Sepsis and Septic Shock Essay Example

Sepsis and Septic Shock Essay Sepsis refers to the uncontrolled systemic immune response to infection. It describes the condition known as systemic inflammatory response syndrome in which as infectious etiology is identified or suspected (Munford, 2001). The key element in sepsis is the overwhelming systemic inflammation as a result of the host’s reaction to microbial invasion. It involves augmented inflammatory signals in response to an infectious insult that is not controlled by local inflammatory processes. Bacteremia, which is the presence of bacteria and in blood or septicemia, which is the presence of any microbial agent in the blood can lead to sepsis. When the regulatory controls that put the inflammatory response in check are unable to contain the overwhelming reaction, unaffected organs are involved and severe sepsis ensues which is characterized by multiorgan dysfunction. As the homeostatic counterregulatory mechanism fails, sepsis progresses to septic shock, which is the presence of hypotension along with along with organ dysfunction. The hypotension, which is defined as systolic blood pressure of less than 90 mmHg or 40 mmHg less than the patient’s usual blood pressure, is unresponsive to fluid resuscitation. Unlike sepsis which is reversible, patients in septic shock have unfavorable prognosis and usually succumb despite aggressive treatment (Munford, 2001).EpidemiologyOver 10 million cases of sepsis have been reported in the United States based on a 22-year period study of discharge data from 750 million hospitalizations (Martin, Mannino, Eaton, Moss, 2003). Annually, approximately 750,000 people develop sepsis and more than 210,000 cases are fatal (Bernard, Vincent, Laterre, Larosa, Dhainaut, Lopez-Rodriguez et al 2001; Hotchkiss Karl, 2003). Despite advances in critical care management, sepsis has a mortality rate of 30 to 50 percent and is among the primary causes of death in intensive care units (Bernard et 2003; Mitchell, Cotran, 1999). It is believed th at the increasing incidence of severe sepsis is due to the growing population among the elderly as a result of increasing longevity among people with chronic diseases and the high prevalence of sepsis developing among patients with acquired immune deficiency syndrome (Munford, p.798 2001).PathophysiologyThere are a lot of factors attributable to the development of sepsis. Several studies have conflicting results on the pathologic basis of the disease and the exact mechanism involved has not been elucidated. The pathogenesis of sepsis is a series of complex interactions between offending microorganism and the host inflammatory, immune and coagulation responses. The accepted theory is that sepsis results from an uncontrolled inflammatory response in which our own defense system becomes so powerful that it causes more damage to our organs than the etiologic agent of the initial infection Hotchkiss Karl, 2003). This is based on the overstimulated immune response seen in studies of anim al models of sepsis which does not seem to correlate which the clinical picture in humans. Clinical trials involving anti-inflammatory agents have not been successful in patients with sepsis which led investigators to question if sepsis is indeed the result of uncontrolled inflammation (Hotchkiss Karl, 2003). In fact, sepsis with organ dysfunction is attributed to an inadequate immune response to primary local infection which allowed it to spill into the bloodstream and the ensuing tissue injury is primarily caused by superantigens and other virulence factors from the infecting microorganism (Russel, J.A., 2006).Approximately 70 percent of cases of septic shock are caused by gram-negative bacilli which produce endotoxin, hence the term endotoxic shock (Mitchell, Cotran, 1999). The endotoxins are the lipopolysaccharides(LPS) from the bacterial cell wall that are released after the wall is degraded during an inflammatory response. The reproduction of the hemodynamic picture of septi c shock through the injection of LPS alone shows that LPS is one of the main culprits of septic shock. The complex inflammatory cascade caused by LPS eventually leads to hypoxic injury and the multi organ failure is mostly evident in the brain, heart, kidneys, lungs, and gastrointestinal tract. The widespread hypoxia during septic shock causes the brain to develop ischemic encephalopathy while in the heart, cardiac muscles undergo coagulation necrosis and subendocardial hemorrhages. The kidneys undergo acute tubular necrosis as a result of extensive ischemic injury. This results into electrolyte disorders, oliguria and anuria which are severe complications of sepsis. Despite the high resistance of lungs tissues to hypoxic injury, diffuse alveolar damage can be seen in severe bacterial sepsis. In the gastrointestinal tract, hemorrhagic enteropathy develops which appears as patchy mucosal hemorrhages and necrosis. The liver undergoes fatty change and in severe ischemic injury, central hemorrhagic necrosis can be seen (Mitchell, Cotran, 1999).Clinical FeaturesThe clinical manifestations of sepsis are usually superimposed with the signs and symptoms of the primary infection and other underlying medical condition of the patient.However, in the course of the disease, an increasing intensity of inflammatory response to infection becomes evident although the rate varies among patients. Hyperventilation is usually one of the early signs. Manifestations of ischemic encephalopathy such as disorientation and confusion may also occur early in sepsis. They are usually seen among the elderly and in patients with preexisting neurocognitive deficits (Munford, 2001). Patients with hypotension usually presents with weak but rapid pulse accompanied by tachypnea and cold, clammy skin. However, patients in septic shock may be initially warm due to peripheral vasodilation in the skin (Mitchell, Cotran, 1999). It should be noted that some patients with sepsis are normothermic and e ven in the presence of infection, fever can be absent especially in neonates, elderly, and patients with uremia or suffering from alcoholism (Munford, p.801 2001).The occurrence of disseminated intravascular coagulation or DIC, which results from the widespread activation of the coagulation system, can predispose patients to ischemic necrosis especially to those with hypotension. This leads to skin lesions seen as pustules, cellulites, bullae or hemorrhagic lesions. Gastrointestinal involvement manifests as nausea, vomiting, diarrhea and ileus. Patients with stress ulcers may present with upper gastrointestinal bleeding. In cases of prolonged and severe hypotension, ischemic bowel necrosis may occur as well as acute hepatic injury. Elevation of serum levels of conjugated bilirubin often leads to cholestatic sepsis. Liver function test may reveal elevated blood levels of alkaline phosphatase which along with the elevated bilirubin represent an underlying hepatocellular or canalicular dysfunction (Munford, 2001).Treatment and PrognosisPatients with sepsis requires urgent management which is best accomplished in an intensive care setting by medical specialist experienced in the care of critically ill patients. The management entails immediate treatment of the focus of infection while providing adequate hemodynamic and ventilatory support.The appropriate antimicrobial therapy should be given immediately based on blood culture and sensitivity although an empiric initial treatment should be started based on known pathogens at identified sites of infection. An adequate antibiotic cover should include therapy against gram-positive and gram-negative microorganism. Pending results from blood cultures, empiric antimicrobial therapy can be based on several factors, especially in patients with no obvious source of infection. In immunocompetent adults, acceptable regimens include ceftriaxone or ticarcillin-clavulanate or piperacillin-tazobactam and imipenem-cilastin or mero penem. Gentamycin or tobramycin may be added to these regimens. If the causative agent is suspected to be methicillin-resistant staphylococcous areus, vancomycin should be added to these regimens (Munford, 2001). In patients with AIDS, ceftazidime, tircacillin-clavilanate or piperacillin-tazobactam plus tobramycin should be used. In patients with drug allergy to beta lactams, ciprofloxacin plus vancomycin and tobramycin should be used (Munford, 2001). Other factors to be considered are the presence of neutropenia or neutrophil count of less than 500 per microliter, splenectomy and history of intravenous drug abuse. These patients require appropriate antimicrobial cover based on their higher susceptibility to certain microorganisms.The immediate removal of the focus of infection is also important in the successful management of patients with sepsis. Sites of infection should be identified immediately and appropriate drainage should be done when possible. In patients with indwelling i ntravenous catheters, microbial cultures should be done and a new catheter should be placed in another site. Adequate hemodynamic and respiratory support should also be provided especially in patients with septic shock to prevent tissue injury secondary to ischemia. The pulmonary wedge pressure and central venous pressure should be monitored constantly. Metabolic support should also be provided. The urine output should be watched closely for oliguria and anuria. Diuretic therapy with furosemide may be used (Munford, 2001).Despite aggressive treatment, many patients with severe sepsis and septic shock succumb to the disease. Several new agents have been developed which should promising outcome in averting death. These are drugs that neutralize the bacterial endotoxin such as monoclonal antibodies to endotoxins and drugs that interfere with the mediators of inflammatory response such as monoclonal antibodies to tumor necrosis factor alpha. Another promising drug for severe sepsis is d rotrecogin alfa or recombinant human activated protein C which has shown antithrombotic, antiinflammatory, and profibrinolytic properties. A clinical study has shown that the drug significantly reduced the mortality in severe sepsis although due to its antithrombotic properties, the patients are at a higher risk of bleeding (Bernard, et al 2001).Further studies are necessary to better understand the pathogenesis leading to sepsis. The knowledge gained in these studies which further enhance the development of newer drugs with better safety profile. In addition, more clinical trials are important to assess the drug efficacy of existing drugs so that better management of sepsis can be formulated to improve the morbidity and mortality of the disease.

Couples Only Essay

Couples Only Essay Couples Only? Essay Lauren Huber-Garcia Mrs. Peterson English 1301-341 February 19, 2013 Couples Only? What’s the deal? Is it the fact that there are heterosexual couples that have rights and benefits available to them unlike the homosexual couples? Or is it based on whether or not people, no matter their sexual preference, are in a marital relationship with another being. This article tries to persuade citizens, especially singles, that giving benefits and rights to married couples, gay or straight, is unreasonable. The author comes from a singles person’s perspective, which â€Å"don’t share in he deal given to married couples† and bears a different viewpoint dealing with the gay marriage issue (Harrop 675). In Froma Harrop’s â€Å"Gay, Straight: What’s The Deal†, she explains â€Å"the deal† through his use of the appeals to Logos, Pathos, and Ethos. In this article Harrop uses facts as examples to show that it’s neither fair nor right that married couples are allotted privileges that single Americans do not. Take the lesbian couple for example, â€Å"†¦the women filed a medical-malpractice lawsuit. One of them suffered from advanced breast cancer, which the suit claimed, a doctor had failed to detect. The other wanted to collect for â€Å"loss of consortium.†(Harrop 675). The author belittles the couple for the â€Å"collection of monetary† which makes it seem as if she is blaming the use of the benefits that are given to married couples. The author uses this fact and compares it to those people who are close but are in a non-marital relationship. â€Å"You can’t read this without thinking about similar hurts being felt all the time in non-marital relationships†¦ Why can’t they sue for loss of companionship, also?† (Harrop 675). On the pathos she uses emotion and an angry tone that makes her irritation over gay marriage clear as well as use the word â€Å"you† and â€Å"us† to make the examples seem more real and personable. â€Å"In doing this, the senators have earned my gratitude- though for reasons not directly related to gay rights. Rather the move will spare us all some of the repetitive back-and-forth that has characterized this debate.† (Harrop 675). This technique Harrop uses allows for the author and the single American audience to meet in the middle and find some common ground on this issue. â€Å"What really rankles me...† and â€Å"So much attention is paid to married couples that most of the public- including single people themselves- think of unmarried adults as a marginal minority.† Further show her anger of the treatment towards the single Americans (Harrop 675). Another use of pathos is show in the example about the sisters. â€Å"Government should have no interest in a citizen’s marital status. It certainly has no business sending a bigger tax bill to cohabiting sisters that to a man-and-wife team reporting the same income and deductions as the sisters.† with this the author implies that the status of the relationship does not set the morality of the government and their beliefs (Harrop 676). By using the choices of words she does, its allows for the audience to see how compassionate she is about this issue and that it is r eally important to her that she portrays that to her readers. What helps make this article a persuasive article is the ethos appeal. â€Å"Quickie marriages get more legal respect that friendships lasting decades.†(Harrop 675). This helps her portray that society does not approve of this certain action just to receive the benefits. Harrop gains the credibility and the sense of confidence by using examples that everyday people in society can relate to. For example Britney Spears â€Å"An hour after Britney Spears gets hooked to her next husband, the federal government will shower her with all sorts of rights and benefits not available to the man who has spent eight years caring for a

Case 12-1; Litchfield Corporation Essay Example | Topics and Well Written Essays - 500 words

Case 12-1; Litchfield Corporation - Essay Example This means that despite Litchfield Corporation of a favourable environment to operate in the UK, the perceived profits will decline as the margin is to be taxed by the federal government. The establishment of an offshore subsidiary firm enables the institution split its profits into two where; export profits from the sale of the umbrellas to the subsidiary which is subject to income tax while export profits from the subsidiary sales to foreign buyers is not subject to the US federal income tax unless distributed to the parent firm in the form of a dividend (Burman & Slemrod, 2013). Litchfield Corporation’s ambitious expansion certainly will have to handle and manage the risks that are associated with exportation so as to ensure maximum profitability and limits losses. The risks likely to be encountered include; Credit risk; this might affect the parent company since the credit worthiness of the offshore subsidiary may be questionable. The credit worthiness limits the risk of late payments, non-payments hence minimizes the risk of reduced profits. Transportation and logistics; the company faces the risks associated with movement of goods over long geographical locations. This increases the costs of operation since more is invested in risk transfer and profit margins are likely to be reduced. Therefore, the risks that might likely to affect the business need to be identified and proper steps undertaken so as to minimize the risk of loss of profit. Some of the risk management options include; insurance that covers country risk cover, credit risk cover, and transit risk cover ensuring that Litchfield competes profitably in UK. Cost-based; this is transfer price based on the cost of production of material. This determination is set to include a profit margin for the producer. However, the simplicity of application of the cost based transfer price method, two problems arise such as the measure of

Networking Assignment Example | Topics and Well Written Essays - 500 words - 2

Networking - Assignment Example For this company I suggest the use of NAPT so that it can allow the company’s computers to participate concurrently in operations. This is the simplest type, which allows for one to one use of IP address. It is where the IP head checksum and IP address only needs to be changed (Kurose & Keith 93). Security reasons-this is because the system provides automatic firewall system security without any complex set up. This is because it allows for connectivity that is from inside network. This implies that an internal user is able to connect to FTP server outside the system but an outsider cannot access the internal FTP server since it does not originate from the source. This thus means that the company’s information is safe and cannot be accessed by unauthorized person (Kurose & Keith 112). Administrative reasons-this is in terms of dividing the network into small units whereby the small parts are exposed to an IP address thus other computers can be connected or disconnected without affecting the outside networks. Again, NAT through its gateways can give a way to prohibit access to the internet, which allows the administration to restrict users from accessing bad materials. Moreover, NAT allows several computers to have connections on the same network courtesy of operations through an IP packet-level (Wendell, Rus, Denise 78). To assign these addresses to devices, a special program will be run in the machine to install the address into its hard memory and saved. Then the program is deleted to ensure that address belongs to that devices and can never be changed any time in the future (Wendell, Rus, Denise

Law Of Evidence Analysis Of Similar Fact Evidence Law Essay

Law Of Evidence Analysis Of Similar Fact Evidence Law Essay The law of evidence is a system under which facts are used to determine the rights and liabilities of the parties. Evidence proves the existence of facts in issue or infers them from related facts. One of the fundamental considerations of criminal evidence law is the balance of justice to the accused against wrongful convictions, ensuring a fair trial and fairness to the victim. Since stakes in criminal trials are generally high, prosecution would have to prove the accuseds guilt beyond a reasonable doubt. Since similar fact evidence as evinced in s  11(b), 14 and 15 of the Evidence Act(EA) can be highly prejudicial to the accused, and yet play an important role in proving culpability, it should be reformed to clarify its scope of application under the EA and reflect the common laws prejudicial propensity balancing test. 2. Similar Fact Evidence A. Background Similar fact evidence is not directly connected to the case but is admitted to prove the existence of facts in issue due to its general similitude.The worry that the trier of facts would convict the accused based solely on evidence of prior conduct has generally led to the inadmissibility of such evidence in the trial as this is severely prejudicial. This concern is amplified in bench trials. Studies have suggested that judges were as influenced as laypersons when exposed to inadmissible evidence, such as prior convictions, even when they held that these evidences were inadmissible.  [6]  This is despite strong confidence in the judges ability to remain neutral to the inadmissible facts.  [7]   Hence, the accuseds past similar offence or behaviour is inadmissible as similar fact evidence based on pure propensity reasoning would colour the courts ability to assess the evidence [objectively].  [8]   Nonetheless, the mere prejudicial effect of such evidence does not render it inadmissible. It may be highly relevant, especially when such evidence is used to determine whether the acts in question were deliberate or to rebut a defence that could have been available.  [9]   B. EA Under s  5 of the EA, a fact is only relevant if it falls within one of the relevancy provisions  [10]  stated in s  6 to s  10 of the EA. These provisions govern specifically the facts in issue, i.e. determinant facts that would decide whether the accused is guilty according to the substantive law governing that offence.In addition, s  11(b) was enacted to be the residuary category for the relevancy provisions. In contrast, similar fact evidence is primarily administrated by s  14 and s  15 as it is concerned with conduct that is merely similar in nature to those facts in issue  [13]  . s  14 is applicable only when the state of mind of the accused is in issue. Similar fact evidence is admissible to prove mens rea or to rebut the defence of good faith.  [14]   s  15 deals with similar fact evidence that forms a series of similar occurrences to prove the mens rea of the accused,  [15]  and enables the prosecution to produce evidence to rebut a potential defence otherwise open to the accused.  [16]   Admission of similar fact evidence under the EA is based on a categorization approach  [17]  , where such evidence is admissible pursuant to the exceptions stated in the EA  [18]  . Hence, similar fact evidence should only be admissible to prove the mens rea of the accused under s  14 and 15.  [19]   Significantly, Singapore, India, Malaysia and Sri Lanka have identical s  11, 14 and 15 provisions in their respective Evidence enactments. With the exception of the Indian Evidence Act  [20]  , the three sections have not been amended since the 19th century.  [21]   C. Case Law Interpretation of Similar Fact Evidence in EA Singapore courts have not strictly adhered to the draftmans intention in recent cases.  [22]  The court has incorporated common laws balancing test  [23]  where the judge would balance between the probative and prejudicial effect of the similar fact evidence.  [24]   In Lee Kwang Peng v PP  [25]  , scope of similar fact evidence was extended to prove actus reus. Pursuant to s  11(b), the court was of the view that the section embodied  [26]  the balancing test. Hence, similar fact evidence is admissible to prove both mens reas and actus reus.  [27]  Although readily admitting that this would be contrary to the draftsmans intention, then Chief Justice Yong held that the EA should be a facilitative statute rather than a mere codification of Stephens statement of the law of evidence  [28]  . The courts, until Law Society of Singapore v Tan Guat Neo Phyllis  [29]  (Phyllis Tan), were generally of the opinion that they had the discretion to exclude evidence substantially unfair to the accused.  [30]   D. Under the Criminal Procedure Code Act (2010)  [31]  (CPC) s  266 of CPC, dealing specifically with stolen goods, allows previous convictions of the accused to be admitted to rebut his defence of good faith and/or prove mens rea. However, notice would have to be given to the accused before adducing such evidence  [32]  . E. In Comparison to Common Law Unlike the EA, admissibility of criminal evidence at common law is exclusionary. As long as the evidence is logically probative, it is admissible unless it contravenes clear public policy or other laws.  [33]   In Makin v A-G for NSW  [34]  , Lord Herschell formulated the two-limbed rule governing the admissibility of similar fact evidence. Under the first limb, the prosecution is not allowed to adduce similar fact evidence for pure propensity reasoning. However, under the second limb, evidence of the accuseds past conduct is admissible if relevant to the facts in issue via the categorization approach.  [35]   Boardman v PP  [36]  reformulated these rules by incorporating the balancing test. Under this test, the probative force of the similar fact evidence must outweigh the prejudicial effect. Furthermore, such evidence should be strikingly similar, such that it would offend common sense if the evidence is excluded.  [37]   However, the requirement of striking similarity was deemed to be too narrow in DPP v PP  [38]  . Instead, sufficient probative force could be gleaned from other circumstances  [39]  . Nonetheless, similar fact evidence used to prove identity must be sufficiently special to portray a signature or other special feature that would reasonably point to the accused as the perpetuator of the crime.  [40]  Hence, similar fact evidence is admissible to establish actus reus  [41]  . F. Defects of EA Singapore courts have incorporated common law principles and extended the applicability of similar fact evidence to prove actus reus. This has resulted in inconsistencies between the draftsmans intention and the courts approach. Further, there are some ambiguities that require clarification. First, there are difficulties superimposing the Boardmans balancing test into s  11, 14 and 15  [42]  as the EA was drafted to suit the categorization approach. The court would have to admit evidence falling under either section even if it may not be very probative or is highly prejudicial. Hence, s  14 and s  15 address only the probative part of the balancing test and leave no room for prejudicial effect considerations.  [43]  As a result, judicial discretion to exclude very detrimental evidence was developed.  [44]   Second, although allowing similar fact evidence to prove actus reus would require the judge to evoke an additional step of inference  [45]  , limiting the use of this evidence to prove mens rea would allow extremely probative evidence to be excluded  [46]  . Third, admissibility rules under the EA do not distinguish situations where the accused adduced similar fact evidence unintentionally. An injurious consequence would result if the prosecution is entitled to use such evidence.  [47]   Fourth, under s 15, a single act, no matter how probative, is inadmissible.  [48]  However, this does not take into account the consideration that an act may be capable of supporting the argument based on the rarity of circumstances  [49]  . Fifth, the courts have admitted similar fact evidence pursuant to s  11  (b) although it may not be pertinent to the facts in issue. Hence, EA should be amended to provide safeguards against such usage of s  11(b). Lastly, in light of Phyllis Tan  [50]  , more protection against admissibility of similar fact evidence should be incorporated into the EA. 3. Possible Options A. Survey of the other Jurisdiction (1) Australia Uniform Evidence Acts  [51]  (UEA) Under UEA, propensity evidence and similar fact evidence are governed by the tendency rule in s 97 and the coincidence rule in s  98. (a) Tendency Rule Evidence pertaining to the character, reputation, conduct or a tendency that the accused possessed is inadmissible unless (a) notice is given to the accused and (b) the evidence has significant probative value. Although UEA does not state how probative the evidence has to be, probative value of the evidence is defined the extent to which the evidence could rationally affect the assessment of the probability of the existence of a fact in issue.  [52]  Operation of s  97 would be invoked when the evidence is adduced for the purpose of proving the accuseds inherent tendency to act in a particular way.  [53]   (b) Coincidence Rule As a general rule, evidence of related events which must be substantially and relevantly similar  [54]   would be inadmissible unless notice is given and the court is convinced that it possesses significant probative value  [55]  . (c) Criminal Proceedings A safeguard was inserted in relation to criminal proceedings under s  101 where the probative value of either the tendency or coincidence evidence would have to substantially outweigh any prejudicial effect. However, the degree of probativeness need not  [56]  be of such a degree that only one conclusion, i.e. culpability of the accused, could be drawn  [57]  . (No rationale explanation test) (d) Analysis UEA clearly adopts the balancing test approach, where the probative effect of the evidence must substantially outweigh the prejudicial effect on the accused. Furthermore, the introduction of the notice system would reduce the prejudicial effect as the accused not be unduly surprised. However, as pointed out by the Australian Law Reform Commission, there is much ambiguity in what constitutes significantly probative and when the probative effect will substantially outweigh the prejudicial effect. Significantly, in Australia, the trier of fact and law are different. Heavy reliance on the judges discretions, added with the ambiguity and wide application of the balancing test, would increase the risk of prejudice in bench trials. (2) India Statutory Amendments Some amendments to s  11, 14 and 15 of The Indian Evidence Act  [58]  , upon which the EA was modeled on  [59]  , had been made pursuant to a review in 2003.  [60]  However, the changes made were very minor.  [61]   (a) Section 11 An explanation, inserted after s  11(2)  [62]  , qualified the type of evidence rendered relevant under s  11 such that the degree of relevancy is dependent on the opinion of the Court  [63]  . (b) Section 14 Clarifications to illustration (h) of s  14 were made such that the similar fact evidence has to show that A either had constructive or actual knowledge of the public notice of the loss of the property.  [64]   (c) Section 15 The changes merely show that the acts made, pursuant to s 15, must be done by the same person.  [65]   (d) Analysis It would appear that the amendments to the Indian Evidence Act do not have any substantial impact on the law. However, the amendment of s  11 explicitly mentions that the degree of relevancy of facts is subjected to the opinions of the court, which suggests an approach more in line with the balancing test. (3) England and Wales Criminal Justice Act 2003  [66]  (CJA) The admissibility of criminal evidence is presently governed entirely  [67]  by the CJA. Part II of CJA addresses the admissibility of bad character  [68]  evidence, which is defined as a persons disposition for a particular misconduct. Evidence of the defendants bad character can be adduced if it falls under one of the seven gateways under s 101(1)  [69]  . Significantly, under s 101 (1) (d), bad character evidence is admissible if it is relevant to an important issue between the defendant and the prosecution  [70]  . This includes the propensity to commit a particular type of offence which the accused is charged with or the propensity to lie  [71]  . Moreover, past convictions may be admissible to prove the defendants propensity to commit the crime he was charged with.  [72]   Regardless, s  101 (3) allows the court to exclude evidence, falling under s 101  (1)(d), upon the application of the defendant if the court views that admission of such evidence would infringe on the fairness of the proceedings.  [73]   The scope for the admissibility of bad character evidence has widened under the CJA.  [74]  In fact, evidence of bad character has changed from one of prima facie inadmissibility to that of prima facie admissibility  [75]  . Although, under s  103, bad character evidence would be inadmissible if it does not heighten the culpability of the accused, suggesting that the evidence must have some probative force, it appears that the CJA has abandoned the balancing test. Hence, similar fact evidence in the form of bad character evidence would be inadmissible if it lacks probative value in the establishment of the defendants culpability. However, s  101 (1), with the exception of s  101(1)(e), merely requires the evidence to be probative, without the need to outweigh prejudicial effect. 4. Proposal The EA would require more than a mere amendment. Hence, the type of reform advocated under the Indian Evidence Act should not be adopted. However, a radical change from the categorization approach to the balancing approach, following UEA, would give the court too much discretion. This is worrying as judges may not be entirely indifferent to inadmissible facts when deciding the case. On the other hand, the approach under the CJA would be contrary to Phyllis Tan  [76]  and potentially allows highly prejudicial similar fact evidence to be admissible as long as the prosecution can show some probative value which points towards the guilt of the accused. Hence, a hybridised model should be adopted where the categorisation approach under s 14 and s 15 is kept, but admissibility of such evidence must be subjected to the balancing test. A. Amendments (1) Changes to the Headings s  5 to s 16, under the general heading of Relevancy of facts, could be further sub-divided. First, s  5 to s  11 should be placed under a sub-heading of Governing Facts in issues  [77]  . Second, s  12 to s  16 could be placed under Relevancy of other facts sub-heading. This sub-division of the relevancy provisions would clarify the functions of each section and discourage courts from admitting similar fact evidence which does not have a specific connection with the facts in issue via s 11(b). (2) Incorporating balancing test Most importantly, EA should be amended to include the balancing test with guidance drawn from the UEA, such that the probative value of the similar fact evidence should substantially outweigh the prejudicial effect. However, the definition of substantially outweigh should be left undefined and allowed to develop under the common law. The courts could draw assistance from the Australian case law. (3) Proving Identity A provision could be inserted to the EA allowing similar fact evidence to prove that the accused was responsible for the offence. In addition to the balancing test, the provision should also reflect the proposition that that such similar fact evidence must satisfy the threshold test of being strikingly similar to the offence, almost akin to a signature or special feature of the accused. However, it is submitted that the extension of similar fact evidence to prove actus reus should be limited to the situation where the identity of the perpetuator is in doubt. B. Clarifications (1) Similar fact evidence produced by the accused mistakenly It is proposed that such evidence should subjected to a higher standard of balancing test where the probative value substantially outweighs prejudicial effect. (2) Only prior convictions are allowed Prior acquittals should not be admissible as similar fact evidence as this would be unduly prejudicial to the accused. Furthermore, this could result in the undesirable situation whereby the accused is subjected to a second round of trials with regards to the prior charges. In relation to the type of prior convictions that should be allowed, the EA should incorporate the definitions found in s 103(2)  [78]  and s  103(4)  [79]  of the CJA. (3) Clarification of s. 15 s  15 should be extended to include single act or conduct of the accused to rebut the defendants defence of accident. However, in light of a potential danger of placing too much importance on a single episode, a qualification, such as the no rationale reason  [80]  test, should be implemented along with the extension of s  15. 5. Additional Safeguards A system of notice, as seen in UEA, should be included into the EA. This reduces the prejudicial effect as the evidence would not be a surprise. Furthermore, this approach would be in line with the CPC, which has already adopted such a procedural reform. 6. Conclusion Regarded as one of the most difficult area of the law of evidence, similar fact evidence can serve as a double-edged sword. It has the potential to convict the accused although the facts do not relate to the facts in issue and is highly prejudicial to the defendant. In light of the rapid development of the rules governing the admissibility of similar fact evidence under the common law and the recent trend of common law countries codifying the test of admissibility into statutes, the EA should be reformed to reflect these developments, instead of relying on case law which can lead to inconsistency and uncertainty. Further, as information of a persons past is easily obtained with present technological advancements, safeguards against similar fact evidence should be incorporated so as to ensure a fair trial.

Person Centred Risk Essay

Traditional methods of risk assessment are full of charts and scoring systems, but the person, their objectives, dreams and life seem to get lost somewhere in the pages of tick boxes and statistics. A person centred approach seeks to focus on people’s rights to have the lifestyle that they chose, including the right to make ‘bad’ decisions. see more:explain how to encourage the individual to take positive risks while maintaining safety The approach described here uses person centred thinking tools, to help people and those who care about them most think in a positive and productive way about how to ensure that they can achieve the changes they want to see while keeping the issue of risk in its place. This in essence is a process to gather, in partnership with the person, the fullest information and evidence to demonstrate that we have thought deeply about all the issues involved. Decisions are then guided by what is important to the person, what is needed to keep them healthy and safe and on what the law says. Papers and Articles Supported Decision Making A key part of risk is decision making. We have co-written a booklet on Supported Decision Making. To view this booklet see the downloads box on the left. A Positive Approach to Risk Requires Person Centred Thinking Max Neill, Julie Allen, Neil Woodhead, Stephen Reid, Lori Irwin and Helen Sanderson 2008 This article looks at the issue of risk in the lives of people who are supported by human services. More accurately, it looks at how the issue of risk, as it has traditionally been approached by these services, imposes a barrier to social inclusion and to an interesting and productive life. The article also proposes an alternative person centred risk process that by beginning with a focus on who the person is, their gifts and skills, and offering a positive vision of success, could avoid the implied aversion to any form of risk embedded in the traditional approaches and attitudes. The full exposition of this process is described in the ‘Person Centred Risk Course Book’ (Allen et al 2008). The problems of traditional risk assessment are becoming increasingly recognised by people who use human services, their families and carers, and now by many service providers, who are looking for alternative approaches to risk: ‘thorough, professional, personalised risk management’ (Bates and Silberman 2007 p6) that recognise that life and risk are inseparable, and that look at risk from the point of view of the person, their family and friends and the wider community, rather than solely from the point of view of the service provider. Bates and Silberman argue that any such positive approach to risk would need to meet a number of requirements, and see it as the ‘holy grail’ of mental health and other services. The authors of this article have been working on applying Person Centred Thinking Tools to the issue of risk, building them in to a ‘Person Centred Approach to Risk’. We believe this alternative approach does not lose the person in a sea of tick boxes and charts, that it has a more balanced approach to risk, having an inbuilt assumption that the purpose of any risk assessment is just as much about the happiness of the person, their family and the community as it is about their safety. We also believe that the ‘Person Centred Approach to Risk’ can be demonstrated to meet all the requirements set by Bates and Silberman in their article, and that it provides a productive way for many people who wish to take meaningful steps forward in their lives, but find themselves trapped in a boring unproductive and segregated lifestyles by traditional service-centred approaches to risk. Finally we argue that any positive approach to risk must include the basic tenets of all Person Centred Approaches; keeping the person at the centre, treating family and friends as partners, a focus on what is important to the person, an intent to build connections with the community, being prepared to go beyond conventional service options, and continuing to listen and learn with the person. What is ‘Risk’? The experience of many people who have to rely on human services for their support is that ‘risk’ is the reason given to them by services why they cannot do the things that other people are doing every day. When we delve into the word ‘risk’, we find that it has a multitude of meanings, and that it is nowhere near as clear and precise as the advocates of traditional risk assessment assert, for example Hansson (2002) identifies five different common uses for the word risk, and Ekberg points out a â€Å"proliferation of risk definitions† and a whole range of different understandings of risk (2007 p345). Risk literature often separates ‘risk’ from ‘uncertainty’, defining the risk as a measurable probability that something will happen, however, even where experts claim they can give an exact probability value to a risk, there is always a possibility that the experts may be wrong (Hansson 2002 p4). In common usage the words ‘risk’ and ‘uncertainty’ are often synonymous (Lupton 1999 p9) Risk is sometimes used as a verb: a person ‘risks’ doing something, and sometimes a noun: a person is labelled as being a ‘risk to society’. The drive for a single definition of ‘Risk’ has been described as â€Å"a futile form of linguistic imperialism† (Hansson 2000 p3), he argues that risk in it’s popular usage is just as valid as the narrow technical values attached to the term, as this allows the inclusion of philosophical and ethical values, the bargaining and compromises that are excluded from â€Å"the expert-driven risk analysis process† but are essential for social and political decision making processes (ibid pp5-8). Risk decision making is often complicated by the fact that the person or group taking the decision is not always the person or group affected by the risk. Hansson argues that â€Å"risks are inextricably connected with interpersonal relationships. They do not just ‘exist’; they are taken, run or imposed† (2000 p4). Differences in power and status affect the extent to which people influence risk decision making – the views of developers wishing to build a dam across a river may well be given more weight than those of people living nearby that river. Where a person with less power and status might wish to take a risk, and the consequences of that risk would affect more powerful people, it is more likely that they will be prevented from taking it. This is the problem faced by people supported by services and professionals, where those services and professionals fear various real and imagined consequences to them of the risk taking of the people they support. www.helensandersonassociates.co.uk This problem is deepened in modern society as the power of the news media can mean that the unpredictable actions of an individual can now have an amplified impact on the reputation of services, and on political and corporate institutions. Services that are now becoming increasingly concerned with ‘reputational risk management’ find that this demands â€Å"The risk management of everything† (Power 2004 p36). In the case of human services, this means an ever more intrusive and obsessive focus on every aspect of the lives, behaviours and potential behaviours of the people they support. It can also mean the increasing ‘proceduralisation’ of work, as defensive practice and blame avoidance (ibid p46) become more important than the particular lives of individual people. Risk can become a highly charged and politically loaded issue. The parties involved can have very different interests at stake in debates about particular risks, and these can often be prone to become full on conflicts, leading to different parties taking entrenched positions that prevent cooperation, agreement and action and further trap the person. Person Centred Approaches, with their focus on the person and strategy of building an alliance of supporters around the person can often cut across this entrenchment and generate new and creative ways forward, providing that services are prepared to face this challenge. This is now being recognised by government departments, the Department of Health publication ‘Independence Choice and Risk’ wholeheartedly commends person centred approaches for everyone because they â€Å"identify what is important to a person from his or her own perspective and find appropriate solutions† (DOH 2007 p4) Regulators too want to see the balance of risk decision making shifting toward â€Å"supporting individuals who choose to take informed risks in order to improve the quality of their lives†( CSCI 2006 pvii) in this case CSCI are talking about older people, but this shift in attitude to risk is being advocated for all services that offer health or social care to human beings. For the purposes of this article, we are considering ‘risk’ as it presents to people that use services – any issue, real or imagined, which is being used as an objection to their moving toward increased inclusion in community life. What is Wrong with Traditional Risk Assessment? A focus on risk â€Å"encourages practitioners to look for what is going wrong rather than what is going right† (Booth and Booth 1998 p205) Traditional technocratic and spuriously ‘objective’ approaches to risk ‘lose the person’ – philosophically they treat the person as an object to be assessed by the ‘experts’ rather than as an agent in their own lives, part of a family, community, society, with legal rights and choices. They focus on what is wrong with the person, often treating the person as a problem to be managed rather than a person to be enabled to fulfil their ambitions and offer a contribution to society. Alaszewski and Alaszewski (2002) argue that â€Å"If agencies and their employees take a narrow hazard approach to risk, they will contribute to the disempowerment of people with learning disabilities† Power (2004) calls for ‘intelligent’ risk management that does not â€Å"swamp managerial attention and independent critical imagination† is characterised by â€Å"learning and experiment rather than rule based processes† and which can be sustained subject to challenge, questioning and criticism (p61), while the Better Regulation Commission has called for an emphasis in risk management on â€Å"resilience, self reliance, freedom, innovation and a spirit of adventure† (BRC 2006 p3). The government too is calling for â€Å"A culture of choice that entails responsible, supported decision making† (Lewis 2007 p1) and calls for everyone involved in the lives of people who use services to â€Å"work together to help people achieve their potential without compromising their safety† (ibid p2). To give proper balanced consideration to issues of risk and achievement in the diverse and complex lives of human beings, we need an entirely different approach from the methods that services use to ‘risk assess’ their hoists, fridges and kettles. Bates and Silberman’s ‘Holy Grail’ Criteria. Bates and Silberman have described effective risk management as the â€Å"‘holy grail’ of mental health and other care services† (2007 p6) They see it as finding an integrated balance between â€Å"positive risk taking† around the values of autonomy and independence and a policy of protection for the person and the community based on minimising harm. While they do not give an exact description of what such an approach would look like, they give a list of 7 criteria that any such approach would have to fulfil, these being: Involvement of Service Users and Relatives in Risk Assessment. Positive and Informed Risk Taking. Proportionality. Contextualising Behaviour. Defensible Decision Making. A Learning Culture. Tolerable Risks. A Person Centred Approach To Risk There are many different tools and approaches available to support Person Centred Thinking, many of which have come from ‘deconstructing’ the processes of Smull and Sanderson’s (2005) ‘Essential Lifestyle Planning’ approach, while some have come from other strands in the growing family of Person Centred Approaches and by early work applying person centred approaches to risk by Duffy and Kinsella (Kinsella 2000). Practitioners of Person Centred Approaches who were unsatisfied with the traditional repertoire of Risk Management tools have begun to recombine these Person Centred Tools in innovative and creative ways, and to apply them to thinking, acting and learning around real risk situations. The learning from this experience, reflection and discussion has been refined and crystallised into a process that can be shared and applied constructively to different risk situations, bringing together people who use services and the people who know and care about them most to think about how they wish to move forward and the risks involved; making decisions, taking actions and learning together. We have called this process a ‘Person Centred Approach to Risk’ (Allen et al 2008). In this section we will look at the ‘holy grail’ criteria put forward by Bates and Silberman and show how we believe the Person Centred Approach to Risk fulfils these criteria. â€Å"Involvement of service users and relatives in risk assessment†: Involving the person concerned and the people that care about them most is one of the most fundamental tenets of any person centred approach. The process we have put together considers carefully the people that need to be involved, using the ‘Relationship Circle’ to help the person and their allies identify key people who could form the persons ‘circle of support’. This group of people is involved from the outset, in the initial gathering of information, in the framing of what the risk under discussion actually is, in thinking that generates ideas and solutions, in evaluating these solutions, in decision making around the risk, in implementing the actions and in the learning that takes place during these actions. Bates and Silberman suggest that â€Å"staff must understand what service users and others want, how they view their own risks and what responsibilities each person has in managing risks effectively† (2007 p7). The Person Centred Approach meets this by asking for a clear picture of what the person wishes to achieve, why this is important to the person, what success would look like, a history of the risk and uses the ‘doughnut’ tool and decision making agreement tools to look at staff roles and responsibilities, and at who will be responsible for different important decisions in relation to the risk. â€Å"Positive and informed risk taking†: The process is built around a positive view of the person – it seeks to learn what the person’s gifts and skills are, what people like and admire about them, as well as investigating what would be necessary to keep them and others safe while taking the risk. The process is based on finding creative solutions rather than simply ruling things out. Bates and Silberman argue here that quality of life should be â€Å"maximised while people and communities are kept as safe as can be reasonably expected within a free society† (2007 p7). Thinking around what it would take to keep the person and others safe while taking the risk is a key part of the Positive and Productive Process, as is the use of the ‘Happy/Safe’ grid, which looks at how much solutions would make the person happy, by meeting what is important to them, and how much they would keep them and others safe, by meeting what is important for them. One section of the process includes a question â€Å"What does the law say?† (Allen et al 2008 p20) enabling the process to be informed by the current law, including legislation such as the Human Rights Act. â€Å"Proportionality†: â€Å"The management of the risk must match the gravity of potential harm† (ibid p8) Using the person centred thinking tools means flexibility. The more serious the issue, the more people and the more time can be spent considering it in greater detail. Unlike conventional risk assessment, the approach explores the consequences of NOT taking the risk, to the person, to their family, community and services, balancing these against the potential consequences of taking the risk. â€Å"Contextualising Behaviour†: â€Å"why did the person behave in this way? At this time? In this Situation?†(ibid p8) Part of the process involves gathering together previous information about the person, including a history of the person’s experience of the risk issue from their own perspective, as well as other historical data, gleaned from a variety of sources including learning logs which look at what has worked and what has not worked in particular situations, and communication charts which explore a person’s words and behaviours, seeking their meanings and considering what the best response to these messages should be. The ‘4+1 Questions’ (What have we tried? what have we learned? What are we pleased about? what are we concerned about?) help not only to gain an understanding of a person’s behaviour in different contexts, but also to build a picture of what has been learned about what is the best support for that person. â€Å"Defensible Decision Making†: â€Å"there is an explicit and justifiable rationale for the risk management decisions† (Ibid p8): Following the person centred approach generates a clear trail of written records of what has been discussed, the different perspectives, issues and solutions that have been considered, along with any legal issues, such as the human rights act or the mental health act that might affect the risk decision. The paperwork generated during the process provides a clear rationale for why the decisions that emerge during the process have been taken, and why other options have been rejected. The rationale for decision making is also more clearly expounded and recorded than in traditional risk assessment forms in common usage. â€Å"A Learning Culture† The positive and productive approach to risk has a deep emphasis within it on ongoing learning using learning and reflective tools like the learning log, the 4+1 Questions and What’s Working/What’s not working, and by clearly defining for staff their core duties and their zone of judgement and creativity in relation to the risk. If it is part of a serious and concerted attempt by services to change their philosophy and practice in a person centred direction, it can contribute significantly to building a learning culture within organisations. â€Å"Tolerable Risks† A key aspect of the Person Centred Approach is that it uses creative thinking techniques around methods to mitigate the risk and improve quality of life, moving from situations which make the person happy but unsafe, to where they and the community are safer, and from strategies where the person is ‘safe but unhappy’, to where they can be happier. Experience of using the process is that it enables participants to take a more balanced and rational approach to risk, finding ways to enable the person to achieve what is important to them while considering what keeps that person and the community safe in a way that makes sense for that individual.

KTG leader ship Essay

Introduction An environmental analysis in strategic management plays a very important  role in businesses by pinpointing current and potential opportunities or threats outside the company in its external environment. The external environment includes political, environmental, technological and sociological events or trends that can affect the business directly or indirectly. The main objective in this report is an environmental analysis using all the factors and analyzing tools , generally conducted as part of an analysis of strengths, weaknesses, opportunities, and threats (SWOT) when a strategic plan is being developed. Managers practicing strategic management must conduct an environmental analysis quarterly, semi-annually, or annually, depending on the nature of the business’s industry focusing on the followings: Analyzing factors effectiveness on our organization as one of the biggest group in the healthcare services in the region. Organization sources and competitors. Organization values chain construction. SWOT analysis evaluation. Ref: http://www.wisegeek.com/what-is-the-role-of-environmental-analysis-in-strategic-management.htm , 2014 3.ANALYSING FACTOR EFFECTIVENESS: 3.1 Macro Environment Analysis: One of the best tools for considering trends in the Macro environment is the PESTEL analysis. (Figure 1) Figure 1 3.1.1Political factors: Since we are located here in the UAE, we have no taxation and this is one of the strength point we are depend on. but at the same time our administration team not recognizing that the minimum wages should be increased comparing with the other facilities and hospitals in our region as a big competitors. 3.1.2Economic: Economic factors include economic growth, interest rates, exchange rates and the inflation rate. These factors have major impacts on how businesses operate and make decisions. For example, interest rates affect a firm’s cost of capital and therefore to what extent a business grows and expands. Exchange rates affect the costs of exporting goods and the supply and price of imported goods in an economy. And since our organization as privet health care facility, based on the profit rate it takes in the consideration all these factors especially after it involved in the stock market last year. Beside that the new plan is to minimize the expenses that related to the interest & exchange rate by following the centralization policy. ex. making one laboratory for all branches with a very controlled transportation system for sending the patients samples to the centralized laboratory instead of having a separate laboratory in each branch 3.1.3Social: Our organization as one of the privet hospitals in the region , is giving all the healthy activities, health care providing, never giving any changing as a demographic trends. We are doing outside activities supporting some certain people those who have a chronic disease like the diabetic patients to have more and more knowledge about themselves and how to take care about it. Ref(CBS course , topic 2 , page # 5) 3.1.4Technology: We are depending on the development of new technology to maintain competitiveness. Ex(opening new department of the Nuclear medicine for early Cancers diagnostics ) 3.1.5 Environment: factors include ecological and environmental aspects such as weather, climate, and climate change, which may especially affect industries such as tourism, farming, and insurance. Furthermore, growing awareness of the potential impacts of climate change is affecting how companies operate and the products they offer, both creating new markets and diminishing or destroying existing ones. Ref http://en.wikipedia.org/wiki/PEST_analysis According to our national regulations and environmental roles ,we are following the EHSMS(Emirates Health & Safety Management System). 3.1.6 Legal  include discrimination law, consumer law, antitrust law, employment law, and health and safety law. These factors can affect how a company operates, its costs, and the demand for its products. The services in the hospital is the same for all patients and the priority is only for the urgent and emergency cases only not according to the nationality, color or any other discrimination issues. And on the other side there is a special track for the VIP patients ,giving the best quality to be the first choice in the region as a privet hospital. 3.2 Micro Environment Analysis: One of the best tools for considering trends in the Micro environment is the porter analysis. (Figure 2) Figure 2 Porter five forces analysis is a framework for industry analysis and business strategy development. It draws upon industrial organization (IO) economics  to derive five forces that determine the competitive intensity and therefore attractiveness of a market. Attractiveness in this context refers to the overall industry profitability. An â€Å"unattractive† industry is one in which the combination of these five forces acts to drive down overall profitability. A very unattractive industry would be one approaching â€Å"pure competition†, in which available profits for all firms are driven to normal profit. This analysis is associated with its principal innovator Michael E. Three of Porter’s five forces refer to competition from external sources. The remainder are internal threats. 3.2.1 Threat of Substitute Products or Services: A substitute is a product that performs the same or similar function as another product. Microeconomics teaches that the more substitutes a product has, the demand for the product becomes more elastic. Elastic demand means increased consumer price sensitivity which equates to less certainty of profits. For example, public-transportation is a substitute for driving a car, and e-mail is a substitute for writing letters. Conditions that increase the threat of substitutes are: 1.2.1.1 An attractive price of substitutes: Our organization as a privet health care facilty depends on the insurance companies in how much they are fixing the prices of the services and products, but they are trying to do some marketing using special prices for the labors in some company by doing full checkup examination for those people who don’t covered by insurance. 1.2.1.2 Increased quality of substitutes: Our facility is trying to give the best quality to be the first choice in the region in the privet health care sector. Focusing more and more to follow the highest international standards like the JCIA (Joint Commission of international accreditation) ,CAP(Collage of American Pathologist) and the ISO ..Etc 1.2.1.3 Low switching costs to consumers: our Administration is not switching the cost to the consumers since they are covered by health insurance. But sometimes they are switching the costs to the staff by minimizing the staff without enough study to the work load or stopping the annual increments. 3.2.2 . Threat of Entry: Profitable markets that yield high returns will attract new firms. This results in many new entrants, which eventually will decrease profitability for all firms in the industry. Unless the entry of new firms can be blocked by incumbents (which in business refers to the largest company in a certain industry, for instance, in telecommunications, the traditional phone company, typically called the â€Å"incumbent operator†), the abnormal profit rate will trend towards zero (perfect competition). The following factors can have an effect on how much of a threat new entrants may pose: The existence of barriers to entry (patents, rights, etc.). The most attractive segment is one in which entry barriers are high and exit barriers are low. Few new firms can enter and non-performing firms can exit easily. Government policy Capital requirements Absolute cost Cost disadvantages independent of size Economies of scale Economies of product differences Product differentiation Brand equity Switching costs or sunk costs Expected retaliation Access to distribution Customer loyalty to established brands Industry profitability (the more profitable the industry the more attractive it will be to new competitors) Rivalry Between Established competitors: Rivalry refers to the degree to which firms respond to competitive moves of the other firms in the industry. Rivalry among existing firms may manifest  itself in a number of ways- price competition, new products, increased levels of customer service, warranties and guarantees, advertising, better networks of wholesale distributors, and so on. The degree of rivalry in and industry is a function of a number of interacting structural features: Rivalry tends to intensify as the number of competitors increases and as they firms become more equal in size and capability. Market rivalry is usually stronger when demand for the product is growing slowly. Competition is more intense when rival firms are tempted to use price cuts or other marketing tactics to boost unit volume. Rivalry is stronger when the costs incurred by customers to switch their purchases from one brand to another are low. Market rivalry increases in proportion to the size of the payoff from a successful strategic move. Market rivalry tends to be more vigorous when it costs more to get out of a business than to stay in and compete. Rivalry becomes more volatile and unpredictable the more diverse competitors are in terms of their strategies, their personalities, their corporate priorities, their resources, and their countries of origin. Rivalry increases when strong companies outside the industry acquire weak firms in the industry and lunch aggressive, well-funded moves to transform their newly-acquired firms into major market contenders. Two principles of competitive rivalry are particularly important: (1) a powerful competitive strategy used by one company intensifies competitive pressures on the other companies, and (2) the manner in which rivals employ various competitive weapons to try to outmaneuver one another shapes â€Å"the rules of competition† in the industry and determines the requirements for competitive success. Since our hospital is the biggest hospital in the area, it depends in the competition on increasing the branches in all areas inside and outside the city for more than 8 branches directed by the corporate office in the Capital. 3.2.4 Bargaining Power of Customers: 3.2.4.1 Markets for Outputs: Selling goods or services to customers (distributors, customers or other manufacturers) Customers’ influence dependent upon importance of products to them & their bargaining power We have a marketing team of 4 members working under the supervision of the corporate office , handling all the outputs issues like : the chronic patients disease health care activates offering free of charge checkup (ex. diabetic patients..) 3.2.4.2 Markets for Inputs: Purchasing raw materials, components and financial & labor services. The same team also cooperating with the purchasing department together working to get the best quality materials for the lowest prices in order to minimize the costs. And that will allow the hospital to give more best services more than the other competitors. 3.2.5 Bargaining Power of Suppliers: The power balance between organization and supplier is similar to the relationship between organization and customer The organization becomes the customer and the producer of the inputs it requires are the suppliers Some small groups of suppliers may form cartels or cooperatives to increase their bargaining strength Suppliers use leverage such as threats to raise prices or reduce quantity or quality of goods they supply We are depending on the process comparison in the market and to services the suppliers will provide to us. In the opposite side, we are a customer for the suppliers and since we are the biggest customer in the privet sector we can manage the deal according to our needs. 3.3 Formulating: Formulating is phase one in the strategic planning process and according to  the diagram below We can see that it plays a very important in taking the best decisions and actions to achieve the objective of the organization. In our hospital there are many plans in how to make all these decisions become a real. At the beginning of each new year , we are making our plan projects for the next 12 months And everyone have to achieve his planed objectives as individual under the umbrella of the administration and corporate office objectives. And at the end of the year will have an assessment to check how many objectives he reached , according to his work assessment will get his increment , so that will let him work harder during the year to achieve the organization objectives. Figure 3 Ref(CBS course , topic 1 , page #12). 3.3.1 Organization sources and competitors : Our hospital sources is strong enough to be a strong competitor in the market depending on: Best medical companies as materials providers.  Best marketing plans based on the corporate marketing plans. Patients (as a customers ): Accepting all the insurance cards at the time that some other hospitals don’t accepting all patients. 3.3.2 Organization value chain construction Value chain is a template that identifies the activities of a company from raw materials to customer, the value added by each activity and the cost of each activity, and that facilitates implementation of business-level strategy . Ref ( CBS Strategic Management Topic 3 Page#6) The axiom is true that you never get a second chance to make a good first impression, and hospitals have many opportunities to do so. Or not. At several junctures along the trek of accessing services, the patient confronts a series of opportunities to continue in the system or not, based on the success of the interaction. These touchpoints are not created equal, and it is important to know which has the greatest impact. Here, we can focus the Service Line Growth strategy. As a tool to understand the impact  of each touchpoint, value-chain service analysis maps the process to help us decide where to focus strategic intent. Hospital business planning adapts a model developed by Michael Porter, who defines the value chain as a means to analyze an organization’s strategically relevant activities to understand how to influence performance and cost. He breaks the activities of the firm into primary and support activities. Primary activities—which, for most firms involves inbound and outbound logistics, operations, sales and marketing—are supported by an infrastructure of underlying support activities, including HR, IT, and purchasing. How the product or service is ultimately developed and delivered to the customer depends on the effective interaction of these variable activities. The hospital value chain is diverse and complex. Our service offerings are far from clear cut, varying sharply between service lines. Each specialty and disease category has a distinct value chain to be flowcharted and analyzed prior to understanding where we can impact choice by creating value. In most cases this is at the physician referral point where patients make initial decisions. This may be a primary care physician or a specialty care physician who is directly involved in managing the hospital encounter. In most cases, it is the loyalty of the physicians and their attitude towards the hospital that determines the direction of the process. This analysis is a good tool for getting stakeholders on the same page. It helps focus planning efforts and gets to the key issue of where to go and what to do. This leads us to the question—what business are we in, and where do we strategically want to focus our efforts, which is the essence of strategy. Figure 4 4.1 Strengths (Internal Factors) The hospital key strengths are the following: Long Standing Reputation – was the previous monopoly Company in the industry Government Affiliated – trusted in the Market Most skilled employees in the industry – generated good client relations 4.2 Weaknesses (Internal Factors) The main functional areas of weakness are the following: Production Costs – in comparison to competitors Profit Margins – in comparison to competitors Service Delivery – poor operational functions Loss of Contracts – lack of continual Contract retention Company Culture – disconnected, divided, tall organisation structure HR Policies & Procedures – poor employee retention, lack of career development, low morale Lack of MIS – no common management information systems in place across functions. Brand Identity/Image – lack of Marketing department Conclusion: The main objective is the consideration of the external and internal analyzing factors, using all the analyzing tools and studies like: PORTER, SWOT and all other analyzing international methods. This report explained clearly the essential required methods for analyzing using the practical example of my organization (Privet Hospital), how to make the competitive advantages and how to use all the efforts to get the best analyzing results. After the analyzing how can we use our strength points to be the first choice in the market and how to correct the weakness points to avoid any problem in the future. In the light of the above there are essential factors which might be affecting in any organization , so we have to cover all the points that I mentioned about it before like : Analyzing factors effectiveness on our organization as one of the biggest group in the healthcare services in the region. Organization sources and competitors. Organization values chain construction. SWOT analysis evaluation. 6. References http://www.wisegeek.com/what-is-the-role-of-environmental-analysis-in-strategic-management.htm , 2014 (http://en.wikipedia.org/wiki/PEST_analysis) , 2014 CBS course , topic 2 , page # 5 , 2014 http://en.wikipedia.org/wiki/PEST_analysis , 2014 http://www.oshad.ae/en/sectors/healthsector/Pages/ehsmsrequirements.aspx, 2014 http://www.dineshbakshi.com/igcse-business-studies/external-environment/revision-notes/63-external-environment-factors, 2014 http://en.wikipedia.org/wiki/Porter_five_forces_analysis ,7 March 2014) http://en.wikipedia.org/wiki/Porter_five_forces_analysis#Threat_of_new_entrants, 2014 http://www.strategy-formulation.24xls.com/en114 CBS course , topic 2 , page #17 , 2014 CBS course , topic 2 , page #20 , 2014 CBS course , topic 1 , page #12 , 2014 CBS Strategic Management Topic 3 Page#6 , 2014 http://healthcarestrategicadvantage.blogspot.ae/2007/11/value-chain-analysis.html , 2014 Strategic Management Unit 306 (CBS) , 2014