Business Process Reengineering

Describe each of the four kinds of organizational change that can be promoted with information technology. What is business process reengineering? What steps are required to make it effective? How does it differ from business process management? Explain with example. In an organization, there are major risks and uncertainties in systems development that need to be addressed by the management. Determining when new systems and business processes can have the greatest impact is involved in these challenges.This may be the reasons why organizational change and development is becoming a common scenario to talk about involving management, organizations, business, and leadership. With the fast-changing environment, business conditions bring consequences in management both in inner and outer factors. That is why in most cases, most of the managerial activities revolve around decision – making. Knowledge plays a major role in organizational development.Organizational changes are also u sually described, including management and employee training requirements, recruiting efforts, changes in business processes and changes in authority, structure or management practices. Information technology can promote various degrees of organizational change, ranging from incremental to far-reaching. There are actually four types of organizational change enabled by information technology: automation, rationalization, reengineering, and paradigm shifts. [pic] This figure shows the four degrees of organizational change.Automation is the easiest and the most common form of change. Being the most common form of IT-enabled change, the using of computer to speed up the performance of existing tasks is an example of automation. This involves assisting employees perform their tasks more efficiently and effectively. AUTOMATION Automation is the use of control systems and information technologies to reduce the need for human work in the production of goods and services. In the scope of ind ustrialization, automation is a step beyond mechanization.Although automation speeds up performance of tasks, it does not guarantee a very high effectivity in business success. It is just the same as repeating the old manual way of disorders but in a faster way. However, this type of change, although common, is slow – moving, thus producing slow returns. Organizations using automation produce the same products and services as before but changes the way the organization functions. Example of automation in business are calculating paychecks and payroll registers, automated checkout and inventory system employed by many supermarkets. nd giving bank tellers instant access to customers deposit records. RATIONALIZATION Rationalization of procedures causes the organization to examine its standard operating procedures, eliminate those no longer needed, and make the organization more efficient. It is the streamlining of existing operating procedures, eliminating obvious bottlenecks so that automation makes operating procedures more efficient. Rationalization follows quickly from automation. Both types of change cause some disruption, but it's usually manageable and relatively accepted by the people.BUSINESS PROCESS REENGINEERING A more powerful type of organizational change is business process reengineering, in which business processes are analyzed, simplified and redesigned. Using information technology, organizations can rethink and streamline their business processes to improve speed, service and quality. Business reengineering reorganizes work flows, combining steps to cut waste and eliminating repetitive, paper intensive tasks. It is usually much more ambitious than rationalization of procedures, requiring a new vision of how the process is to be organized.Business process reengineering in simpler words is Radical redesign of processes to improve cost, quality, and service, to maximize the benefits of technology. Process reengineering have been used by many companies to deal with a wide variety of problem. For example, the EMI Records Group was having difficulty filling orders for its most popular CDs. Retailers and recording stars were rebelling–it took the company as much as 20 days to deliver a big order for a hit CD, and then nearly 20% of the order would be missing. Small, incremental improvements would not have been adequate, so the company reengineered its entire istribution process with dramatic effects on on-time delivery and order fill rates. In business process reengineering, the organization can develop the business vision and process objective. It can identify the processes to be redesigned (core and highest payback) and understand and measure the performance of existing processes. It can also identify the opportunities for applying information technology and build a prototype of the new process. PARADIGM SHIFT It is about changing the very nature of the business and the structure of the organization itself, whole new products or services that didn't even exist before.In other words, paradigm shifts deals with major disruption and extreme change. Paradigm is a complete mental model of how a complex system works or functions. In other words, a paradigm shift involves rethinking the nature of the business and the organization. It is a complete re-conception of how the systems should function. For example, higher education is undergoing a major paradigm shift in the online delivery of education. Classes are now offered through the Internet so that students don't even go to classrooms. Many tried-and-true teaching methodologies are being radically altered to accommodate this shift in how education is offered.Paradigm shift is a radical re-conceptualization of the nature of the business and the nature of the organization. Deciding which business process to get right is half the challenge to the management. It is said that seventy percent of time programmatic reengineering efforts fail. But still o rganizations change. The reason is because the rewards are high. Paradigm shift involves great risks, but great returns too. The Internet is causing all kinds of industries and businesses to alter their products, their services, and their processes in radical ways.Entire organizations are being created to handle the paradigm shifts involved in e-commerce. Look at the automobile industry as an example of this type of change: Traditional dealerships are being disrupted by auto malls and online buying opportunities. BUSINESS PROCESS REENGINEERING In today’s ever-changing world, the only thing that doesn’t change is ‘change’ itself. In a world increasingly driven by the three Cs: Customer, Competition and Change, companies are on the lookout for new solutions for their business problems.Recently, some of the more successful business corporations in the world seem to have hit upon an incredible solution: BUSINESS PROCESS REENGINEERING (BPR). Business Process Re engineering (BPR) involves the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance such as cost, quality, service and speed. A reengineered organization is process oriented, where: 1) Processes are identified and named, 2) Everyone is aware of the processes they are involved in, 3) Process measurement, i. e. onitoring and control, is performed BPR advocates that enterprises go back to the basics and reexamine their very roots. It doesn’t believe in small improvements. Rather it aims at total reinvention. As for results: BPR is clearly not for companies who want a 10% improvement. It is for the ones that need a ten-fold increase. BPR focuses on processes and not on tasks, jobs or people. It endeavors to redesign the strategic and value added processes that transcend organizational boundaries. According to many in the BPR field reengineering should focus on processes and not be limit ed to thinking about the organizations.After all the organization is only as effective as its processes. Processes are currently invisible and unnamed because people think about the individual departments more often than the process with which all of them are involved. So companies that are currently used to talking in terms of departments such as marketing and manufacturing must switch to giving names to the processes that they do such that they express the beginning and end states. These names should imply all the work that gets done between the start and finish. For example, order fulfillment can be called order to payment process. Steps to an effective BPR are as follows – . Prepare for reengineering – Planning and Preparation are vital factors for any activity or event to be successful, and reengineering is no exception. Before attempting reengineering, the question ‘Is BPR necessary? ’ should be asked. There should be a significant need for the proce ss to be reengineered. Preparation activity begins with the development of executive consensus on the importance of reengineering and the link between breakthrough business goals and reengineering projects. A mandate for change is produced and a cross-functional team is established with a game plan for the process of reengineering.While forming the cross functional team, steps should be taken to ensure that the organization continues to function in the absence of several key players. As typical BPR projects involve cross-functional cooperation and significant changes to the status quo, the planning for organizational changes is difficult to conduct without strategic direction from the top. The impact of the environmental changes that serve as the impetus for the reengineering effort must also be considered in establishing guidelines for the reengineering project.Another important factor to be considered while establishing the strategic goals for the reengineering effort, is to make it your first priority to understand the expectations of your customers and where your existing process falls short of meeting those requirements. Having identified the customer driven objectives, the mission or vision statement is formulated. The vision is what a company believes it wants to achieve when it is done, and a well-defined vision will sustain a company’s resolve through the stress of the reengineering process. 2.Map and Analyze As-Is Process – Before the reengineering team can proceed to redesign the process, they should understand the existing process. Although some BPR proponents argue against analyzing the current enterprise, saying that it inhibits the creative process, that might not always hold true. It varies from case to case. While some organizations which are in dire straits might attempt a new process design while totally ignoring the existing processes, most organizations need to map the existing processes first, analyze and improve on it to de sign new processes.The important aspect of BPR is that the improvement should provide dramatic results. Many people do not understand the value of an As-Is analysis and rather prefer to spend a larger chunk of their valuable time on designing the To-Be model directly. The main objective of this phase is to identify disconnects (anything that prevents the process from achieving desired results and in particular information transfer between organizations or people) and value adding processes. This is initiated by first creation and documentation of Activity and Process models making use of the various modeling methods available.Then, the amount of time that each activity takes and the cost that each activity requires in terms of resources is calculated through simulation and activity based costing (ABC). All the groundwork required having been completed, the processes that need to be reengineered are identified. 3. Design To-Be process – The objective of this phase is to produc e one or more alternatives to the current situation, which satisfy the strategic goals of the enterprise. The first step in this phase is benchmarking.The peer organizations need not be competitors or even from the same industry. Innovative practices can be adopted from anywhere, no matter what their source. Having identified the potential improvements to the existing processes, the development of the To-Be models is done using the various modeling methods available, bearing in mind the principles of process design. Then, similar to the As-Is model, we perform simulation and ABC to analyze factors like the time and cost involved. It should be noted that this activity is an iterative process and cannot be done overnight.The several To-Be models that are finally arrived at are validated. By performing Trade off Analysis the best possible To-Be scenarios are selected for implementation. 4. Implement Reengineered Process- The implementation stage is where reengineering efforts meet the most resistance and hence it is by far the most difficult one. When so much time and effort is spent on analyzing the current processes, redesigning them and planning the migration, it would indeed be prudent to run a culture change program simultaneously with all the planning and preparation.This would enable the organization to undergo a much more facile transition. But whatever may be the juncture in time that the culture change program may be initiated, it should be rooted in our minds that ‘winning the hearts and minds of everyone involved in the BPR effort is most vital for the success of the effort. Once this has been done, the next step is to develop a transition plan from the As-Is to the redesigned process. This plan must align the organizational structure, information systems, and the business policies and procedures with the redesigned processes. 5.Improve Process Continously- A very vital part in the success of every reengineering effort lies in improving the reen gineered process continuously. The first step in this activity is monitoring. Two things have to be monitored – the progress of action and the results. The progress of action is measured by seeing how much more informed the people feel, how much more commitment the management shows and how well the change teams are accepted in the broader perspective of the organization. This can be achieved by conducting attitude surveys and discrete ‘fireside chats’ with those initially not directly involved with the change.Communication is strengthened throughout the organization, ongoing measurement is initiated, team reviewing of performance against clearly defined targets is done and a feedback loop is set up wherein the process is remapped, reanalyzed and redesigned. Thereby continuous improvement of performance is ensured through a performance tracking system and application of problem solving skills. An intense customer focus, superior process design and a strong and mot ivated leadership are vital ingredients to the recipe for the success of any business corporation.Reengineering is the key that every organization should possess to attain these prerequisites to success. BPR doesn’t offer a miracle cure on a platter. Nor does it provide a painless quick fix. Rather it advocates strenuous hard work and instigates the people involved to not only to change what they do but targets at altering their basic way of thinking itself. BUSINESS PROCESS MANAGEMENT Business process management (BPM) is a systematic approach to improving an organization's business processes.BPM activities seek to make business processes more effective, more efficient, and more capable of adapting to an ever-changing environment. BPM is a subset of infrastructure management, the administrative area of concern dealing with maintenance and optimization of an organization's equipment and core operations. BPM Vs. BPR If BPM is a system software, then BPR is a method. BPR re-eval uates the processes used by the enterprise from the very basics and thoroughly redesigns them, enabling enterprises to have significant breakthroughs in cost, service, and speed.BPR can enable enterprises to reform from deep within, and create a new organization structure. Therefore, BPR is for the whole enterprise and may even include basic organization structures in its large modifications. BPM is a concept built internally in an enterprise that continuous to manage business processes. In an environment that stores internal and external events, BPM starts from a group of dependent processes, that describes, understands, indicates, and manages the whole process.BPM can integrate internal resources in an enterprise, automatically linking each department, enabling the enterprise to become a single united special forces team. As well, establishing standardized business processes through a single portal, the system can automatically make decisions based on rules and processes of the en terprise to satisfy the management needs of the enterprise, creating comprehensive core competitive force. Key aspects on which BPM differs from BPR are as follows: – Marked difference between BPR and BPM | |Aspect |BPR |BPM | |Level of change |Radical, one step change |Evolutionary & continuous | |Time taken for implementation |Long |Short time and smooth takeover | |Starting point |Drawing board |Current processes and automation levels | |Implementation |Huge effort required for the |Incremental | | |disruptive change | | |Expanse |One major process at a time |Flexible – simultaneously across one or more / | | | |small or major processes | |Methodology |Redesigning of business |Process and decision models | | |processes | | |Enabling technology |Primarily IT |Primarily process technology | |Involvement |Business and process experts |Process experts and all related people | |Risk |High |Low | |Outcome |Drastic |Incremental improvement | |Cultural issues |Major concern |Not much concern | |Implementation stress and concern|High |Low | BPM tools have taken the advantage of the BPR experience and conceptually are more flexible in terms of expanse and intensity.Unlike BPR which targets end-to-end process by radically redesigning it, BPM tools can be applied part by part to the whole enterprise at a time, by adopting much more manageable and smaller changes in the process. This way the investments, risks and amount of change are minimized but at the same time the tangible impact is much more modest than what was a possibility with BPR. Yet BPM tools for automating processes have their basis on the fundamental concepts that were emphasized by BPR, such as: †¢ Simple processes delivering on the metrics of quality, service, flexibility †¢ Focus on eliminating non-value adding activities †¢ Decisions becoming integral part of the processBPM unifies discrete tools through extension of technologies like BPR, EAI, Workflow automation and any other business application package in such a form where the implementation and upgradation is much easily handled and underlying business process are efficiently managed. In addition to the strength inherited from BPR that BPM is built around business processes and not business applications per se, yet another promising feature of BPM is that it is based on mathematical process models. For example: – BPM helps you improve predictability and repeatability. For example, it will help you identify and recruit 10 candidates for a specified position in 8 weeks. BPR helps you study this and reduce this 8 weeks to 6 weeks or 4 weeks , depending on the context. Once this is done, we need to again use BPM to stabilize this and get back to predictability. Business Process Reengineering Describe each of the four kinds of organizational change that can be promoted with information technology. What is business process reengineering? What steps are required to make it effective? How does it differ from business process management? Explain with example. In an organization, there are major risks and uncertainties in systems development that need to be addressed by the management. Determining when new systems and business processes can have the greatest impact is involved in these challenges.This may be the reasons why organizational change and development is becoming a common scenario to talk about involving management, organizations, business, and leadership. With the fast-changing environment, business conditions bring consequences in management both in inner and outer factors. That is why in most cases, most of the managerial activities revolve around decision – making. Knowledge plays a major role in organizational development.Organizational changes are also u sually described, including management and employee training requirements, recruiting efforts, changes in business processes and changes in authority, structure or management practices. Information technology can promote various degrees of organizational change, ranging from incremental to far-reaching. There are actually four types of organizational change enabled by information technology: automation, rationalization, reengineering, and paradigm shifts. [pic] This figure shows the four degrees of organizational change.Automation is the easiest and the most common form of change. Being the most common form of IT-enabled change, the using of computer to speed up the performance of existing tasks is an example of automation. This involves assisting employees perform their tasks more efficiently and effectively. AUTOMATION Automation is the use of control systems and information technologies to reduce the need for human work in the production of goods and services. In the scope of ind ustrialization, automation is a step beyond mechanization.Although automation speeds up performance of tasks, it does not guarantee a very high effectivity in business success. It is just the same as repeating the old manual way of disorders but in a faster way. However, this type of change, although common, is slow – moving, thus producing slow returns. Organizations using automation produce the same products and services as before but changes the way the organization functions. Example of automation in business are calculating paychecks and payroll registers, automated checkout and inventory system employed by many supermarkets. nd giving bank tellers instant access to customers deposit records. RATIONALIZATION Rationalization of procedures causes the organization to examine its standard operating procedures, eliminate those no longer needed, and make the organization more efficient. It is the streamlining of existing operating procedures, eliminating obvious bottlenecks so that automation makes operating procedures more efficient. Rationalization follows quickly from automation. Both types of change cause some disruption, but it's usually manageable and relatively accepted by the people.BUSINESS PROCESS REENGINEERING A more powerful type of organizational change is business process reengineering, in which business processes are analyzed, simplified and redesigned. Using information technology, organizations can rethink and streamline their business processes to improve speed, service and quality. Business reengineering reorganizes work flows, combining steps to cut waste and eliminating repetitive, paper intensive tasks. It is usually much more ambitious than rationalization of procedures, requiring a new vision of how the process is to be organized.Business process reengineering in simpler words is Radical redesign of processes to improve cost, quality, and service, to maximize the benefits of technology. Process reengineering have been used by many companies to deal with a wide variety of problem. For example, the EMI Records Group was having difficulty filling orders for its most popular CDs. Retailers and recording stars were rebelling–it took the company as much as 20 days to deliver a big order for a hit CD, and then nearly 20% of the order would be missing. Small, incremental improvements would not have been adequate, so the company reengineered its entire istribution process with dramatic effects on on-time delivery and order fill rates. In business process reengineering, the organization can develop the business vision and process objective. It can identify the processes to be redesigned (core and highest payback) and understand and measure the performance of existing processes. It can also identify the opportunities for applying information technology and build a prototype of the new process. PARADIGM SHIFT It is about changing the very nature of the business and the structure of the organization itself, whole new products or services that didn't even exist before.In other words, paradigm shifts deals with major disruption and extreme change. Paradigm is a complete mental model of how a complex system works or functions. In other words, a paradigm shift involves rethinking the nature of the business and the organization. It is a complete re-conception of how the systems should function. For example, higher education is undergoing a major paradigm shift in the online delivery of education. Classes are now offered through the Internet so that students don't even go to classrooms. Many tried-and-true teaching methodologies are being radically altered to accommodate this shift in how education is offered.Paradigm shift is a radical re-conceptualization of the nature of the business and the nature of the organization. Deciding which business process to get right is half the challenge to the management. It is said that seventy percent of time programmatic reengineering efforts fail. But still o rganizations change. The reason is because the rewards are high. Paradigm shift involves great risks, but great returns too. The Internet is causing all kinds of industries and businesses to alter their products, their services, and their processes in radical ways.Entire organizations are being created to handle the paradigm shifts involved in e-commerce. Look at the automobile industry as an example of this type of change: Traditional dealerships are being disrupted by auto malls and online buying opportunities. BUSINESS PROCESS REENGINEERING In today’s ever-changing world, the only thing that doesn’t change is ‘change’ itself. In a world increasingly driven by the three Cs: Customer, Competition and Change, companies are on the lookout for new solutions for their business problems.Recently, some of the more successful business corporations in the world seem to have hit upon an incredible solution: BUSINESS PROCESS REENGINEERING (BPR). Business Process Re engineering (BPR) involves the fundamental rethinking and radical redesign of business processes to achieve dramatic improvements in critical contemporary measures of performance such as cost, quality, service and speed. A reengineered organization is process oriented, where: 1) Processes are identified and named, 2) Everyone is aware of the processes they are involved in, 3) Process measurement, i. e. onitoring and control, is performed BPR advocates that enterprises go back to the basics and reexamine their very roots. It doesn’t believe in small improvements. Rather it aims at total reinvention. As for results: BPR is clearly not for companies who want a 10% improvement. It is for the ones that need a ten-fold increase. BPR focuses on processes and not on tasks, jobs or people. It endeavors to redesign the strategic and value added processes that transcend organizational boundaries. According to many in the BPR field reengineering should focus on processes and not be limit ed to thinking about the organizations.After all the organization is only as effective as its processes. Processes are currently invisible and unnamed because people think about the individual departments more often than the process with which all of them are involved. So companies that are currently used to talking in terms of departments such as marketing and manufacturing must switch to giving names to the processes that they do such that they express the beginning and end states. These names should imply all the work that gets done between the start and finish. For example, order fulfillment can be called order to payment process. Steps to an effective BPR are as follows – . Prepare for reengineering – Planning and Preparation are vital factors for any activity or event to be successful, and reengineering is no exception. Before attempting reengineering, the question ‘Is BPR necessary? ’ should be asked. There should be a significant need for the proce ss to be reengineered. Preparation activity begins with the development of executive consensus on the importance of reengineering and the link between breakthrough business goals and reengineering projects. A mandate for change is produced and a cross-functional team is established with a game plan for the process of reengineering.While forming the cross functional team, steps should be taken to ensure that the organization continues to function in the absence of several key players. As typical BPR projects involve cross-functional cooperation and significant changes to the status quo, the planning for organizational changes is difficult to conduct without strategic direction from the top. The impact of the environmental changes that serve as the impetus for the reengineering effort must also be considered in establishing guidelines for the reengineering project.Another important factor to be considered while establishing the strategic goals for the reengineering effort, is to make it your first priority to understand the expectations of your customers and where your existing process falls short of meeting those requirements. Having identified the customer driven objectives, the mission or vision statement is formulated. The vision is what a company believes it wants to achieve when it is done, and a well-defined vision will sustain a company’s resolve through the stress of the reengineering process. 2.Map and Analyze As-Is Process – Before the reengineering team can proceed to redesign the process, they should understand the existing process. Although some BPR proponents argue against analyzing the current enterprise, saying that it inhibits the creative process, that might not always hold true. It varies from case to case. While some organizations which are in dire straits might attempt a new process design while totally ignoring the existing processes, most organizations need to map the existing processes first, analyze and improve on it to de sign new processes.The important aspect of BPR is that the improvement should provide dramatic results. Many people do not understand the value of an As-Is analysis and rather prefer to spend a larger chunk of their valuable time on designing the To-Be model directly. The main objective of this phase is to identify disconnects (anything that prevents the process from achieving desired results and in particular information transfer between organizations or people) and value adding processes. This is initiated by first creation and documentation of Activity and Process models making use of the various modeling methods available.Then, the amount of time that each activity takes and the cost that each activity requires in terms of resources is calculated through simulation and activity based costing (ABC). All the groundwork required having been completed, the processes that need to be reengineered are identified. 3. Design To-Be process – The objective of this phase is to produc e one or more alternatives to the current situation, which satisfy the strategic goals of the enterprise. The first step in this phase is benchmarking.The peer organizations need not be competitors or even from the same industry. Innovative practices can be adopted from anywhere, no matter what their source. Having identified the potential improvements to the existing processes, the development of the To-Be models is done using the various modeling methods available, bearing in mind the principles of process design. Then, similar to the As-Is model, we perform simulation and ABC to analyze factors like the time and cost involved. It should be noted that this activity is an iterative process and cannot be done overnight.The several To-Be models that are finally arrived at are validated. By performing Trade off Analysis the best possible To-Be scenarios are selected for implementation. 4. Implement Reengineered Process- The implementation stage is where reengineering efforts meet the most resistance and hence it is by far the most difficult one. When so much time and effort is spent on analyzing the current processes, redesigning them and planning the migration, it would indeed be prudent to run a culture change program simultaneously with all the planning and preparation.This would enable the organization to undergo a much more facile transition. But whatever may be the juncture in time that the culture change program may be initiated, it should be rooted in our minds that ‘winning the hearts and minds of everyone involved in the BPR effort is most vital for the success of the effort. Once this has been done, the next step is to develop a transition plan from the As-Is to the redesigned process. This plan must align the organizational structure, information systems, and the business policies and procedures with the redesigned processes. 5.Improve Process Continously- A very vital part in the success of every reengineering effort lies in improving the reen gineered process continuously. The first step in this activity is monitoring. Two things have to be monitored – the progress of action and the results. The progress of action is measured by seeing how much more informed the people feel, how much more commitment the management shows and how well the change teams are accepted in the broader perspective of the organization. This can be achieved by conducting attitude surveys and discrete ‘fireside chats’ with those initially not directly involved with the change.Communication is strengthened throughout the organization, ongoing measurement is initiated, team reviewing of performance against clearly defined targets is done and a feedback loop is set up wherein the process is remapped, reanalyzed and redesigned. Thereby continuous improvement of performance is ensured through a performance tracking system and application of problem solving skills. An intense customer focus, superior process design and a strong and mot ivated leadership are vital ingredients to the recipe for the success of any business corporation.Reengineering is the key that every organization should possess to attain these prerequisites to success. BPR doesn’t offer a miracle cure on a platter. Nor does it provide a painless quick fix. Rather it advocates strenuous hard work and instigates the people involved to not only to change what they do but targets at altering their basic way of thinking itself. BUSINESS PROCESS MANAGEMENT Business process management (BPM) is a systematic approach to improving an organization's business processes.BPM activities seek to make business processes more effective, more efficient, and more capable of adapting to an ever-changing environment. BPM is a subset of infrastructure management, the administrative area of concern dealing with maintenance and optimization of an organization's equipment and core operations. BPM Vs. BPR If BPM is a system software, then BPR is a method. BPR re-eval uates the processes used by the enterprise from the very basics and thoroughly redesigns them, enabling enterprises to have significant breakthroughs in cost, service, and speed.BPR can enable enterprises to reform from deep within, and create a new organization structure. Therefore, BPR is for the whole enterprise and may even include basic organization structures in its large modifications. BPM is a concept built internally in an enterprise that continuous to manage business processes. In an environment that stores internal and external events, BPM starts from a group of dependent processes, that describes, understands, indicates, and manages the whole process.BPM can integrate internal resources in an enterprise, automatically linking each department, enabling the enterprise to become a single united special forces team. As well, establishing standardized business processes through a single portal, the system can automatically make decisions based on rules and processes of the en terprise to satisfy the management needs of the enterprise, creating comprehensive core competitive force. Key aspects on which BPM differs from BPR are as follows: – Marked difference between BPR and BPM | |Aspect |BPR |BPM | |Level of change |Radical, one step change |Evolutionary & continuous | |Time taken for implementation |Long |Short time and smooth takeover | |Starting point |Drawing board |Current processes and automation levels | |Implementation |Huge effort required for the |Incremental | | |disruptive change | | |Expanse |One major process at a time |Flexible – simultaneously across one or more / | | | |small or major processes | |Methodology |Redesigning of business |Process and decision models | | |processes | | |Enabling technology |Primarily IT |Primarily process technology | |Involvement |Business and process experts |Process experts and all related people | |Risk |High |Low | |Outcome |Drastic |Incremental improvement | |Cultural issues |Major concern |Not much concern | |Implementation stress and concern|High |Low | BPM tools have taken the advantage of the BPR experience and conceptually are more flexible in terms of expanse and intensity.Unlike BPR which targets end-to-end process by radically redesigning it, BPM tools can be applied part by part to the whole enterprise at a time, by adopting much more manageable and smaller changes in the process. This way the investments, risks and amount of change are minimized but at the same time the tangible impact is much more modest than what was a possibility with BPR. Yet BPM tools for automating processes have their basis on the fundamental concepts that were emphasized by BPR, such as: †¢ Simple processes delivering on the metrics of quality, service, flexibility †¢ Focus on eliminating non-value adding activities †¢ Decisions becoming integral part of the processBPM unifies discrete tools through extension of technologies like BPR, EAI, Workflow automation and any other business application package in such a form where the implementation and upgradation is much easily handled and underlying business process are efficiently managed. In addition to the strength inherited from BPR that BPM is built around business processes and not business applications per se, yet another promising feature of BPM is that it is based on mathematical process models. For example: – BPM helps you improve predictability and repeatability. For example, it will help you identify and recruit 10 candidates for a specified position in 8 weeks. BPR helps you study this and reduce this 8 weeks to 6 weeks or 4 weeks , depending on the context. Once this is done, we need to again use BPM to stabilize this and get back to predictability.

Case Study Child Development Project Essay

Abstract After an extended period watching and observing Adrian, the bystander is able to see where Adrian is developmentally. He is growing physically, mentally, and emotionally as a child his age, four years old, should be maturing according to many theorists. While he has not mastered all the required steps for his age group he is achieving more and more of them each day. The following case study will discuss where Adrian is excelling and where he still needs a little work. A Case Study about Child Development Adrian is almost four years old and lives with his parents and older sister in an apartment. His father is a financial advisor in a bank, allowing him to spend time with the family on the weekends, while his mother stays at home as a housewife. They have a lot of neighbors and no pets. Adrian loves trains, cars, dinosaurs, animals, juice, and being inside and outside of his house. His favorite movie is Cars. He does not like the word â€Å"No† and often ignores something when it doesn’t interest him. Adrian has fun, loving, goofy, energetic personality. Throughout this study, the observation of Adrian will take place at two places: his house, inside and out and his grandmother’s house. Physical Development Adrian developed normally through the prenatal, infancy, and toddler stages. He was born on August twenty eighth in 2010 by natural birth after a full term, normal pregnancy. At birth, he weighed eight pounds eleven ounces and measured twenty-two inches long, which according to the Center for Disease Control (2000), put him in the seventy-fifth percentile for weight and ninetieth percentile for length. As an infant Adrian’s mother, chose not to breast feed and instead gave him formula. As a toddler, Adrian hit all the  important milestones, according to his mother, included learning to walk which occurred around fifteen months. As Adrian progressed from a toddler to preschooler, he continued to progress as he should according to the normal growth and developmental process. At four years, he is forty-two inches tall and weights around forty-six pounds, keeping him in the same percentiles as birth, again according to the CDC (2000). Most of this growth occurred, as it should, during the toddler years. Even though Adrian just turned four he had accomplished many of the required gross and fine motor skills according Berger (Chapter 8), he can run, hop, jump, walk up and down stairs alone, dress and undress, use the bathroom on his own. I have witnessed Adrian running or jumping many times whether it be running to tackle someone for a hug or a warm welcome, jumping on the bed/couch usually when he gets excited about a movie or favorite cartoon, or when he is playing with his cousin who is just a few months older. Going up and down the stairs at his grandmother’s house, this is not a problem problem because Adrian gets plenty of practice due to must of the time he’s visiting his gradmother’s house. Using the bathroom is a big accomplishment for him, because it took him a long time and has only mastered it within the last few months. However, he still needs practice skipping and being comfortable using scissors. Adrian is right where he should be with his physical development. Cognitive Development Similarly to Adrian’s physical development his cognitive develop is also maturing at what theorist would say is a normal rate. Piaget and Vygotsky writes that upon reaching the age of four a child should be rapidly expanding his vocabulary, beginning to think intuitively but still thinking almost entirely on himself. He progressed through the building blocks of language beginning with babbling and moving through his first word around fifteen months and first sentence a little while later. While his mother does not know the exact time when he started babbling and spoke his first sentence, she does recall this never being a concerned about the development. Currently, he is speaking in full sentences that vary in lengths and purposes. He enjoys watching television shows about super heroes and if given the chance, he will spend large amounts of time, sometimes up to twenty minutes, telling his listener all about them. Adrian’s cognitive  development in the area of language has a lot to do with the fact he is inquisitive and seems to enjoy learning. According to many theories and developmental checklist a four year old should be able to count and should be drawn to letters and sounds. Adrian demonstrates an inclination to want to read and will often ask someone around him to read him his favorite book or play with the magnetic letters his mom bought him. Additionally, by playing games like Candy Land or Chutes and Ladders where he can count the required spaces indicating a beginning understanding of numbers. Another example a time when I noticed Adrian genuinely wanting to learn and wanting things to be perfect, he spent a few seconds growing more and more frustrated as he angrily smashed the top and bottom boxes together. Eventually, he got the two pieces together but not before tearing the corners of them. However, when someone stepped in and showed him how to correctly put the two pieces together he welcomed the advice and was then able to properly close the box. Like Vygotsky mentioned the mentor provide scaffolding, or temporary sensitive support, to help the developmental zone. After getting the box together, he started to think of ways to fix the box. He suggested taping it, and was excited when that idea was welcomed and put to use. This not only demonstrated intuitive thought but helped Adrian feel intelligent and begin to learn that it is perfectly fine and acceptable to ask for help when needed. Adrian is developing cognitively a little more everyday and seems to be on his way to accomplishing all the key milestones. His language skills are growing each day and he is learning to try new things on his own with the idea that he can always ask for help. Emotional/Social Development As with physical and cognitive development, observer is able to see that Adrian is attaining the social developmental milestones as he progresses to the preschool age. While Adrian hit all the important points through in infancy and toddlerhood. For example, he was always able to show a wide range of emotions, classified as a key achievement by Freud and Erikson. He was quick to show observers his happiness, sadness, confusion, or frightfulness. He also quickly established a secure attachment to his mother, another one of Ainsworth’s milestones. Adrian was child who needed and wanted to be with his mother and would cry or search for her as soon as  she left his sight. By achieving both of these Adrian was able to understand that he could trust people, which allowed him to make the transition from toddlerhood to the pre-school period successfully. As an energetic and, for the most part, easy going four year old, Adrian is accomplishing many of the expected landmarks yet needs more time to complete other. Observers can watch Adrian feeling safe and comfortable in areas other than those he is familiar too. Similarly, however, he can/will lose complete control of his temper and lash out violently to those around him. Other noticeable developments for Adrian are his ability to play with others, cooperatively and the idea that he is beginning to get a sense of gender. He enjoys playing games with his cousin who is just a few months older and they will play with cars or whatever suits their mood that day. He will also play board games, such as Candy Land or Chutes and Ladders, with the understanding that it is not always possible to win. Presently, he is fascinated with Wonder Woman and when asked why he likes her so much his response was because she is a girl and has boobs, as reported by Adrian’s mother. He is getting to the point also, where he understands that there are boys clothes and girls clothes, last year for example he enjoyed trying on the clothes his cousin received for Christmas. Yet this year, when his family went shopping and glanced through the area with all the children’s clothes he had no problem telling everyone which ones were for boys and which ones where not. Over all, Adrian is where he needs to be given he still has two years left in the preschool stage to improve and grow socially and emotionally developmental wise. Reflection This experience has taught me a lot about how preschoolers act and why they do the things they do. I truly enjoyed watching Adrian in a different, more professional light during the past few weeks. I cannot say I am thrilled with how I did everything throughout the project but for the most part, I am happy. By observing Adrian for specific characteristics in the areas of physical, cognitive, and emotional growth I was able to bring the lectures and information from class to life and am thrilled to be able to say I am leaving this class with the understanding of how a preschool-aged child operates. While I am happy about learning the Adrian is on target with his developments, I wish I could have observed him at different times and  places. Also, it would have been interesting to see how he reacted at different locations but that did not work like I had hoped it would have at the beginning, instead, I primarily just watched him inside his house: inside because it always seemed to be either too hot or rainy when I would visit. By completing this case study, I was able to accomplish a lot. I now have a much better idea of where a preschool-aged child is cognitively, emotionally, and physically and if that is the age. I really enjoyed being able to step out of my family role and see how Adrian is from a different, more professional standpoint.

Finny The Great

Throughout the novel A Separate Peace by John Knowles, there were two dominant characters. Gene who is the narrator and Finny who is Gene’s best friend have a great relationship shown in A Separate Peace. Finny whose real name is Phineas has three qualities, manipulation, athleticism, and is a strong leader. Manipulation is shown all through the novel by Finny and is one of his best assets that he has. We see his manipulation skills from getting out of trouble when they skipped dinner to the time he made Gene first jump out of the tree. The reason sir is that we just had to jump out of that tree. You know that tree†¦because we’re all getting ready for the war†¦Mr. Prud’homme released his breath with a sort of amazed laugh, stared at Finny for awhile, and that was all there was to it’† (15,16). Finny, in this quote, gets Gene and himself out of trouble after they skipped dinner the night before and every time they get in trouble. In the Super Suicide Society of the Summer Session he persuades Gene to go on the jump every night even though Gene does not want to and would rather study. Finny is an incredible athlete, modest, and is very brave, this is shown through his breaking of the long-standing school swimming record and not wanting to show off his talent. Another athletic move Finny makes is inventing a new game called blitzball during the summer classes, which they play all the time. When Finny breaks his leg and is never able to play sports again it devastates him. â€Å"‘Listen, pal, if I cant play sports, you’re going to play them for me’† (77). When Finny says this his anger is so high since he cannot play sports that he ant someone else to play for him to have that security of sports still around him. Throughout the novel Finny shows great leadership. Everything done by Finny and his friends he is leading. When they made up Blitzball he was the one who made up the rules and tells Gene and their friends how to play the game. â€Å"‘Now Leper has just brought out a really important fine point of the game. The receiver can refuse a pass if he happens to choose to. Sine we’re all enemies, we can and will turn on each other all the time. We call that the Lepellier Refusal’† 30). Finny has a knack for leading people and does this when they first start the Super Suicide Society of the Summer Session. Without Phineas using his charismatic attitude, athleticism and his leadership skills the novel would be very boring. Finny `s charismatic attitude shown all throughout the novel helps him get the things he wants and has excitement in the novel. His athleticism makes him competitive and makes up the game of the summer blitzball. Finny has great leadership skills so he can manipulate people and get what he wants from his friends.

Economic Analysis of the Fast Food Industry in Houston Essay

Economic Analysis of the Fast Food Industry in Houston - Essay Example This is because these people have the greatest disposable income. As a result, most fast food establishments in the region are usually set up in places where such population can manage to access them easily. Factors influencing demand and supply The demand for fast food in Houston is projected to expand in the future. This is because of the various factors that influence the demand and supply of products. The tastes and preferences of consumers influence the demand for a product. For example, the US is described as a fast food nation. This means that most people in the region are attached to fast foods. Most people prefer to consume food from fast food restaurants because of their good price and suitability that makes it possible for people to cook. Moreover, because of the consumers desire to reduce food wastage, they prefer to take fast food. This state of affairs has made most people prefer fast foods to cooking food at home (Ritter). It is evident from the graph above that an inc rease in the expected prices causes an increase in demand. Thus, there will be a right ward shift of the demand curve. The availability of substitutes and compliments also influences the demand for fast food in Houston. There are many establishments that offer different kinds of fast food in the region. This state of affairs has led to a growth in competition in the fast food industry. In this case, only the restaurants that offer the best food in the market have been able to stay ahead of the rivalry. Supermarkets also offer convenience foods thereby tampering with the growth of the fast food industry. However, the growing popularity of the fast food industry has led to reduced demand of convenience... This essay offers a modern comprehensive review of the recent economic developments in the fast food industry in Houston. As it has been shown in the essay, the industry generates huge income for government, employees and the fast food establishments. The value of the fast food industry is anticipated to keep rising at a rate of 4 percent every year because of the increased demand of fast food in the region. Most people who take food in fast food restaurants usually have busy schedules. This implies that they cannot manage to prepare their own meals in an appropriate manner. This state of affairs has made most people develop great reliance on fast foods. The main players in the fast food industry in Houston include McDonalds, Burger King, Pizza Hut and KFC. The demand for fast food in Houston is projected to expand in the future. This is because of the various factors that influence the demand and supply of products. The tastes and preferences of consumers influence the demand for a product. Most people prefer to consume food from fast food restaurants because of their good price and suitability that makes it possible for people to cook. In order for businesses to operate in accordance to the expectations of their customers, it is important for the government to set up measures that regulate the operations of the businesses. In the case of the fast food industry, it is important for the government in Houston to set measures whose focus would be to ensure that the industry is sustainable.

National Health expenditures Assignment Example | Topics and Well Written Essays - 500 words

National Health expenditures - Assignment Example Similarly, the net cost of health insurance steadily rose from $2.6 billion in 1970 to $210.6 in 2013.Furthermore, the government expenditure on public health activities $1.4 billion in the year 1970 (CMS, 2007). Based on the National Health Expenditure figures, the value also increased to $75.4 billion by 2013.In addition, the Federal government has also increased its allocation in making the investment in the health sector. In 1970, the Federal government spent $7.8 billion in health investment. In 2013, a staggering $164.6 billion was allocated towards making new investments in the health sector (CMS, 2007). The percentage of GDP spent on NHE has been fluctuating from time to time. In some instance, the percentage change in GDP was negative and in some cases it was positive. In the year 1991, the percentage of GDP reduced sharply with a margin of -8%. In 2009, the percentage increase in GDP was the highest reaching the mark of 5.8% (Hennessy et al., 2007). According to the figures presented above, the analysis indicates that the government has been increasing funding for the purposing of improving quality health provision. One of the core mandates of the Federal government is to provide accessible medical care to its citizens. The federal government has ensured that it provides quality and available medical attention. Furthermore, the emergence of deadly diseases such as cancer that is most prevalent in most developed countries, the need to invest in medical care has been necessitated (CMS, 2010). The prices of medical care coverage have been relatively affordable. Affordability of care services has been made possible with the Federal government commitment to invest in the public health sector. Since the government expenditure in medical investment, medical services have been made affordable. The Federal government has promoted the creation of new national hospitals in a bid to ensure there is the accessibility of medical

Immigration Policy Coursework Example | Topics and Well Written Essays - 250 words

Immigration Policy - Coursework Example The essence and necessity of reforming the immigration sector in the US cannot be overemphasized. Most of the immigrants in the US fall short of the technical competence and skills required to ensure growth (Flannery, 2014). The immigration reforms should focus on providing visas to individuals who have the skills in engineering, science and other technical areas as a consequence of ensuring productivity. Most sectors of the American economy depend on the people who have technological and innovative skills capable of redefining growth in key sectors of the economy (Kramer, 2014). Unfortunately, most of the immigrants in the US are less productive and more established in the informal sectors other than the mainstream economical zones. Growth is directly correlated to the technical ability and skills of individuals in various sectors. Statistics have shown that scientists, engineers and programmers are responsible for growth that have been experienced in the US over the past few years (Kramer, 2014). It is, therefore, important to reform the immigration to ensure that skilled individuals are given a priority in terms of visa presentation. Flannery, N.P. (2014, March 24). Can corporate leaders push through immigration reform in 2014? Forbes. Retrieved from . Kramer, H. (2014, February 11). How immigration reform or lack thereof is hurting our economic competitiveness. Forbes. Retrieved

Skip navigation links BFS 3430-09D, PRINCIPLES OF FIRE BEHAVIOR Essay - 2

Skip navigation links BFS 3430-09D, PRINCIPLES OF FIRE BEHAVIOR (BFS3430-09D) - Essay Example Moisture is necessary in order to make the wild lands less vulnerable to fire (International Association of Fire Chiefs, 2008). With lacking moisture, there are more chances of spread of fire. Less moisture is there when the weather is dry and hot. With higher humidity, the chances of fire spread are less and with low humidity, the chances of fire spread are more. Therefore, it can be said that hot and dry weather in which the humidity ratio is less is more vulnerable for wild land fires and fire fighters are required to cool down the fuel in order to extinguish the fire. Like moisture, winds are also such weather conditions that can add to the wild land fires. Windy weather usually becomes a reason for the spread of fire in wild lands. The windy weather will help the fuel to burn more and will also spread the burning fire. Fire is spread with great speed because of the windy weather (International Association of Fire Chiefs, 2008). Windy weather is very dangerous for the conditions where there are wild land fires. Fire fighting also becomes difficult with weathers that help in ignition. The fire fighters should be trained in order to fight the fire with differing weather conditions. International Association of Fire Chiefs, International Association of fire Chiefs (COR) and National Fire Protection Association. (2008). Fundamentals of Fire Fighting Skills. Massachusetts: Jones & Bartlett Publishers. Also Available at

Dynamic Development of Marketing Management Strategies and Article

Dynamic Development of Marketing Management Strategies and Organizational Performance - Article Example The strategy is simply a choice. Prosperity is linked not only with profitability but also the long term growth. It's like steering a ship in the ocean with the danger that pirates may take over, or it might become the victim of the deadly waves. The ship here refers to the company itself and the challenged here include the competitors, the environment etc. Thus, there is a strong need for the managers to make a strategy that works as an action plan to achieve the aimed objectives. The objectives may be both financial such as higher revenues, lower costs, high profits and non-financial just to be the top in the industry, largest market share, or to place the product in the top minds of the customers. Thus, the need arises to have a blueprint that tells how to go about it Companies need to diverse, differentiate, integrate backward or forwards, and manage business portfolio balanced. The managers need to do planning, develop a vision, has to set their mission, develop long term plans and these all are further divided into different objectives and goals. But it is important that the strategy is to be consistent with the organizational goals and policies, it should be flexible enough to respond to the faster-changing environment in which it is operating, and it should add value to the organization and become a source of advantage over its competitors, and lastly, it should be feasible and practical enough to get through. Strategic management can be defined as the art and science of formulating, implementing, and evaluating cross-functional decisions that enable an organization to achieve its objectives (David F.R., Strategic Management). The process of strategic management involves three stages, viz. formulation of a strategy, implementing a strategy and lastly, evaluating the strategy. Since organizations have limited resources thus they need to choose from amongst the alternatives available. Setting a strategy starts with developing a strategic vision so as to provide long term direction, and provide a purpose to the organization. The strategic vision is then converted into specific performance objectives for the company to achieve. And then forming strategies to achieve the desired outcomes that have been developed in the form of objectives. This all was the planning portion of the process; no strategy is useful until it is implemented and executed effectively and efficiently. In the end, the eval uation stage begins which requires comparing actual i.e. the reality with the planned.

Discuss the roles and the purposes of higher education Should 50% of PowerPoint Presentation

Discuss the roles and the purposes of higher education Should 50% of 18-30 years old go to University - PowerPoint Presentation Example ide quality education so that it ensures that education outcomes that are both measurable and recognizable are attained especially in numeracy, communication, and literacy skills. Quality education will ensure that those who pass the system have the right qualifications (Layer 2002a,p.148). Students doing practicals Higher education in every institution ensures that the learners participate during election of their leaders. This will in turn boost their democratic right as well s a civil participation. This produces individual who will actively with in their countries and communities affair Higher education has the role of developing education whose content and methodologies aims at promoting individual social and cultural realities. This means that higher education ha the capacity of ensuring that the social aspect of individual is promoted. This produces an individual who can successfully socialize with others from different societal setting. Higher education also produces individuals who can appreciate different cultures from the world (Arche 2003,p.206). The institutions of higher education are charged with the process of national development and majorly they involved in development of their immediate societies. These institutions play a key role in uplifting lives in the community by establishing life-sustaining projects through 3xtension and community service. The research done in institutions of higher education, link the community and these institutions thus contributing directly to the welfare of the community (Catelles 2000, p.98). Institutions of higher education have well-trained teachers that equip the learners with adequate knowledge, attitudes, skills, and cultures, which will enable the learners to effect the much needed change in the society. In this regard the institutions produce holistic individuals. This means that the knowledge received in colleges and universities will enable them to agents of change in the society. The learners from

Your More Than A Label Essay Example | Topics and Well Written Essays - 500 words

Your More Than A Label - Essay Example In an attempt to get the labels off their children, parents try things like changing children’s school or shifting to a different city. Any decision they take costs them a lot of time, effort, and also money. As children grow up with the labels, their irritation and repulsiveness toward the labels recedes and they start to unintentionally accept the labels. Labels bother them no more. They accept the labels as a fundamental part of their identity. This serves as a sign that reflects that the child has been mentally tortured and psychologically harmed to the extent where he/she does not sense the gravity of the label as something negative. Although this happens gradually and unintentionally, yet its effects reflect in the behavior of the children as they grow up. If a child is given a certain label because of being diagnosed with Fetal Alcohol Syndrome and ADD, the child understands that he/she is integrally linked with alcohol in people’s perception. Drinking and becoming alcoholic is much easier for such a labeled individual as compared to others that are not expected to do such things. The labeled individuals easily endorse and adopt roles and behaviors that are expected of them according to their label. In this way, these individuals not only put their own health and life in risk, but also pose risks to the safety of others around them. A potential example of this is the accidents caused because of drunk driving. Pastor Joel Osteen puts forth a wonderful example of how powerful can labeling be if people accept the labels they are assigned and yet how fake it can be if people do not get rid of the labels they are assigned, â€Å"Albert Einstein’s teacher told Einstein’s father, â€Å"No matter what Albert does, he will never be successful†Ã¢â‚¬ ¦friends, people don’t determine our destiny, God does† (Osteen cited in â€Å"Pastor Joel Osteen†). Neither

Romeo and Juliet Essay Example for Free

Romeo and Juliet Essay How does the opening scene of Romeo and Juliet grab the audiences attention? How does Shakespeare prepare us for what happens in the rest of the play? Romeo and Juliet is one of Shakespeares most famous romantic tragedies, which was written in 1599. This tale of romance and hatred starts with a dramatic first scene of the opposing families. These characters are shown in the first scene, focusing on the way Shakespeare captures the audiences attention and how he created this action packed, tense first scene to prepare us for the rest of the play. Shakespeares Act 1 Scene 1 sees two angry characters enter armed with swords and bucklers which are publicly seen in their possession. In the society of that time, this would have been common and the audience would not find it strange whereas the society of today would find this threatening, as well as illegal. This gives us an impression of what the people and the society was like 400 years ago. These two fiery characters are Capulet servants called Sampson and Gregory who start the first scene off with humour: Well not carry coals Sampson. No, for then we should be colliers Gregory. This would have been funny in Shakespearean times as Gregory is contradicting what Sampson has said, and is taking him literally to make light of the situation. Shakespeares audience would have understood the reference whereas a modern audience would see the implication differently and the joke wouldnt be understood, as the Shakespearean language is not commonly known these days. Shakespeare uses sexual references towards the Montague household and Sampson comments that he is a pretty piece of flesh. This sexual reference would have been amusing to the Shakespearean audience, and even though we do not fully understand the comment, we would still pick up what he is implying. We still have amusing sexual references in plays and films today which show how the society then and the society now use sexual comments in their scripts to create humour. This humour helps to capture the audiences attention. These two characters help start off the first scene as they help us to realise the anger and hatred between the two families, and prepare us for what we hope will be more fighting and excitement later on in the play. The next two characters to enter are Montague servants called Abram and Balthasar. Sampson and Gregory are clearly angered by their arrival, and comment that they will bite their thumb at them. This action was an insult in Shakespearean times, and would have been taken in an offensive way. The two Montague servants begin quarrelling with the Capulets, and they begin provoking each other: Do you bite your thumb at us sir? Abram No, sir, I do not bite my thumb at you Sampson Later on in Act 1 they continue: Do you quarrel sir? Gregory Quarrel, sir? No sir. Abram. As the provocation warms up, and the two opposing families begin to get angrier, the pace of the play quickens. Modern audiences may not have understood the insult of biting thumbs, but we would feel the tension that was building up on stage between the Montagues and the Capulets, and would see that the characters are very much alike in the fact that they detest the other family and use aggressive language to try and provoke each other. These two characters are added to make the plot more interesting, although they do not show the anger they have for the Capulets as much as the Capulets show us their hatred for the Montagues. Evidence of this is that Sampson and Gregory in Act 1 Scene 1 talk about how they will inflict pain and violence on the Monatagues if they come across one: A dog of the house of Montague moves me. The bickering between these four characters adds tension and excitement to the first scene of the play, and helps move the scene along. The next character to enter is Benvolio and he is clearly angered by the fighting that has occurred between the two families. He beats down their swords saying put up your swords; you know not what you do. We can already see a big contrast between Benvolio and the other four characters: Benvolio is a peacemaker who wishes for the family feud to end, whereas the others provoke each other into a fight, quarrel and hold hatred for each other. Tybalt then enters, angry and fired up over the Montague presence. He speaks of how he hates the word peace as he hates hell, all Montagues and thee. We begin to learn that Tybalt is a very angry and aggressive character that would love to get his own revenge on the Montague household. Although the language is still written and spoken as if in Shakespearean times, we would still feel the tension and pace quickening, and understand the personalities of the different characters. Shakespeare has given Benvolio and Tybalt different tones of language: Tybalts is strong, aggressive and angry whereas Benvolios is a little less strong and is more polite when talking. These two characters, I feel, are created by Shakespeare to add tension and excitement to the play, and prepare us for more action packed scenes with the two characters later on. The contrast between these two characters would grab the audiences attention and leave us wondering what will happen between these two later on in the play. This fighting leads to several citizens (which are split between the Monatgues and the Capulets) that next enter the scene. A big fight ensues between the two families, and the citizens get involved. This would make us (and the audience 400 years ago) very edgy and would add tension in the audience. These characters are added to show us the hatred that has built between the Capulets and Montagues, and to show us that the anger and contempt between them goes as far as the citizens. Watching this on stage would add fear and tension between the characters on stage and the audience, and Shakespeare would have added swords and angry colours to show the hatred. Capulet, Lady Capulet, Montague and Lady Montague enter and when seeing the upheaval of the fights go to join in. The Ladies of the two households try to calm them down but they are defiant; Hold me not; let me go. Montague This shows us that the women in the society of that time did not have any power or say over their husbands, and is a factual part of the play that helps us understand what society was like 400 years ago. During these fights, our next character, Prince Escalus, enters. He immediately stops the fight and issues his last warning. If ever you disturb our streets again, your lives shall pay the forfeit of the peace. In Shakespearean times, there was no government to help rule the country: it was the princes last word that everyone followed. Shakespeare uses this language as it is a clear and stern statement that easily makes the audience anticipated on what may happen further on in the play. This would add contrast to the play as we would know that we were to expect more fighting, but the Princes ultimatum would leave us wondering what was going to happen next, which would create more interest in the play and change our first thoughts of what we were to expect as we think that Shakespeare will cause more hatred and fighting between his characters to keep us interested. Shakespeare creates a very clear, polite but strong character here with an easy dialogue that audiences of today would easily understand. All the characters exit leaving Montague, Lady Montague and Benvolio talking of what happened. In this part of the scene, Shakespeare shows us that not only is Benvolio a peacemaking character, but also a truthful one that we can trust. This ensures us that whatever may happen later on in the play, we can trust Benvolio to tell the truth. The language Shakespeare uses is clear and to the point, giving as much detail as possible without giving to much away of what is to come later on in the play. They then start talking about Benvolios cousin, Romeo. This is when Shakespeare introduces his main, love struck character. We learn that Lady Montague is particularly caring about her son: O where is Romeo? Right glad I am he was not at this fray. They talk of how he shuts up his windows, locks fair daylight out, and our first impressions of Romeo is that he is a very miserable, lonely person (not the person we originally think of when we hear his name). Shakespeare leaves us again confused of what may happen later on in the play as the name Romeo is synonymous with romance, but when we hear what Romeo is like, we are left wondering if the play will be as it was first expected. Modern audiences would understand this part of the play, as the language is clear and understandable. The dialogues are introducing the contrast of hatred to love but at the same time it also stays informative and gives us our first impressions of Romeo. This part of the play is important as it helps move the scene along from the fighting earlier on, and informs us on our first of the main characters, Romeo. Our main character now enters and Shakespeares language tells us a lot of how Romeo is feeling: Is the day so long? Ay me! Sad hours seem long. We learn that Romeo is an extremely depressed character who doesnt seem to be this romantic character (that we suspected from his name) we first imagined. Shakespeare keeps us wondering about why Romeo is depressed, giving Romeo small dialogues of little information. We later learn that Romeo is out of her favour where I am in love. This now tells us more of Romeos character and instead of what our first impressions were, we now feel that he is a soppy romantic who is in love with love. Romeo later talks in riddles as he states: O heavy lightness O loving hate feather of lead This shows us how he feels confused over his feelings of love, and that he will feel no love like this. Again our impression is that he is very romantic and loves to be loved. This part of the scene from when Romeo enters prepares us for more romance and we feel that the romance and love will be the cause of the fighting later on in the play, which links to Prince Escalus warning. In conclusion, I feel that this first scene is successful in helping us predict but also wonder what will happen later on in the play. It prepares us for more fighting and for a romance that may be the cause of death, betrayal and hurt. Ive learnt of how inferior the women were 400 years ago, and how royalty ruled everything. Shakespeare has used the period that he lived in to create this play, and along with being an interesting love tale, it is in some ways factual as well. This play is very dramatic, tense and action-packed and I feel that this first scene starts the play off brilliantly.

Gothic Horror Stories Essay Example for Free

Gothic Horror Stories Essay Gothic horror is a type of romantic, horror fiction based on irrational fear that predominated in 18th century England. The term gothic originated from the architectural style of the middle ages, but came to describe the dark, terrifying tales that achieved such popularity. Gothic horror can be determined by many things which exist in all gothic horror stories, for example eerie settings such as gothic monasteries, bleak comfortless castles, grave yards and cobwebbed rooms lit by guttering candles. It can also be determined by a unique character such as a beast, monster, ghost, evil creature and innocent person. Usually the innocent person is killed by the evil creature in a gothic horror story. Fear, supernatural and the macabre were also essential elements in gothic horror. I looked at six stories but I will focus on three of the stories which appear to fit the genre, these stories are The Judges House written by Bram Stoker who lived from 1847 to 1912. It is about a person called Malcomson who moves into an old house. He gets disturbed by rats while living in the house and then gets killed by a judge. The Tell Tale Heart written by Edgar Allen Poe who lived from 1809 to 1849. This is about a man who is killed by another man at his house, police go to the house after getting a disturbance call from the neighbours then the killer confesses about the murder to the police. The Signalman written by Charles Dickens who lived from 1812 to 1870. The story is about a signalman who sees a ghost and every time he sees it, the ghost shows something in the future which is going to happen. The signalman tells a passing man about this incident, the man and him become friends. Then the signalman sees his own death without knowing, he tells the man about this, they think of a rational reason for this but however the signalman dies. All three stories were written in the 19th century. They were all set at the same time when they were written. This is a good effect because at the time when they were written, horror stories containing superstition and the macabre were popular because the people at that time believed in witchcraft, ghosts and demons. The location of the action is of great importance in the gothic novel because it creates an atmosphere and feeling to the story. The Judges House is located in the dining room of an old, quiet and isolated house. An old, rambling, heavy built house, this creates a scary atmosphere thus matching the typical setting of a gothic horror story. It goes on to describe the dining room as a, room in darkness, this also creates a scary and terrifying atmosphere because you cant see in the dark and you dont know whats in the dark, this also is an essential gothic horror element because darkness creates a creepy and scary atmosphere. The Tell Tale Heart is located in a house that is probably old as a lantern is used by the narrator, this creates a scary atmosphere like the Judges House because you cant see in the dark and you dont know what is in the darkness so the reader imagines things that create the scary atmosphere, for example, the reader may imagine evil creatures emerging from the darkness, or someone suddenly jumping out from the dark surroundings. The Signalman is located in a railway station that is isolated which is gloomy and dark. This creates an intimidating atmosphere because isolation makes the reader think why it is isolated and the darkness as I said before creates a scary atmosphere. Also it refers to the place as being a great dungeon which is a typical setting of a gothic horror story. From the three stories I have read, the plot in the story was similar, it is really about good versus evil and because its a gothic horror story evil is supposed to win. The Judges House it is about a person called Malcomson who moves into a old house because he wanted to get on with his studies he was doing, in this house Malcomson gets disturbed by rats, especially one rat that was bigger and looked evil. Then one day he was killed by the judge that haunted the house, who was in fact the bigger and evil rat. This is a typical gothic horror plot because the good is killed by the evil. I think Stoker wrote the story well because he always throughout the story created a scary and macabre atmosphere by using descriptive words baleful eyes to describe a thing such as the rat which would produce a frightening image in the readers mind. I think Stoker did this well because his usual style is horror. This is a typical gothic horror plot because the good is killed by the evil. The Tell Tale Heart is about a crazy man who kills an old man because he didnt like the old mans eye. I think Poe wrote the plot as he did because his usual style is being a critic, so he put a bit of criticism in the story as the man killed the old man because he didnt like his eye, he thought it resembled that of a vulture. This also is a typical gothic horror plot because the innocent person (the old man) is killed by the evil person (the crazy man). The Signalman differs from The Judges House and The Tell Tale Heart because the evil doesnt kill the good or innocent this time. The Signalman is about a signalman who sees a ghost which warns him about something which is going to happen. The thing which the ghost warns the signalman about is his death, and then the signalman dies. This isnt really a typical gothic horror plot. I think Dickens wanted to create a mystery in the story as well as horror because his usual style of writing is mystery and horror, so he put mystery in because he is use to it. Characterisation plays a major part in all three gothic horror stories. In The Judges House Malcomson is studying mathematics and people who study are thought to have a more mature approach to the supernatural, this is why he laughs when Mrs Dempster, the charwomen, warned him about mysterious somethings I think Stoker chose this character because he would fit a typical character as he is a innocent and rational person, Stoker knows this because horror is his usual style of writing. Also Malcomson is a very intrigued in his studies, I think Stoker gave these characteristics in Malcomson because Stoker himself went to college and knows how studying is interesting and affects a young person. The judge, who is another main character, only comes in the story at the end, but at the end we also find out that the judge is in the story before the end as the big, evil rat. I know that the judge is evil because every time this big rat comes, all the other rats go because of its present. I also know its evil by how Stoker described the rat, baleful eyes, and these descriptions produced, an image in my head showing that it was evil. The judge meets the character determinant as he is the evil creature, he is like a ghost that haunts the house and he is described in a certain way to make him look wicked and evil.

Postoperative Nausea and Vomiting: Causes and Treatments

Postoperative Nausea and Vomiting: Causes and Treatments Postoperative nausea and vomiting is the nausea and vomiting symptoms which occurred after a surgery, medicines intake or anaesthesia usage. Around 18 to 30 of surgical patients have PONV and the nausea and vomiting symptoms are usually self-limiting in most cases.1 Uncomplicated PONV usually resolve within 24 hours after an operation whereas intractable PONV involve various triggering factors and resist to medical treatment, making it harder to treat. Studies revealed that most patients dislike chronic PONV more than postoperative pain as it is a more distressing illness and it may lead to several serious clinical consequences if left untreated. In the case of repeated vomiting, PONV patients might suffer from dehydration and have a higher chance of developing hiatal hernia, a condition where the upper part of stomach protrudes into the thorax through the opening of diaphragm. Other than that, patients might also experience anorexia, gastrointestinal discomfort, headache, weakness, dizziness and nausea while not vomiting. Chronic vomiting can also cause complications like dental damage and sore throats due to exposure of oesophageal lining and mouth cavity to the low pH gastric acid. Moreover, PONV may induce serious problems like pulmonary aspiration, electrolyte abnormalities, wound dehiscence, increased pain and oesophageal rupture.4,5 Despite causing patients discomfort, patients also have to pay more for the delayed hospital discharge. Each incidence of vomiting has increased postanaesthetic care unit (PACU) stay duration by 20mins. Therefore, to reduce the unanticipated hospital admission and the financial burden broug ht by PONV, there is a need to understand the disease pathophysiology so that precise and mechanism-based treatment strategies can be developed to tackle the emesis problem. The vomiting centre and the chemoreceptor trigger zone (CTZ) are the two main parts of the brain controlling the vomiting action. The vomiting centre is located within the medulla oblongata and the emesis action is initiated via the stimulation of five primary afferent pathways. They are the chemoreceptor trigger zone, vagal mucosal pathway of the gastrointestinal system, neuronal pathways from the vestibular apparatus system, inputs from the periphery glossopharyngeal nerve and reflex afferent pathways from  cerebral cortex C2,3 and midbrain afferents. Next, efferent nerve impulses are sent to various place of the body such as the pharynx, larynx, diaphragm, intercostals muscles and gut to initiate the vomiting reflex. During the ejection phase of the vomiting reflex, the diaphragm and abdominal muscles  simultaneously contract and the elevated intra-abdominal pressure leads to the throw up and expulsion of gastric contents. A variety of receptors are participated in the emesis action. They are the histaminergic(H1), dopaminergic(D2), serotonergic(5-HT3), muscarinic and neurokinin-1 receptors. Consequently, pharmacological agents which target on these receptors can be utilized to treat PONV. However, the British National Formulary (BNF) had advised that antiemetic agents should only be used once the causative factor for nausea and vomiting was identified. This is because the use of antiemetic is sometimes dangerous and inappropriate in clinical cases like diabetic ketoacidosis, digoxin or antiepileptic overdose.6 Hence, the aetiology and possible causative factors of PONV should be investigated to guide the planning of the pharmaceutical management steps and the antiemetic selection for treating PONV. There are patient-specific factors, surgical factors and anaesthetic risk factors which contribute to PONV prevalence. Patients who aged 6 to 16 year old, female, non-smoker, obese or have a history of motion sickness or PONV are proven to be the high-risk patient group. Moreover, patients who have chemotherapy, migraine and gastroparesis problems are also susceptible to PONV. Other causative factors include elevated intracranial pressure, metabolic abnormalities, gastroduodenal ulcers, dehydration and infections of the gastroesophageal lining. As for the surgical factors, PONV is related to the premedication side-effect, prolong fasting, conditions of gastric inflation during mask ventilation, use of long-acting opioids, nitrous oxide, volatile anaesthetics and high dose neostigmine in surgery. In addition, frequent head movement of patient and early intake of food after surgery can also potentiate the nausea problem.1 Some types of operations have higher chance of developing PONV, they are the gynaecological surgery, ear, nose and throat operation, intra-abdominal and squint correction surgery. Furthermore, the surgical duration is also an important contributor which predisposes patients to a higher risk of PONV. Every 30 minutes extension in surgical time can increase risk of PONV by 60% as patient is taking in more anaesthetics into the body. Hence, healthcare team should control and minimize the surgery duration such that risk of getting PONV is reduced. Although it is not relevant to discuss anaesthetic techniques in this case scenario, it is important to note that regional anaesthesia should be preferred over general anaesthesia during surgical process. According to SOGC guideline, there is an 11-fold increase in the PONV risk when using general anaesthesia rather than regional anaesthesia. Apart from that, volatile anaesthesia, long-acting opioid and neostigmine should also avoid in surgery as these agents predispose patient to PONV. If the use of general anaesthesia is unavoidable in a surgery, propofol can be a suitable induction agent because it induces less PONV incidence. A thorough assessment should be carried out to serve as a rationale for the management plan of PONV. The past medical history, frequency and nature of the vomiting episode, blood electrolyte test and physical examination can be evaluated to identify the severity of disease condition and the aetiology of PONV. Subsequently, the appropriate pharmacological agents which target on the responsible pathway of emesis can be given. Many antiemetic preparations are available in the market and patients can choose between formulations of solution, buccal tablets, rectal suppository and subcutaneous (SC), intravenous (IV) or intramuscular (IM) injections when oral route is not feasible.6 As no single agent provides complete control in emesis, most hospital has adopted a multimodal approach and a combination strategy where different antiemetics which target on different receptors are utilized in the treatment of PONV.1 Combination therapy becomes the preferable way to treat PONV and the generally used combination is 5-HT3 receptor antagonists with droperidol or dexamethasone. Granisetron and ondansetron are examples of 5-HT3 or serotonin receptor antagonists. They exert their effects in the chemoreceptor trigger zone and at vagal afferents of the gastrointestinal tract. Previous studies showed that no single agent performed exceptionally well than the others of same class as all 5-HT3 antagonists illustrated similar safety and efficacy profile. Yet, a recent meta-analysis which includes 85 randomized controlled, double-blind studies with 15,269 patients involvement had established that the antiemetic effect of granisetron is significantly superior to ondansetron and dolasetron. Ondansetron was also found to be more cost effective than granisetron. 1-2mg of granisetron or 4-8mg of ondansetron can be delivered in intravascular route at the end of surgery for PONV treatment. Long-acting serotonin antagonist with higher binding affinity to 5-HT3 receptors, palonosetron, is also available in the market with a long half-life of about 40 hours. Patients receivin g these agents might experience headache, constipation and dizziness problems. Droperidol is a butyrophenone which acts competitively on central dopaminergic receptors in the chemoreceptor trigger zone (CTZ). It is applied in 0.625-1.25mg IV route at the end of surgery. A systematic review of 24 randomized studies was carried out by Schaub and team, they concluded that droperidol decreases PONV incidence regardless of the dose given to patients. However, this drug is only used as a third-line antiemetic for intractable PONV when other alternative treatments failed because droperidol can lead to adverse effects associated with QT prolongation and torsades de points, sedation, anxiety, hypotension and extrapyramidal symptoms. Due to its possibility in causing fatal arrhythmia, electrocardiographic monitoring is compulsory each time upon its usage. Nonetheless, a double-blinded randomized clinical study which included 120 patients stated that there was insufficient evidence to prove the QTc prolongation effect induced by droperidol after surgery. Dexamethasone is classified under corticosteroids and often delivered in a 4 to 5mg one-off dose via IV or IM route.19 The exact mechanism of action is unknown but it is related to the peripheral inhibition of prostaglandin synthesis and its ability to reduce 5-HT turnover in the CNS. Although dexamethasone is not licensed for the indication of PONV, this drug is as effective as other conventional antiemetic drugs like droperidol and serotonin antagonists. A single blinded, randomized-controlled interventional study had illustrated that the administration of dexamethasone is useful for the reduction of PONV episodes (30% in contrast to 70% of the placebo group).20 Moreover, Ormel et al. illustrated that the addition of dexamethasone to droperidol and ondansetron showed a profound amplification in the efficacy profile of these triple agents combination. It stands as a good alternative for PONV treatment due to the advantage of cost-effectiveness issue and its characteristic of long ac tion duration. As dexamethasone can increase plasma glucose level, it is not recommended for diabetic patient. Furthermore, unfavorable side-effect like postoperative euphoria, impaired wound healing, irritability and adrenal suppression can happen in patient taking long-term corticosteroids. Metoclopramide is a gastroprokinetic agent which acts on the D2 receptors of the gastrointestinal tract. It can accelerate the gastric emptying rate of gastroparesis and GI obstruction patients.2,6 Despite blocking the D2 receptors, it also has antagonist action on 5-HT3 receptors in the CTZ and vomiting centre when delivered in high doses. 5 to 20mg dose of metoclopramide in subcutaneous, oral or IV route is commonly taken by patient before meal and before bed.6 This medicine is commonly administered as combination therapy because there is conflicting evidence stating that metoclopramide alone is ineffective for PONV and it should not be use unless the causative factor for PONV is gastric stasis. Yet, a recent meta-analysis has proved that 10mg IV metoclopramide does well in preventing nausea and vomiting problems after the general anaesthesia surgery. As with the phenothiazines discussed below, both drugs have limited use in practice due to the adverse reactions like extrapyramidal effects and dystonia disorder particularly in pediatric and young adults population. Phenothiazines is an example of strong dopamine antagonist which also act on medullary CTZ. Promethazine, prochlorperazine and perphenazine belong to this group and take part in the prophylaxis and treatment of PONV.24 Prochlorperazine is often administered as a 12.5mg deep intramuscular injection or in a 3 to 6mg dose buccal preparation 12 hourly after the surgery. These agents show superior efficacy in treating opioid-induced PONV. However, high-dose metoclopramide and phenothiazines are now less likely used in clinical practice because of their significant side effects like acute dystonic reactions, sedation, dizziness and extrapyramidal symptoms.9,25 A systematic analysis consisting of 19 non-randomized and randomized clinical trials had demonstrated that most studies supported the effectiveness of promethazine in reducing PONV occurrence when compared to placebo and that combination therapy is always preferable and more effective than promethazine alone. Cyclizine is an antihistamine drugs which block the H1 sympathetic pathway in the vomiting centre. The antimuscarinic and antihistamine properties of cyclizine render it to become an antiemetic drug in PONV treatment. A randomised double-blinded study which involved the participations of 960 women had shown that patients who received cyclizine monotherapy showed a slightly greater antiemetic effect than granisetron alone (PONV incidence of 24% with cyclizine compare to 23% in granisetron group).26 Cyclizine can be given orally, intramuscularly or intravenously, with common antimuscarinic side-effects like sedation and dry mouth. Severe heart failure patient should avoid taking this medicine because it leads to detrimental haemodynamic effect.6 The acidic pH of cyclizine at 3.2 also causes pain and irritancy to body upon injection.10 As a result, patients usually have 50mg of cyclizine IV injection every 8 hours after proper dilution. A lower dose of 25mg in oral, IM or IV preparation s can also be applied in elderly patient. Scopolamine has anticholinergic property which inhibits the muscarinic as well as the histaminergic receptors in the vestibular apparatus and the nucleus of the tractus solitarus.3,9 Patients who undergo middle ear surgery or use opioids as postoperative anaesthetics are recommended to take scopolamine for their profound efficacy in reducing PONV.3 Scopolamine requires 2 to 4 hours for onset of duration. Hence, a fast-acting antiemetic or a loading bolus dose is needed in urgent case. It is available in transdermal form as a 1.5mg patch which can be placed behind the ear. This slow-release formulation can have sustained effect up to 72 hours. Apfel C et al. had reported that transdermal scopolamine had significantly reduced the risk of PONV when compared to the placebo group although it has the main side-effects of dry mouth, sedation and visual disturbances.28 Furthermore, a comparative study between the combination use of ondansetron plus scopolamine patch and ondansetron alone als o proved that the earlier group significantly decrease the nausea and vomiting incidence after surgery. Other than a mechanism-based approach, less conventional therapeutic agents can also be used to treat intractable PONV cases. An antidepressant with a novel indication, mirtazapine, is able to ease the nausea and vomiting symptoms because it can antagonize 5-HT3 receptors. A small scale randomized trial which compared the therapeutic outcome of mirtazapine and ondansetron had showed that patients using mirtazapine were less anxious and had fewer PONV episodes than the ondansetron group. Next, olanzapine which is recognized as an atypical antipsychotic drug also proved to have potential in treating PONV. It can inhibit several receptors such as the dopamine, acetylcholine, histamine and 5-HT3 receptors. Ibrahim M et al. had conducted a randomized controlled study which involved 82 surgical patients. The result proved the efficacy and safety profile of olanzapine against PONV especially during the late postoperative stage. Other than medications approach, non-pharmacological interventi ons also show potential therapeutic efficacy in PONV management. Acupuncture, acustimulation or acupressure serves as a good alternative or adjuvant therapy for PONV patients as it shows good tolerability and safety profile. The P6 point (Neiguan) which located at 5cm near to the ventral wrist is the target site of these alternative approaches. Transcutaneous electrical stimulation delivered to the P6 point of the pericardium meridian has been proved to be an efficient way in preventing emesis. Patients only complain of light side-effects like needle fainting, allergy, needle site pain, anxiety or lethargy problems when using this method. In order to solve the labour intensive and time-consuming issues of traditional Chinese acupuncture, the acupressure and acustimulation wristband are introduced in the market (Sea-Band and ReliefBand). Sea-Band applies steady, continuous pressure on the P6 point whereas ReliefBand is a watch-like device which conducts low current to P6 point via electrodes in contact with the skin. Based on the well-established efficacy profile and good evidence-base literature support, healthcare professionals can involve more acupuncture interventions in treatment practice as part of the multimodal approach. In this case, the intractable emesis symptoms experienced by the old woman might indicate the failure of prophylaxis treatment or the need to start a primary antiemetic treatment. Before the initiation of a rescue treatment, a bedside examination and a patient interview should be done to find out whether the PONV symptom is associated to issues such as morphine analgesia, surgical pain management, infection, intestinal obstruction, hypotension, hypoxia, blood in the pharynx, anxiety or removal and insertion of nasogastric tube. 5-HT3 antagonist is the recommended drug for patients who previously do not receive a prophylaxis treatment. Patient can start with a low dose regimen such as ondansetron 1 mg, dolasetron 12.5 mg and granisetron 0.1 mg. If drugs for prophylaxis had been given but fail, patients can then try other class of antiemetics to tackle more diverse receptor pathways. For instance, Habib et al. had found that the failure of prophylactic ondansetron or droperidol can be replaced with rescue agents like promethazine (12.5-25 mg IV), prochloperazine (12.5mg IM) or cyclizine (25-50mg IV or IM) to achieve a better outcome. This is because consensus guideline support that the repeat use of 5-HT3 antagonist within the initial 6 hours postoperative period provides no extra recovery response. If patient use dexamethasone as prevention agent, small dose 5-HT3 antagonist (25% of prophylactic dose) can then be given as a rescue approach. A study also concluded that the cost-effectiven ess of ondansetron in low dose treatment group was higher than that in the high dose prophylatic group. Moreover, in the case of the aggressive treatment failure, such as those who had taken 5-HT3 antagonist, droperidol and dexamethasone altogether but failed, repeat dosing of same prophylactic regimen except dexamethasone can only be considered 6 hours after the surgery though the optimal dosage and timing for readministration still remain unknown. Transdermal scopolamine can also be prescribed for outpatients as it is a more convenient preparation than the parenteral drugs. Prolong use of opioids for pain control after surgery should also be minimized as side-effects like nausea and vomiting are correlated to the prescribed dose. Alternative analgesics like NSAIDS can be used to substitute the causative opioids. In persisting case, pharmacist can review the prescription and anaesthetic charts to ensure adequate maintenance of analgesia, antiemetic and oxygen supply. Dose escalation under safety and therapeutic dosage range can also be worked on. However, pharmacist should be cautious on polypharmacy problem as it may aggravate nausea and vomiting in susceptible patient. Non-oral drug preparations can be considered over oral route to avoid burdening of patient with excessive pills at one time. If necessary, the acupuncture treatment can also be applied to attempt a multimodal approach. Pharmacist should also concern about the possible dehydration risk that might be encountered by chronic PONV patients. For this reason, the blood pressure, hydration and perfusion level of patients have to be checked on a regular basis. Patients should be told to report of symptoms like dry or sticky mouth, sunken eyes, reduced urination or dark yellow urine. If constipation or diarrhea happens, intravenous fluid replacement therapy, osmotic or stimulant laxative can be given to solve the issues. For the dietary measures, patients should avoid oily or spicy food which might aggravate the nausea. Small, frequent meal is preferable over big heavy meal as light meal reduce the possibility of gastric discomfort. Patients should be advised to not move around too often to avoid triggering the vomiting centre. Furthermore, in post-discharged nausea and vomiting (PDNV) case, the antiemetic efficacy profiles are different from PONVs as they have dissimilar underlying cause. Droperidol should be avoided as it is ineffective in treating PDNV.2 If the patient still not responsive to all these approaches, specialist intervention should be initiated to treat intractable nausea and vomiting symptoms. Serious causative factors like surgical complication might be suspected and further investigations are required to treat this disease. In a nutshell, the optimization management of PONV disease requires the participation of the multimodal approach. Patients should be treated accordingly after the accurate disease assessment and further modifications of treatment approaches like (dose-adjustment, introduction of new agents or alternative approaches) can be done to control patients nausea and vomiting symptoms. Lifestyle modification and non-pharmacological interventions also play an important part in treating PONV. Proper patient education about symptoms management should be delivered and follow-up session can be arranged to assess patients rehabilitation progress. Apart from that, reassurance and full supportive care from healthcare teams also play an important role in reducing patient distress and anxiety level.