasons for exclusion are explained in table 2. The mean length of treatment was 387 days  ±268, with the shortest length of treatment being 1 day and the longest being 873 days. Of the 53 patients involved at the start of the audit, 65% (n=35) were initiated on an inpatient basis; this means the patients were initiated at the hospital, on a ward. ECG monitoring A baseline ECG had been completed in 96% (n=51)(Figure 1) of patients within 3 months prior to the commencement of clozapine. One patient refused to have an ECG prior to initiation. The percentage of patients who received ECGs decreased to 20% (n=9), 24% (n=11), 17%(n=8) and 9% (n=4) of patients for the following 4 weeks after commencement respectively. A total of 41 out of 45 (Table 4) patients did not receive an ECG in week four of clozapine titration. During week one, a patient complained of flu like symptoms and was given an ECG to rule out myocarditis; likewise, one patient during week three was given an ECG after complaining of centralized chest pain. Temperature monitoring The quantity of patients who had recorded temperatures fluctuated through-out the weeks, being highest in week two of monitoring (n=. Week four had the lowest recorded amount of temperature monitoring of all 5 weeks at patients 69% (n=31) (table 4). In week one, n=2 patients refused to have measurements taken. Pulse and blood pressure monitoring The amount of patients who did not receive BP monitoring was highest in the week prior to initiating clozapine (n=13) and in week four (n=13). The highest proportion of patients who had their blood pressures taken occurred during week one at 96% (n=44 ), with 63% (n=29) of them having their blood pressure taken once and 34% (n=15) having their blood pressure taken twice (one reading measured whilst lying or sitting and one reading measured whilst standing). Week four had the highest proportion of patients who did not have their pulse measured at 29% (n=13) (table 4). One patient was discontinued from clozapine after one day of treatment when the BP check revealed them to be extremely hypotensive, in conjunction with a rapid pulse. Full blood count monitoring FBC monitoring occurred in the highest proportion of patients throughout the monitoring period; 100%, 98%, 93%, 100% and 96% respectively. CRP and Troponin monitoring The majority (>50%) of patients did not receive CRP or troponin T blood tests throughout the duration of the monitoring period. Figure 2 shows a substantial decrease in the number of patients who had CRP tests prior to initiation (n=25) and the following weeks (n=10, n=11,n=11, n=7 respectively). A large propotion of patients (84%, n= 38) did not receive CRP blood tests during their fourth week of clozapine treatement. The number of patients who received troponin T tests were less than those who received CRP tests. Only 36%(n=19) of patients received troponin T tests prior to initiation, reducing to 26%(n=12), 20%(n=9), 15%(n=7) and 9%(n=4) in the following four weeks after initiation respectively. There were n=14 patients who had no CRP or troponin T tests throughout the entirety of the monitoring period. There were no patients who had weekly CRP and troponin T tests throughout the duration of the mointoring period. Other monitoring parameters In total, the number of patients who had their CRP and troponin checked by clinicians was less than 100% in all cases (69% (n=9), 75% (n=9), 56% (n=6) and 63% (n=5) for weeks one through four respectively).   Due to the lack of data regarding criterion 4 (table 3), there are no results available to be discussed. Summary of main findings FBC monitoring requirements were met in the week prior to monitoring and in week three. All other standards were not met in any of the five weeks. Over all, there was a better outcome seen in the week prior to initiation for most of the standards. CRP and troponin T tests were completed in less than 50% of patients throughout the five weeks measured. Likewise, excluding the week prior to initiation, less than 50% of patients received an ECG for weeks one to four. Limitations Study data was collected using patient notes and the trusts clinical portal, data was therefore reliant on the relevant health care professional entering the information onto the systems. Consequently, the lack of data could be attributed to the lack of documentation of the monitoring, as opposed to the lack of monitoring all together, especially in regards to criterion 4 (table 3). No useful results could be drawn for criterion 4 and criterion 2 may have also been significantly affected by a lack of documentation. The sample size of this audit was small (n=53), any conclusions drawn from this data may not be relevant to a larger sample size. However, in future studies, a larger sample size could be used, if this is not possible the audit could be expanded to include other trusts. Results could also be affected if the patient refused to have the relevant monitoring required, as advised in the trusts clozapine guidelines.    This audit is the first one to be completed at this trust, therefore it cannot be compared to any previous data. However, the results are being measured against set standards (table x) and can be used to compare to future audits. Results in context      Ã‚   Clozapine is highly effective in the management of treatment-resistant schizophrenia; it reduces the risk of suicidal behaviours[5, 6]and it is effective in the treatment of both the positive and negative symptoms of schizophrenia.[1] It is not widely used due to its extensive side effect profile [8], most recognised being haematological disorders, such as agranulocytosis and neutropenia which have strict monitoring protocols in place.   However, cardiac side effects of clozapine treatment have become more widely recognised over the past few years.[5] Myocarditis is an inflammatory condition of the myocardium, which is normally attributed to viral aetiology. Clozapine-induced myocarditis is a rare, but potentially fatal result of treatment. Over 75% of cases occur within the first month of treatment, making it important to monitor for myocarditis during the first four weeks of treatment.[2, 14-16] A study by Ronaldson et al.[18] developed an evidence-based monitoring tool, based on 75 cases and 94 controls for routine monitoring up to 28 days. It suggested that an ECG, CRP and troponin I/T should be completed at baseline, with routine vitals every other day. CRP and troponin I/T tests should also be repeated on days 7, 14, 21 and 28. This study proposes that combining CRP and troponin tests provides a 100% sensitivity for myocarditis. The trusts clozapine guidelines also suggest the same monitoring protocol, with the addition of an ECG every week, for the first four weeks. Individuals with schizophrenia have a 20% shorter life expectancy than that of the general population and a greater vulnerability to several illnesses (diabetes, coronary heart disease).[19] Due to the nature of the illness and the heightened health risks associated with schizophrenia and the antipsychotic medications used in its treatment, it is important to adhere to the relevant monitoring protocols. It is evident, from the results, that the proposed guidelines for the monitoring of clozapine-induced myocarditis are not being met. Likewise, a number of studies have shown a poor adherence to standards in the monitoring of antipsychotic medications.[20] Physicians may have doubts about the relevance of monitoring, or feel that it is not necessary as the incidence of myocarditis is very low; rate of incidence occur in approximately 0.15-1.2%[1, 13, 21] of patients. If we consider other medications with stringent monitoring protocols, such as insulin, due to health care professionals awareness of this medication and the implications if the standards are not met, there is often a higher standard of monitoring. There may also be an implication of cost; extensive monitoring is often expensive, making it appear to be an unnecessary expense, particularly when the chances of myocarditis occurring are very low. Health care professionals may have a lack of awareness of the need for the monitoring of myocarditis, and the implications if these are not met. The incidence of fatality due to clozapine-induced myocarditis can be as high as 50%[1], making it important to abide by the set guidelines. The monitoring guidelines are made to reduce the harm caused to patients and reduce the possibility of fatalities. However, a delayed diagnosis could result in poorer outcomes for the patients.[1] The standards allow for earlier detection and diagnosis of myocarditis, reducing the chance of poorer outcomes. The results of this audit indicate a need for an increased awareness of clozapine-induced myocarditis among health care professionals. This would improve the clinicians awareness of the need for the monitoring of myocarditis and highlight the implications if the standards are not met. A standardised questionnaire could be created to monitor the signs and symptoms of myocarditis and be used by nurses to document the results, this could be incorporated into the clinical notes. This baseline audit emphasises the need for future re-audits, to evaluate whether the standards have improved. Table 1: Reasons for not initiating treatment Number of patients (n) Consistent amber results 1 Patient changed mind/ refused 2 Previous health conditions made the patient unsuitable to start clozapine 2 Unknown 1 Total 6 Table 2: Reasons for not being included it length of treatment calculation Number of patients (n) Never initaited clozapine 6 Patient transferred to another trust 2 Patient returned to country of origin (unknown if they continued treatment) 2 Total 10 Table 3: Policy Title Clozapine Guide Trust-Wide Medication Policy Date July 2016 Local/National Local Standard Setting Criterion 1 Criterion 2 Criterion 3 Criterion 4 Criterion Full blood count, including troponin T, CRP, neutrophil and white blood cell count should be done prior to initiating clozapine and then weekly for the first four weeks. A clinician verifies the blood test results every week before treatment can be approved. An ECG is to be performed prior to clozapine commencement and every week for the first four weeks after initiation of clozapine. A nurse or physician enquires about the signs and symptoms of myocarditis weekly for the first 4 weeks of titration. Target 100% 100% 100% 100% Exceptions None None None None Table 4: Monitoring Prior to initiating (Total number of patients n=53) Week 1 (Total number of patients n=46) Week 2 (Total number of patients n=46) Week 3 (Total number of patients n=46) Week 4   (Total number of patients n=45) ECG Yes 51 (96%) 9 (20%) 11 (24%) 8 (17%) 4 (9%) No 2 (4%) 37 (80%) 35 (76%) 38 (83%) 41 (91%) Blood pressure Taken once 36 (68%) 29 (63%) 26 (56%) 25 (54%) 21 (47%) Taken twice 4 (7.5%) 15 (33%) 15 (33%) 12 (26%) 11 (24%) Not taken 13 (24.5%) 2 (4%) 5 (11%) 9 (20%) 13 (29%) Temperature Yes 39 (74%) 38 (83%) 40 (87%) 37 (80%) 31 (69%) No 14 (26%) 8 (17%) 6 (13%) 9 (20%) 13 (31%) Pulse Yes 42 (79%) 43 (93%) 41 (89%) 37 (80%) 32 (71%) No 11 (21%) 3 (7%) 5 (11%) 9 (20%) 13 (29%) FBC Yes 53 (100%) 45 (98%) 43 (93%) 46 (100%) 43 (96%) No 0 (0%) 1 (2%) 3 (7%) 0 (0%) 2 (4%) CRP Yes 25 (47%) 10 (22%) 11 (24%) 11 (24%) 7 (16%) No 28 (53%) 36 (78%) 35 (76%) 35 (76%) 38 (84%) Troponin Yes 19 (36%) 12 (26%) 9 (20%) 7 (15%) 4 (9%) No 34 (64%) 34 (74%) 37 (80%) 39 (85%) 41 (81%) References 1.Munshi, T.A., et al., Clozapine-induced myocarditis: is mandatory monitoring warranted for its early recognition? Case Rep Psychiatry, 2014. 2014: p. 513108. 2.Aboueid, L. and N. Toteja, Clozapine-Induced Myocarditis: A Case Report of an Adolescent Boy with Intellectual Disability. Case Rep Psychiatry, 2015. 2015: p. 482375. 3.Fineschi, V., et al., Sudden cardiac death due to hypersensitivity myocarditis during clozapine treatment. Int J Legal Med, 2004. 118(5): p. 307-9. 4.Bruno, V., A. Valiente-Gà ³mez, and O. Alcoverro, Clozapine and Fever: A Case of Continued Therapy With Clozapine. Clin Neuropharmacol, 2015. 38(4): p. 151-3. 5.Swart, L.E., et al., Clozapine-induced myocarditis. Schizophr Res, 2016. 174(1-3): p. 161-4. 6.Castle, D., et al., A clinical monitoring system for clozapine. Australas Psychiatry, 2006. 14(2): p. 156-68. 7.Annamraju, S., et al., Early recognition of clozapine-induced myocarditis. J Clin Psychopharmacol, 2007. 27(5): p. 479-83. 8.Murch, S., et al., Echocardiographic monitoring for clozapine cardiac toxicity: lessons from real-world experience. Australas Psychiatry, 2013. 21(3): p. 258-61. 9.Wooltorton, E., Antipsychotic clozapine (Clozaril): myocarditis and cardiovascular toxicity. CMAJ, 2002. 166(9): p. 1185-6. 10.Kar, N., S. Barreto, and R. Chandavarkar, Clozapine Monitoring in Clinical Practice: Beyond the Mandatory Requirement. Clin Psychopharmacol Neurosci, 2016. 14(4): p. 323-329. 11.Cohen, R., et al., A Case of Clozapine-Induced Myocarditis in a Young Patient with Bipolar Disorder. Case Rep Cardiol, 2015. 2015: p. 283156. 12.Merrill, D.B., G.W. Dec, and D.C. Goff, Adverse cardiac effects associated with clozapine. J Clin Psychopharmacol, 2005. 25(1): p. 32-41. 13.Ronaldson, K.J., et al., Clinical course and analysis of ten fatal cases of clozapine-induced myocarditis and comparison with 66 surviving cases. Schizophrenia Research, 2011. 128(1-3): p. 161-165. 14.Haas, S.J., et al., Clozapine-Associated Myocarditis. Drug Safety, 2007. 30(1): p. 47-57. 15.Barry, A.R., J.D. Windram, and M.M. Graham, Clozapine-Associated Myocarditis: Case Report and Literature Review. Can J Hosp Pharm, 2015. 68(5): p. 427-9. 16.Ronaldson, K.J., P.B. Fitzgerald, and J.J. McNeil, Clozapine-induced myocarditis, a widely overlooked adverse reaction. Acta Psychiatr Scand, 2015. 132(4): p. 231-40.

Recovering History, Constructing Race: the Indian, Black, and White Roo

Recovering History, Constructing Race: the Indian, Black, and White Roots of Mexican Americans Recovering Aztlan : Racial Formation Through a Shared History (1) Traditionally history of the Americas and American population has been taught in a direction heading west from Europe to the California frontier. In Recovering History, Constructing Race, Martha Mencahca locates the origins of the history of the Americas in a floral pattern where migration from Asia, Europe, and Africa both voluntary and forced converge magnetically in Mexico then spreads out again to the north and northeast. By creating this patters she complicates the idea of race, history, and nationality. The term Mexican, which today refers to a specific nationality in Central America, is instead used as a shared historic and cultural identity of a people who spread from Mexico across the southwest United States. To create this shared identity Menchaca carefully constructs the Mexican race from prehistoric records to current battles for Civil Rights. What emerges is a story in which Anglo-Americans become the illegal immigrants crossing the border into Texas and mestizo Mexicans can earn an upgrade in class distinction through heroic military acts. In short what emerges is a sometimes upside down always creative reinvention of history and the creation of the Mexican "race (?)". Mexicans, as constructed by Menchaca, are a predominantly mestizo population whose mixed ancestry she traces to early Latin American civilizations. In 200 BC the largest city in the Americas, Teotihuacà ¡n, was founded. Teotihuacà ¡n would one day be the site of Mexico City, and by 650 AD there were between 120,000 and 250,000 inhabitants. (2) Groups that inhabited the region fro... ...e, history, and blood. The specific commingling that emerges, however, has common roots in its very diversity. Throughout her tale Menchaca's allegiance is clearly to her race, and while the bias comes through, the history she traces is never the less compelling. The strongest achievement of this book is that it fundamentally shifts the gaze of its reader by reifying race and celebrating its complexity. Notes 1. Aztlan is the quasimythylogical homeland of the Chichimec people who were expelled by their god and traveled south to found civilizations in Mexico. It is theoretically located in present day New Mexico. 2. Martha Menchaca, Recovering History, Constructing Race: the Indian, Black, and White Roots of Mexican Americans (Texas: University of Texas Press, 2001), 29. 3. Menchaca, 47. 4. Menchaca, 50. 5. Menchaca, 199.

Effects of computer games to students

The widespread belief that dopamine regulates pleasure could go down in history with the latest research results on the role of this neurotransmitter. Researchers have proved that it regulates motivation, causing individuals to initiate and persevere to obtain something either positive or negative. The neuroscience journal Neuron publishes an article by researchers at the Universitat Jaume I of Castellon that reviews the prevailing theory on dopamine and poses a major paradigm shift with applications in diseases related to lack of motivation and mental fatigue and depression, Parkinson's, multiple sclerosis, fibromyalgia, etc.  and diseases where there is excessive motivation and persistence as in the case of addictions.â€Å"It was believed that dopamine regulated pleasure and reward and that we release it when we obtain something that satisfies us, but in fact the latest scientific evidence shows that this neurotransmitter acts before that, it actually encourages us to act. In o ther words, dopamine is released in order to achieve something good or to avoid something evil,† explains Merce Correa. Studies had shown that dopamine is released by pleasurable sensations but also by stress, pain or loss.These research results however had been skewed to only highlight the positive influence, according to Correa. The new article is a review of the paradigm based on the data from several investigations, including those conducted over the past two decades by the Castellon group in collaboration with the John Salamone of the University of Connecticut (USA), on the role of dopamine in the motivated behaviour in animals. The level of dopamine depends on individuals, so some people are more persistent than others to achieve a goal.â€Å"Dopamine leads to maintain the level of activity to achieve what is intended. This in principle is positive, however, it will always depend on the stimuli that are sought: whether the goal is to be a good student or to abuse of dru gs† says Correa. High levels of dopamine could also explain the behaviour of the so-called sensation seekers as they are more motivated to act. Application for depression and addiction To know the neurobiological parameters that make people be motivated by something is important to many areas such as work, education or health.Dopamine is now seen as a core neurotransmitter to address symptoms such as the lack of energy that occurs in diseases such as depression. â€Å"Depressed people do not feel like doing anything and that's because of low dopamine levels,† explains Correa. Lack of energy and motivation is also related to other syndromes with mental fatigue such as Parkinson's, multiple sclerosis or fibromyalgia, among others. In the opposite case, dopamine may be involved in addictive behaviour problems, leading to an attitude of compulsive perseverance.In this sense, Correa indicates that dopamine antagonists which have been applied so far in addiction problems prob ably have not worked because of inadequate treatments based on a misunderstanding of the function of dopamine (http://www. sciencedaily. com/releases/2013/01/130110094415. htm) The effect of a dopamine agonist on dysarthric speech production: a case study.AbstractThe effect of Permax (pergolide mesylate), a dopamine agonist, was assessed in an individual with traumatic brain injury. The participant evidenced symptoms of hypokinetic dysarthria. His performance on and off Permax was evaluated in a BABA design. Measures were obtained across physiological systems. There were few differences in the on and off conditions. In the on condition, he evidenced an abnormally large velopharyngeal orifice area, dysfluencies in stimulus sentences, and less precise articulation. However, listeners perceived him to be more animated in the on condition. In addition, he reported better performance in the on condition.The study highlights potential discrepancies among participant report, listener perce ption, and objective measures. Learning outcomes: As a result of this activity, the participant will be able (1) to recognize the effect of dopamine agonists as an adjunct to other pharmacological interventions and (2) to determine potential discrepancies among participant report, listener perception and objective physiological and acoustic measures. (Transitional Learning Center, Department of Communication Disorders, University of Houston, TX 77204-6018, USA. [email  protected] edu/ http://www. ncbi. nlm. nih. gov/pubmed/11565961)

Just-in-Time Production and Total Quality Management

JUST-IN-TIME Production and TOTAL QUALITY MANAGEMENT Introduction In today’s competitive world shorter product life cycles, customers rapid demands and quickly changing business environment is putting lot of pressures on manufacturers for quicker response and shorter cycle times. Now the manufacturers put pressures on their suppliers. One way to ensure quick turnaround is by holding inventory, but inventory costs can easily become prohibitive. A wiser approach is to make your production agile, able to adapt to changing customer demands. This can only be done by JUST IN TIME (JIT) philosophy. JIT is both a philosophy and collection of management methods and techniques used to eliminate waste (particularly inventory). Waste results from any activity that adds cost without adding value, such as moving and storing. Just-in-time (JIT) is a management philosophy that strives to eliminate sources of such manufacturing waste by producing the right part in the right place at the right time. Features JIT (also known as lean production or stockless production) should improve profits and return on investment by reducing inventory levels (increasing the inventory turnover rate), reducing variability, improving product quality, reducing production and delivery lead times, and reducing other costs (such as those associated with machine setup and equipment breakdown). The basic elements of JIT manufacturing are people involvement, plants, and system. People involvement deal with maintaining a good support and agreement with the people involved in the production. This is not only to reduce the time and effort of implementation of JIT, but also to minimize the chance of creating implementation problems. The plant itself also has certain requirements that are needed to implement the JIT, and those are plant layout, demand pull production, Kanban, self-inspection, and continuous improvement. The plant layout mainly focuses on maximizing working flexibility. It requires the use of multi-function workers†. Demand pull production is where you produce when the order is received. This allows for better management of quantity and time more appropriately. Kanban is a Japanese term for card or tag. This is where special inventory and process information are written on the card. This helps in tying and linking the process more efficiently. Self-inspection is where the workers on the line inspect products as they move along, this helps in catching mistakes immediately. Lastly continuous improvement which is the most important concept of the JIT system. This simply asks the organization to improve its productivity, service, operation, and customer service in an on-going basis. In a JIT system, underutilized (excess) capacity is used instead of buffer inventories to hedge against problems that may arise. The target of JIT is to speed up customer response while minimizing inventories at the same time. Inventories help to response quickly to changing customer demands, but inevitably cost money and increase the needed working capital. JIT requires precision, as the right parts must arrive â€Å"just-in-time† at the right position (work station at the assembly line). It is used primarily for high-vPolume repetitive flow manufacturing processes. History The technique was first used by the Ford Motor Company as described explicitly by Henry Ford’s My Life and Work (1922): â€Å"We have found in buying materials that it is not worth while to buy for other than immediate needs. † They bought only enough to fit into the plan of production, taking into consideration the state of transportation at the time. If transportation were perfect and an even flow of materials could be assured, it would not be necessary to carry any stock whatsoever. The carloads of raw materials would arrive on schedule and in the planned order and amounts, and go from the railway cars into production. That would save a great deal of money, for it would give a very rapid turnover and thus decrease the amount of money tied up in materials. With bad transportation one has to carry larger stocks. They followed the concept of â€Å"dock to factory floor† in which incoming materials are not even stored or warehoused before going into production. This paragraph also shows the need for an effective freight management system (FMS) and Ford’s Today and Tomorrow (1926) describes one. The technique was subsequently adopted and publicised by Toyota Motor Corporation of Japan as part of its Toyota Production System (TPS). Japanese corporations could afford large amounts of land to warehouse finished products and parts. Before the 1950s, this was thought to be a disadvantage because it reduced the economic lot size. (An economic lot size is the number of identical products that should be produced, given the cost of changing the production process over to another product. ) The undesirable result was poor return on investment for a factory. Also at that time, Japanese companies had a bad reputation as far as quality of manufacturing and car manufacturing in particular was concerned. One motivated reason for developing JIT and some other better production techniques was that after World War II, Japanese people had a very strong incentive to develop a good manufacturing technique which would help them rebuild their economy. They also had a strong working ethic which was concentrated on work rather than on leisure, and this kind of motivation was what drove Japanese economy to succeed. Therefore Japan’s wish to improve the quality of its production led to the worldwide launch of JIT method of inventory Toyota Motors The basic elements of JIT were developed by Toyota in the 1950’s, and became known as the Toyota Production System (TPS). The chief engineer Taiichi Ohno, a former shop manager and eventually vice president of Toyota Motor Company at Toyota in the 1950s examined accounting assumptions and realized that another method was possible. The factory could be made more flexible, reducing the overhead costs of retooling and reducing the economic lot size to the available warehouse space. Over a period of several years, Toyota engineers redesigned car models for commonality of tooling for such production processes as paint-spraying and welding. Toyota was one of the first to apply flexible robotic systems for these tasks. Some of the changes were as simple as standardizing the hole sizes used to hang parts on hooks. The number and types of fasteners were reduced in order to standardize assembly steps and tools. In some cases, identical subassemblies could be used in several models. Toyota engineers then determined that the remaining critical bottleneck in the retooling process was the time required to change the stamping dies used for body parts. These were adjusted by hand, using crowbars and wrenches. It sometimes took as long as several days to install a large (multiton) die set and adjust it for acceptable quality. Further, these were usually installed one at a time by a team of experts, so that the line was down for several weeks. Toyota implemented a program called Single Minute Exchange of Die (SMED). With very simple fixtures, measurements were substituted for adjustments. Almost immediately, die change times fell to about half an hour. At the same time, quality of the stampings became controlled by a written recipe, reducing the skill required for the change. Analysis showed that the remaining time was used to search for hand tools and move dies. Procedural changes (such as moving the new die in place with the line in operation) and dedicated tool-racks reduced the die-change times to as little as 40 seconds. Dies were changed in a ripple through the factory as a new product began flowing. After SMED, economic lot sizes fell to as little as one vehicle in some Toyota plants. Carrying the process into parts-storage made it possible to store as little as one part in each assembly station. When a part disappeared, that was used as a signal to produce or order a replacement. JIT was firmly in place in numerous Japanese plants by the early 1970’s. JIT began to be adopted in the U. S. in the 1980’s. Requirements JIT applies primarily to repetitive manufacturing processes in which the same products and components are produced over and over again For Example Cars, Fast Food Chains The requirements for a proper just-in-time management are: STANDARDIZATION: Where the supplies are standardized and the suppliers are trustable and close to the plant. As there is little buffer inventory between the workstations, so the quality must be high and efforts are made to prevent machine breakdowns. Those organizations that need to respond to customer demands regularly this system is also being able to respond to changes in customer demands. SOFTWARE: For JIT to work efficiently Supply Chain Planning software, companies have in the mean time extended Just-in-time manufacturing externally, by demanding from their suppliers to deliver inventory to the factory only when it’s needed for assembly, making JIT manufacturing, ordering and delivery processes even speedier, more flexible and more efficient. MULTI-FUNCTIONALITY In JIT workers are multifunctional and are required to perform different tasks. Machines are also multifunction and are arranged in small U-shaped work cells that enable parts to processed in a continuous flow through the cell. Workers produce pars one at a time within cells and transport those parts between cells in small lots. CLEANLINESS Environment is kept clean and free of waste so that any unusual occurrence are visible. SCHEDULES: Schedules are prepared only for the final assembly line, in which several different models are assembled at the same line. Requirements for the component parts and subassemblies are then pulled through the system. The â€Å"PULL† element of JIT will not work unless production is uniform and lot sizes are low. Pull system is also used to order material from suppliers (fewer in numbers usually). They make be requested to make multiple deliveries of the same item in the same day, so the manufacturing system must be flexible. QUALITY: Quality within JIT manufacturing is necessary, because without a quality program in JIT, the JIT will fail. Here we think about quality at the source and the Plan, Do, Check, Action with its statistical process control. Furthermore, techniques are also very important. The JIT technique is a pull system rather than a pull system, based on not producing things until they are needed. The well known Kanban card is used as a signal to produce. Moreover, integration also plays a key role in JIT systems. JIT integration can be found in four points of the manufacturing firm. The Accounting side, Engineering side, Customer side and Supplier side. At the accounting side, JIT has concern for WIP, utilization and overhead allocation and at the engineering side of JIT focuses on simultaneously and participative design of products and processes. Just-In-Time Total Quality Management Just-In-Time Total Quality Management is the mean of market and factory management within a humanistic environment of continuing improvement. Moreover, it means continuing improvement in social life, and working life. When applied to the factory, Kaizen means continual improvement involving managers and workers alike. When it comes to Total Quality Management, Japans strong industrial reputation is well-known around the world. Total quality control is the system, which Japan has developed to implement Kaizen or continuous improvement. The traditional description of Just-In-Time is a system for manufacturing and supplying goods that are needed. There are several important tools that are important for total quality management control, but there are seven that are even more important. These are relations diagram, affinity diagram, systematic diagram or tree diagram, matrix diagram, matrix data analysis, process decision program chart, and arrow diagram. When used properly, these seven tools will help the total quality management system by eliminating defective products. Moreover, they will help in assisting to improve productivity, complete tasks on time, eliminate waste, and reduce lead time and inventory cost. Pros and Cons of Just-in-Time Pros of Just-In-Time: Goals of JIT can vary, but there are a few that should be constant in any JIT system:   1. Increasing the organization’s ability to compete with others and remain competitive over the long run is very important. 2. The competitiveness of the firms is increased by the use of JIT manufacturing process as they can develop a more optimal process for their firms. . The key is to identify and respond to consumers needs. Customers’ needs and wants should be the most important focus for business today. This objective will help the firm on what is demanded from customers, and what is required of production. 4. Moreover, the optimal quality and cost relationship is also important. The organization should focus on zero-defect production process. Although it seems to be unrealistic in t he long run, it will eliminate a huge amount of resources and effort in inspecting, and reworking defected goods. 5. Another important goal should be to develop a reliable relationship between the suppliers. A good and long-term relationship between an organization and its suppliers helps to manage a more efficient process in inventory management, material management, and delivery system. It will also assure that the supply is stable and available when needed. 6. Moreover, adopt the idea of continuous improvement. If committed to a long-term continuous improvement idea, it will help the organization to remain competitive in the future. Cons of Just-In-Time: Regardless of the great benefits of JIT, it has its limitations: 1. For example cultural differences. The organizations cultures vary from firm to firm. There are some cultures that tie to JIT’s success, but it is difficult for an organization to change its cultures within a short time. 2. Also manufacturers that use the traditional approach which relies on storing up large amounts of inventory for backing up during bad times may have problems with getting use to the JIT system. 3. Also JIT is quite different for workers, in the sense that due to the shorter cycle time, lots of pressure and stress is added on the workers. 4. Also the JIT system throws workers off in the sense that if a problem occurs, they cannot use their own method of fixing the problem, but use methods that have been previously defined. 5. Moreover, the JIT system only works best for medium to high range of production volume manufacturers, thus leaving a question to whether it might work for low volume companies. Case in which JIT has failed Just in Time production allows companies to reduce both inventory and the entire production chain. It encourages the removal of all surplus, including surplus factories. Under normal business conditions this is not a problem. However, if there is any disruption at any given point in the supply chain, then all production grinds to a halt. Evidence of the problem with Just in Time production became clear in the wake of Hurricane Katrina and Hurricane Rita, both of which hit the US Gulf coast in 2005. At that time, no new oil refineries had been built in the US since 1976. During that time period, companies actually shut down several refineries to reduce capacity. The old refineries still operating ran at full capacity, so no new refineries were needed according to Just in Time theory since they would only produce surplus gasoline. However, most of these refineries were clustered around the Gulf coast. When the Katrina hit, 15 oil refineries in Mississippi and Louisiana representing 20% of US refining capacity was shut down. Rita damaged another 16 refineries in Texas, accounting for 2. 3 million barrels per day of capacity shut down. The lack of surplus in oil refining caused a shock to the United States. Gasoline prices surged. Had companies not shut down refineries in order to reduce capacity according to Just in Time theory, particularly refineries on the west coast, then it is likely that gasoline prices would have remained stable. US regular grade gasoline prices were $2. 154 per gallon on November 28, 2005, down from a spike of $3. 09 on September 19, 2005 in the immediate aftermath of the hurricane Katrina disaster Case-Study The work described  in this case study was undertaken in a young, rapidly expanding company in the financial services sector with no previous experience with Total Quality Management (TQM). The quality project began with a two-day introductory awareness program covering concepts, cases, implementation strategies and imperatives of TQM. The program was conducted for the senior management team of the company. This program used interactive exercises and real life case studies to explain the concepts of TQM and to interest them in committing resources for a demonstration project. Step 1. Define the Problem 1. 1 Selecting the theme: A meeting of the senior management of the company was held. Brainstorming produced a list of around 10 problems. The list was prioritized using the weighted average table, followed by a structured discussion to arrive at a consensus on the two most important themes — customer service and sales productivity. Under the customer service theme, â€Å"Reducing the Turnaround Time from an Insurance Proposal to Policy† was selected as the most obvious and urgent problem. The company was young, and therefore had few claims to process so far. The proposal-to-policy process therefore impacted the greatest number of customers. An appropriate cross functional group was set up to tackle this problem. . 2 Problem = customer desire – current status. Current status: What did the individual group members think the turnaround is currently? As each member began thinking questions came up. â€Å"What type of policies do we address? † Medical policies or non-medical? The latter are take longer because of the medical examination of the client required. â€Å"Between what stages do we con sider turnaround? † Perceptions varied, with each person thinking about the turnaround within their department. The key process stages were mapped: [pic] Several sales branches in different parts of the country sent proposals into the Central Processing Center. After considerable debate it was agreed at first to consider turnaround between entry into the computer system at the Company Sales Branch and dispatch to the customer from the Central Processing Center (CPC). Later the entire cycle could be included. The perception of the length of turnaround by different members of the team was recorded. It was found that on an average Non-Medical Policies took 17 days and Medical Policies  took 35 days. Customer desire: What was the turnaround desired by the customer? Since a customer survey was not available, individual group members were asked to think as customers — imagine they had just given a completed proposal form to a sales agent. When would they expect the policy in hand? From the customer’s point of view they realized that they did not differentiate between medical and non-medical policies. Their perception averaged out six days for the required turnaround. â€Å"Is this the average time or maximum time that you expect? † they were asked. â€Å"Maximum,† they responded. It was clear therefore that the average must be less than six days. The importance of â€Å"variability† had struck home. For 99. 7 percent delivery within the customer limit the metric was defined. Therefore the average customer desire was less than 6 days and the current status was that of 64 days for non-medical policies and for medical policies it was 118 days. Therefore the problem was to reduce the non-medical policies from 64 to 6 days and medical policies from 118 to 6 days. The performance requirement appeared daunting. Therefore the initial target taken in the Mission Sheet (project charter) was to reduce the turnaround by 50 percent — to 32 and 59 days respectively. Step 2. Analysis of the Problem In a session the factors causing large turnaround times from the principles of JIT were explained. These were Input arrival patterns †¢ Waiting times in process. o Batching of work. o Imbalanced processing line. o Too many handovers. o Non-value added activities, etc. †¢ Processing times †¢ Scheduling †¢ Transport times †¢ Deployment of manpower Typically it was found that waiting times constitute the bulk of processing turnaround times. Process Mapping (Value Stream Mapping in Lean) was undertaken. The aggregate results are summarized below: Number of operations 84 Number of handovers 13 In-house processing time (estimated) 126 man-mins. Range of individual stage time 2 to 13 mins. To check this estimate it was decided to collect data — run two policies without waiting and record the time at each stage. The trial results amazed everyone: Policy No. 1 took 100 minutes and Policy No. 2 took 97 minutes. Almost instantly the mindset changed from doubt to desire: â€Å"Why can’t we process every proposal in this way? † Step 3. Generating Ideas In the introductory program of TQM during the JIT session the advantages of flow versus batch processing had been dramatically demonstrated using a simple exercise. Using that background a balanced flow line was designed as follows: 1. Determine the station with the maximum time cycle which cannot be split up by reallocation 8 minutes. 2. Balance the line to make the time taken at each stage equal 8 minutes as far as possible. 3. Reduce the stages and handovers — 13 to 8. 4. Eliminate non-value added activities — transport — make personnel sit next to each other. 5. Agree processing to be done in batch of one proposal. Changing the mindset of the employees so they will accept and welcome change is critical to building a self-sustaining culture of improvement. In this case, the line personnel were involved in a Quality Mindset Program so that they understood the reasons for change and the concepts behind them and are keen to experiment with new methods of working. The line was ready for a test run. Step 4. Testing the Idea Testing in stages is a critical stage. It allows modification of ideas based upon practical experience and equally importantly ensures acceptance of the new methods gradually by the operating personnel. Stage 1: Run five proposals flowing through the system and confirm results. The test produced the following results: Average turnaround time: < 1 day In-house processing time: 76 mins. There was jubilation in the team. The productivity had increased by 24 percent. Stage 2:  It was agreed to run the new system for five days — and compute the average turnaround to measure the improvement. It was agreed that only in-house processing was covered at this stage and that the test would involve all policies at the CPC but only one branch as a model. This model, once proved, could be replicated at other branches. The test results showed a significant reduction in turnaround: 1. For all non-medical policies from 64 to 42 days or 34% 2. For policies of the model branch from 64 to 27 days of 60% The Mission Sheet goal of 50 percent reduction had been bettered for the combined model branch and CPC. Further analysis of the data revealed other measures which could reduce the turnaround further. Overall reduction reached an amazing 75 percent. Turnaround, which had been pegged at 64 days, was now happening at 99. 7 percent on-time delivery in 15 days. Step 5. Implementing the Ideas Regular operations with the new system was planned to commence. However, two weeks later it was still not implemented. One of the personnel on the line n CPC had been released by his department for the five-day trial to sit on the line but was not released on a regular basis. The departmental head had not attended the TQM awareness program and therefore did not understand why this change was required. There were two options — mandate the change or change the mindset to accept the change. Since the latter option produces a robust impleme ntation that will not break down under pressures it was agreed that the group would summarize TQM, the journey and the results obtained in the project so far and also simulate the process with a simple exercise in front of the department head. This session was highly successful and led to the release of the person concerned on a regular basis. Step 6. Follow-up †¢ The process was run for one month with regular checks. The results obtained were marginally better and average time reduced to 11 days. †¢ Customer reaction: Sales management and sales agents (internal customers) clearly noticed the difference. For instance one sales manager reported that a customer had received a policy within a week of giving a proposal and was so amazed that he said, â€Å"If you give such service I will give you the next policy also! †¢ Adoption of a similar process at the CPC and the model branch for medical policies has already reduced the average turnaround time by 70 percent — from 118 days to 37 days. The corresponding all-India reduction was from 118 days to 71 days — a 60 percent reduction. †¢ The project objective of 50 percent in the first stage has been achieved. A quality improvement story was com piled by the project Leader for training and motivating all employees.