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Delayed brainstem auditory evoked potential latencies in 14-year-old children exposed to treatment bulging disc purchase antivert 25 mg fast delivery methylmercury. Blood organic mercury and dietary mercury intake: National Health and Nutrition Examination Survey, 1999 and 2000. A possible resolution of clinical and epidemiological perspectives on neurobehavioral toxicity. Androgens and environmental antiandrogens affect reproductive development and play behavior in the SpragueDawley rat. Effects of perinatal exposure to bisphenol A on play behavior of female and male juvenile rats. There are clearly some common factors across various species, but those discussed here represent only a small number of the species about which we are concerned. We are almost invariably exposed to multiple species of molds when we are dealing with indoor environments. When we listen to what patients tell us about their symptoms and signs, and we look at their laboratory reports, we get a composite picture of the impact of the multiple toxins associated with different species of molds. Some of the common features are that hyphae and spores are involved, and most of these organisms are multi-nucleated. Spore production is dependent on a number of environmental variables: light, oxygen levels, temperature, nutrient availability, and moisture. Typical molds, particularly the so-called filamentous molds or terrestrial molds, grow through a series of phases where they form hyphae. Yeasts and several other organisms and fungi will do this when there are multiple spores just along the hyphael structure. Germination requires specific environmental factors to exist-availability of nutrients, oxygen, and moisture levels. There have been some experiments that grew spores from sedimentary rock shaved over a petri dish. Hyphae have a function in the life of these organisms, other than just being a place to produce spores: they engage in exodigestion. This all happens outside of the organism, unlike the process in the eukaryotic cells that most animals-including humans-are made of, which digest nutrients by bringing them into the cell interior through phagocytosis, marrying them with a packet of enzymes in the lysosome, and then digesting them there. In the desert environment, for example, that means only the most tenacious molds have survived. Within a matter of 24 to 36 hours, they can come to life, develop a colony, and then, as it gets very dry, desiccate. We usually associate molds with damp environments, but they are also ever present in the desert. In fact, they are ever present in the air because, whenever the wind kicks up, the dust in the soils and in the environment contains fragments of spores and of colonies that have broken apart. Although we are often told that we can clean moldy environments by using bleach, problems arise from chlorinating the toxins we are trying to get rid of. You can easily get rid of the growing organism, but getting rid of the spore can be very problematic. Prior to 1999 and early 2000, we all pretty much assumed and were taught that sinusitis had perhaps a 6% to 7% involvement of fungi. It turns out that work done by Ponikau and Sherris3, 4 at the Mayo Clinic has changed that estimate dramatically. In addition to linking fungi to rhinitis, we know that they are significantly associated with asthma. At Mayo, 250 consecutive patients were evaluated after presenting to their ear, nose, and throat clinic with diagnoses of rhinitis and rhinosinusitis. They were able to culture specimens using rhinoscopic techniques and found that 95% of those patients grew mold, or fungus, as the primary organism. When they looked at the distribution of the bacterial flora in the cultures, it was similar to that seen in the general population, significantly identifying the fungi and molds. Their work has been replicated several times, 5, 6 with multiple species found in each individual. S 146 Managing Biotransformation: the Metabolic, Genomic, and Detoxification Balance Points Gray Sherris worked a little bit further on the ultra-structure and the histology. Because fungi and molds attract eosinophils, these infections set the stage for the development of allergic fungal rhinitis.
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Clichйs area easy ways to symptoms influenza order 25mg antivert communicate your message, but you might pay for that ease with negative feelings about you as a speaker from your audience. Try to avoid using clichйs so that audiences are more likely to perceive you positively as a speaker. Another consideration for speakers is whether or not to use language central to the popular culture of a time period. Like slang or profanity, language stemming from popular culture can be limited in its appeal. Some audiences may not understand it, some audiences may negatively evaluate you for using language that is too informal, and other audiences will have negative preconceived notions about "the kind of people" that use such language. It is important for speakers to remember the power of language and to harness that power effectively, yet ethically. The difference between choosing one word over another can be as significant as an audience member remembering your presentation or forgetting it and/or an audience turning against you and your ideas. Taking a few extra moments to add some alliteration or to check for language that might offend others is time very well spent. The next time you have to write or speak about an issue, remember the importance of language and its impact on our lives- carefully consider what language will you use and how will those language choices make a difference in how your audiences defines and understands your topic. This chapter has discussed a number of important aspects of language that good speakers should always consider. Explain the relationship between language and the way that humans perceive their worlds. The use of concrete and precise language in your speeches helps prevent what sorts of problems? Give an example of a metaphor and explain how that metaphor functions to communicate a specific idea more clearly. What are some examples of types of sexist language and what is the impact of those examples? What are two problems associated with using exaggerated language in your speeches? Consider the sexist words and phrases listed below and think of as many replacement words as you can. Kennedy and isolate one paragraph that you believe exemplifies a careful and effective use of language. Rewrite that paragraph as I did for my classes, using more common and less careful word choices. Look at these common clichйs, reworded using language that obstructs rather than clarifies, and see if you can figure out which clichйs have been rewritten. A utensil often used for writing is more prodigious than a certain long-edged weapon. Antithesis Rhetorical strategy that uses contrasting statements in order to make a rhetorical point. Clichйs Phrases or expressions that, because of overuse, have lost their rhetorical power. Colloquialisms Words or phrases used in informal speech but not typically used in formal speech. Communication Attempts to reproduce what is in our minds in the minds of our audience. Generic "he" or "man" Language that uses words such as "he" or "mankind" to refer to the male and female population. Hedges Powerless phrases such as "I thought we should, " "I sort of think, " or "Maybe we should" that communicate uncertainty. Heterosexist Language Language that assumes the heterosexual orientation of a person or group of people. Language the means by which we communicate-a system of symbols we use to form messages.
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Reviews and confirms treatment decisions symptoms hypothyroidism purchase 25mg antivert free shipping, including potential transitions in care settings, and documents patient wishes and preferences d. Provides information and support to the family and others who are providing care to the patient 7. The care plan addresses the focus on end-of-life care and treatments to meet the physical, emotional, social, and spiritual needs of patients and families. Cultural and spiritual preferences of the patient and family are particularly relevant when developing this plan. Reassessment and revision of the plan occurs regularly, with the frequency identified in agency or program policies. Care of the patient at the end of life is time- and detail intensive, requiring expert clinical, psychological, social, and spiritual attention to the process as it evolves. Post-death care is delivered in a manner that honors patient and family cultural and spiritual beliefs, values, and practices. Clinical Practice Guidelines for Quality Palliative Care, 4th edition 47 Domain 7 a. Post-death care is in accordance with agency practice, local laws, and state regulations. Information and educational resources regarding grief, including the potential physical manifestations of grief c. Rituals that acknowledge loss and transition, provide opportunity for remembrance, and establish a sense of community 7. Grief and bereavement support and interventions are in accordance with developmental, cultural, and spiritual needs and the expectations and preferences of the family. Grieving children are referred to pediatric grief specialists, programs, and camps based on their age and needs. Emotional support services are also made available to ancillary team members involved in supporting palliative care patients. Operational Implications Caring for patients nearing the end of life may take place in any setting (eg, hospital, nursing home, assisted living facility, hospice inpatient facility, or at home). Decisions regarding preference and need for transitions in care settings may be required. Attention to patient comfort and wishes, as well as support to family members during the dying process are paramount operational concerns. Care near the end of life is often more intense than care earlier in the disease process, requiring increased visit length and frequency, as well as timely telephone response, to adequately care for patients and their families. Essential Palliative Care Skills Needed by All Clinicians Clinicians in all care settings who learn the hospice eligibility criteria can make timely referrals to hospice. In addition, clinicians can improve patient care by learning how to assess and manage physical symptoms common among patients nearing the end of life. All clinicians must have the knowledge and skills to talk to patients and families about dying. The evidence tables in the systematic review describe the key findings of each included review. The perinatal and neonatology teams provide training for all staff in palliative care, and a team of prenatal/neonatal clinicians, including social work, physicians, nurses, child life, and chaplaincy, have become the leaders for this care. This team has developed protocols for symptom management, and converted a hospital room dedicated to imminently dying infants to provide privacy and support. Practice Example D7-B A large renal dialysis group has several dialysis centers located in urban and rural settings. They identify that few of their patients are referred to hospice, and most are dying in acute care settings (often in intensive care). They receive complaints from families who felt ill-prepared for the sudden death of their loved one. The dialysis centers begin with palliative care education for all staff, and establish a collaborative relationship with an area hospice to develop educational materials and resources for staff regarding hospice eligibility. The social workers in the dialysis centers take the lead in implementing a systematic approach to advance care planning for all dialysis patients, often facilitating family meetings. This advance care planning initiative identifies the need for more family- and caregiver support, such as educational materials and support groups for family members while patients are receiving dialysis. The dialysis centers in several locations work closely with area hospice programs to ensure that transitions of care are optimized for patients who have decided to stop dialysis.
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Andrew Lester; was a soldier under Lothrop and fell; at Thome the Bloody brook treatment for shingles discount antivert 25 mg visa, 18 Sept. He was, in 1692, one of the is and wretch, witness, against Philip English, charg. He was 14 Harwich), came with him, and was of the first ten one of the earliest selectmen of the town, at the first gen. The name 1707; Judith, 1708; Joanna, 1710; and Benjamin, 26 May of his youngest s. I think, youngest of Middleborough 1692, was one of the found, of the Edmund, rem. Patience; Agnes, 1661; Martha; John, 1663; Hope- still, 1672; and Zaccheus; beside John, again, 1676, b. Mary left Samuel, ; Edward, Rebecca, Mary, Ellen, and Dorothy, all of full age, exc. Hannah, he had Mary, again Hannah Joseph Ebenezer Roger, 18;;;; and Zipporah, 21 May 1662, d. Blachley and Blackley, sometimes represent this name, New Haven latter his especially the latter, wh. There he had preach, and with much effect, if it be true, as is said, that many wh. Plymouth in 1 640, pursued his pleas ure in cross, to the opposite side of the bay coming under ano. Felt adds, that he was of Newport 1649, then aged 58, and he is seen in the list of freem. Richard, 11, came, to join him, in the Francis, from Ips His wich, 1634, and this renders it prob. May 1666, Isaac Warner of Hatfield, and next, in John Loomis of Windsor; Lydia, wh. Mary, John, Deliverance, James, Isaac, Sarah, Ebenezer, Thomas, Martha, Hannah, and Orlando, and had three wh. Grievous is our feeling of regret at find, the Court, in June 1638, led to forbid the w. We may therefore doubt, that here must be error in that very correct work, as we kn. Perry, by me would be regard, so strange a name as almost to invite invasion of conject. In read, the name, not one in a thousand experts would be likely to differ from us, as John appears in the reverse pro Yet from the unusual distinctness of the Roxbury ch. Mather was not, I think, present to witness this triumph over the devil in the enforc. He was at Exeter 1643 and 5, short time at Hampton, but of Kittery 1647-53, went back;;;;; to the neighb. Ulalia names for Jonathan David;; first, first, 1643, Judah Gregory, and, next, Henry 1644, Francis Ball; next, 1649, Benja min Mun, and bore him five ch. Once or twice since there have been partial outcries against witchcraft, but for more than a century no influence has been exert, to renew crimin. Cols, in the Royal chart, where this name is insert, and after that union 1665 and 6, then rem. Marmaduke Matthews of Yarmouth, may have sett, at Barnstable, where long the name prevail, and spread thence in the last century, to Gorham, Me. Elizabeth 1635, from London, aged 20, a ship-carpenter of Southwark in there, 23 Willis, Surry, close to London, and sat down, first, at Duxbury, Nov. John, William, Samuel, Jeremiah, Joseph, Sarah, and Rebecca but little can be learn, as to any of the s. Kent, it Scituate, is said, came from London in the Increase, 1635, aged 51, with w.
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The reuse utility may be a separate agency that simply takes wastewater treated to medications elavil side effects cheap antivert 25 mg overnight delivery discharge standards and provides the necessary extra level of treatment to produce reclaimed water. Situations can also be found where treatment costs are split and any responsibility borne by the water utility could be included in the reuse connection fees. Each situation is unique, and various costs must be identified to be sure a nexus exists between the cost and the ultimate service being provided to end users. The amount of the potable water connection fees must be considered when setting the reuse connection fees. If the reuse connection fee is higher than the potable water connection fee, there will be less incentive for a user to choose reclaimed water over potable water, unless the reclaimed water is priced at a discount to potable water. Thus, while it may be possible to justify higher reuse fees, practical considerations may dictate that such fees are set below cost. Where new development occurs on sizeable tracts of open land, requiring the installation of a reuse system is an efficient method to provide for facilities to deliver reclaimed water. Examples exist in the southwest where reclaimed water systems were installed years prior to reclaimed water becoming available. Typically, such systems are designed to serve irrigation demands for the common areas of the new development, such as median strips, green belts, and 7-12 2012 Guidelines for Water Reuse Chapter 7 Funding Water Reuse Systems An excellent case study example of a city successfully expanding its reclaimed water system by managing customer concerns about connection fees is the city of Pompano Beach, Fla. Economic Feasibility of Reclaimed Water Use by Non-Utility Water Use Permittees and Applicants, Final Report, prepared for the Southwest Florida Water Management District, Brooksville, Florida, June 2010. In addition to building community support for a reuse program, public participation can also provide valuable community-specific information to reuse planners. Community residents may have legitimate concerns that quite often reflect their knowledge of detailed technical information. In reuse planning, especially, where one sector of the public comprises potential users of reclaimed water, this point is critical. Public outreach, participation, and consultation programs work to identify and engage key stakeholder audiences on planned projects that directly impact the population. Generally, effective public participation programs invite two-way communication, provide education, and ask for meaningful input as the reuse program is developed and refined. Depending on the project, public involvement can involve a range of types and levels of outreach, participation, and consultation. Others take an expanded approach to include formation of a formal advisory committee or an extensive campaign with multiple methods of public engagement. Regulatory agencies often require some level of public involvement in water management decisions, and stakeholders are increasingly vocal about being involved in those decisions. This is strikingly different from the past when members of the public were often informed about projects only after final decisions had been made. Today, responsible leaders recognize the need to inform and consult with the public to obtain their values and advice about science, technology, and legal aspects. Advancing the understanding of water issues can facilitate real, workable, and implementable solutions tailored to meet specific needs. Public information efforts often begin by targeting the most impacted stakeholders. Over time, as an early education base is built among stakeholders, the education effort then broadens to include the public at large. Regardless of the audience, all public involvement efforts are geared to help ensure that adoption of a selected water reuse program will communicate benefits and fulfill real user needs and generally recognized community goals, including public health, safety, and program cost. Proactive education and involvement programs that put water reuse into perspective and promote shared decision-making help to ensure that public understanding develops. A study conducted by San Diego County Water Authority demonstrates a shift in public opinion about reuse in the community between 2004 and 2011 (Figure 8-1). The percentage of respondents who "strongly oppose" using advanced treated recycled water as an addition to drinking water supply dropped from 45 percent in 2004 to 11 percent in 2011 (San Diego County Water Authority, n. In the past, dialogue has focused on risks and the associated mitigating technologies rather than beginning from a collaborative problem-solving standpoint. The report concludes that, "Although a compelling value may be created with products or services, the customer or audience must perceive that benefit. When a meaningful problem is solved, the perception will likely be that the state of affairs has improved. Other key benefits that were found to be strong motivators were "positive impact on wetland, streams, and wildlife habitat;" and "irrigating crops without wasting water. Equally important is discussion of the benefits: What will the community and the individuals that comprise it gain from each of the solutions?
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Acquisition and maintenance of monopsony power are still recognized harms under the Sherman and Clayton Acts symptoms 1974 buy discount antivert 25mg on-line, even though few cases are brought today. Cross-subsidization schemes can have widely different effects, depending on how the two submarkets are or are not interrelated. Under the predatory pricing jurisprudence of the early and mid-twentieth century, harm to the diversity and vibrancy of ideas in the book market may have been a primary basis for government intervention. For instance, the risk that Amazon may retaliate against books that it disfavors- either to impose greater pressure on publishers or for other political reasons- raises concerns about media freedom. A market with less choice and diversity for readers amounts to a form of consumer injury. By contrast, the cross-subsidization model used by publishers has no analogous crossover effects. A publisher might decide to publish an obscure book, even if it knows it will lose money, and subsidize those losses through profits made on a more popular book. The market effects across its different segments are significant in ways that do not hold for brick-and-mortar stores or other non-platform entities. First, Amazon is positioned to recoup its losses by raising prices on less popular or obscure e-books, or by raising prices on print books. In either case, Amazon would be recouping outside the original market where it sustained losses (bestseller e-books), so courts are unlikely to look for or consider these scenarios. Additionally, constant fluctuations in prices and the ability to price discriminate enable Amazon to raise prices with little chance of detection. Lastly, Amazon could recoup its losses by extracting more from publishers, who are dependent on its platform to market both e-books and print books. This may diminish the quality and breadth of the works that are published, but since this is most directly a supplier-side rather than buyerside harm, it is less likely that a modern court would consider it closely. Acquisition of Quidsi and Flawed Assumptions About Entry and Exit Barriers In addition to using below-cost pricing to establish a dominant position in e-books, Amazon has also used this practice to put pressure on and ultimately acquire a chief rival. While theory may predict that entry barriers for online retail are low, this account shows that in practice significant investment is needed to establish a successful platform that will attract traffic. Stone, supra note 297 (noting that Amazon offered $540 million, giving Quidsi a fortyeight-hour window in which to respond and "rachet[ing] up the pressure, " telling Quidsi 296. Amazon achieved this by slashing prices and bleeding money, 306 losses that its investors have given it a free pass to incur-and that a smaller and newer venture like Quidsi, by contrast, could not maintain. After completing its buy-up of a key rival-and seemingly losing hundreds of millions of dollars in the process-Amazon went on to raise prices. In November 2011, a year after buying out Quidsi, Amazon shut down new memberships in its Amazon Mom program. As of February 2012, discounts that had previously been 30% were reduced to 20%, and the one year of free Prime membership was cut to three months. In the Antitrust Paradox, Bork wrote, "[T]he modern law of horizontal mergers makes it all but impossible for the predator to bring the war to an end by purchasing his victim. For instance, "[r]ailroading, which involves specialized facilities, is difficult to enter, but the potential victim of predation would be difficult to drive out precisely because railroad facilities are not useful in other industries. Given the absence of formal barriers, entry should be easy: unlike railroading, selling baby products online requires no heavy investment or fixed costs. However, the economics of online retailing are not quite like traditional shoe retailing. Given that attracting traffic and generating sales as an independent online retailer involves steep search costs, the vast majority of online commerce is conducted on platforms, central marketplaces that connect buyers and sellers. As several commentators have observed, the practical barriers to successful and sustained entry as an online platform are very high, given the huge first-mover advantages stemming from data collection and network effects. Investment in online platforms lies not in physical infrastructure that might be repurposed, but in intangibles like brand recognition. These intangibles can be absorbed by a rival platform or retailer with greater ease than a railroad could take over a competing line. Courts also tend to discount that predators can use psychological intimidation to keep out the competition.
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An appreciation of the energy require ments necessary were the kinetic energy of these atmospheric subsys tems to medicine misuse definition purchase antivert 25mg without prescription be changed by 10 percent can be obtained from the next table. The column on the right lists the time 35 demand on the total electrical energy generating system of the United States if that source were to be drawn upon to change the kinetic energy of the atmospheric subsystem by ten percent. Atmospheric Subsystem Approx ima the * Time Tornado 30 seconds 5 minutes Small thunderstorm Large thunderstorm several hours several days Hurricane 5-6 weeks Extratropical cyclone General circulation in the 6 years Northern Hemisphere * Data for the tornado funnel and thunder storms refer to a total lifetime of kinetic energy. Data for the other phenomena refer to kinetic energy at any given moment during maturity-which may be considerably less than the lifetime expenditure. One concludes that it is not immedi ately practicable to think of altering these atmospheric subsystems to this extent by a direct application of energy. For example, the additional latent heat released by an increase of 10 per cent in a rainfall totaling one inch over an area one hundred miles on a side would be the equivalent of about six days of the daily output of the electrical generating capacity of the United States. On the other hand, as 36 will be seen presently, there exists some evidence that increases in rain fall of this order may be obtained by seeding. It is appropriate, then, to con sider the question of possible insta bilities in the atmosphere. From simple observations of the life cycle of cumulus clouds, thunder storms, tornadoes, hurricanes, and extratropical cyclones, it is evident that-within certain limits-the atmos phere is unstable, that is, the ampli tude of disturbance increases with time over a period of time which varies with the size of the disturbance. Moreover, significant energy transfor mations are involved in the amplitude growth associated with these releases of energy initially in unstable form. The phase instability of water in the vapor phase in a condi tion of supersaturation and in the liquid phase in the condi tion of supercooling which, when released, provides a local source of sensible heat. The colloidal instability of cloud particles which when released by precipitation, com pletes the cycle by which latent heat is exchanged between the underlying surface and the atmosphere. The convective instability of the atmosphere which, when released, redistributes sensible energy in the vertical and often produces high local concentra tions of kinetic and electrical energy. The baroclinic instability of the large scale circulation which, when released, redis tribute sensible and kinetic energy in the horizontal plane, i. The difficulties of treating quantitatively the non-linear processes inherent in instabilities are sobering. Some offset is provided, however, by the indica tions that energy can progress upward through the several scales of exchange. All of this has been observed, on a very small scale, in the seeding of stratocumulus clouds. It is not hard to imagine that induced convection or induced snowfall on a much larger scale could sufficiently alter the horizontal temperature distribution to trigger or subdue baroclinic instability, changing the natural development of large cyclonic storms. This, in turn, might alter the global radi ation balance and thus influ ence a fifth scale of instability 37 about which we can only con jecture: the possible instability of global climate. The great variability of an cient climates is accepted as fact, yet the cause of climatic change is far from being a set tled issue. It is obvious that the earth-atmosphere system can support radically different cli matic regimes, some of which could be disastrous to civiliza tion. We do not yet know what can cause a shift from one climatic regime to another, whether change can occur in an "instant" of geologic time or only as a secular, cyclic proc ess; our few theories still hang on the most tenuous of evi dence. This, in barest outline, is the nature of the problem and some of its impli cations. It is appropriate now to turn to some advances in recent years that suggest the present moment to be a propitious one to accelerate and strengthen the systematic exploration of the question. Some aspects of weather and climate modification are ready for practical applications, others are sufficiently promising to warrant programs of mission-oriented or applied research, still others are more remote possibili ties for which no more than basic re search can be justified at the present time. Furthest advanced is the prob lem of dissipation of supercooled fog and stratus clouds by seeding, which has reached the stage of engineering applications for clearing of fog at air ports. Experiments done here and abroad on cloud seeding for local in crease of precipitation and for sup pression of hail and of lightning, while far from conclusive, have shown some promise of success. Vigorous pro grams of applied research should be pursued in these areas to delineate the potential and to optimize the proce dures used. Such a research program, although difficult and expen sive, can be justified for aid in longrange forecasting and for making pos sible predictions of consequences of inadvertent changes in the atmos phere caused by activities of man. The possibility that such a program will in the future suggest methods for bene ficial modification of climate is added incentive for undertaking it.
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Brother c a n you or have you been rendered deaf by the constant bombardment of the static noise packaged as music? Have you conditioned your spirit to medicine for high blood pressure discount 25 mg antivert mastercard receive the hard bass line which is fol lowed by words with genocidal intent? Brothers can you hear the cries of the or phaned Black babies whose parents were killed by Black hands. Brothers can you hear the dying gasp of dreams being smothered by foreign Ambitions? The purpose of ridding the state of prisons is to weaken it so destruction is more easily accomplished. When a state is founded on white supremacy and its policies and logic reflect this hundreds of years later, reform is inadequate as an ends in itself. I know the abolition of prisons in this country will not happen, at least in my lifetime. The views presented in this report are those of the Institute of Medicine Committee on the Quality of Health Care in America and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Crossing the quality chasm: a new health system for the 21st century / Committee on Quality Health Care in America, Institute of Medicine. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. Crossing the Quality Chasm: A New Health System for the 21st Century "Knowing is not enough; we must apply. Crossing the Quality Chasm: A New Health System for the 21st Century National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council the National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. Appointed by the National Research Council and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Crossing the Quality Chasm: A New Health System for the 21st Century Preface this is the second and final report of the Committee on the Quality of Health Care in America, which was appointed in 1998 to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. This second report focuses more broadly on how the health care delivery system can be designed to innovate and improve care. This report does not recommend specific organizational approaches to achieve the aims set forth. Rather than being an organizational construct, redesign refers to a new perspective on the purpose and aims of the health care system, how patients and their clinicians should relate, and how care processes can be designed to optimize responsiveness to patient needs. The principles and guidance for redesign that are offered in this report represent fundamental changes in the way the system meets the needs of the people it serves. Redesign is not aimed only at the health care organizations and professionals that comprise the delivery system. Change is also required in the structures and processes of the environment in which those organizations and professionals function. Such change includes setting national priorities for improvement, creating better methods for disseminating and applying knowledge to practice, fostering the use of information technology in clinical care, creating payment policies that encourage innovation and reward improvement in performance, and enhancing educational programs to strengthen the health care workforce. The Quality of Health Care in America project is supported largely by the income from an endowment established within the Institute of Medicine by the ix Copyright National Academy of Sciences. Generous support was provided by the Commonwealth Fund for a workshop on applying information technology to improve the quality of clinical care, by the Health Care Financing Administration for a workshop aimed at exploring the relationship between payment policy and quality improvement, by the Robert Wood Johnson Foundation for a survey of exemplary systems of care, by the California Health Care Foundation for a workshop to explore methods for communicating with the public about quality in health care, and by the Agency for Healthcare Research and Quality for a workshop on the relationship between patient outcomes and provider volume. Although the committee takes full responsibility for the content of this report, many people have made important contributions. The Subcommittee on Designing the Health System of the 21st Century, under the direction of Donald Berwick, combined a depth of knowledge and creativity to propose a vision on how health care could be delivered in the 21st century. The Subcommittee on Creating an External Environment for Quality, under the direction of J. Cris Bisgard and Molly Joel Coye, provided expert guidance and a wealth of experience on how the external environment could support improved delivery of care. Technological advances make it possible to accomplish things today that were impossible only a few years ago.