Geographic and Environmental Factors Essays

Geographic and Environmental Factors Essays Geographic and Environmental Factors Paper Geographic and Environmental Factors Paper The early colonists had trouble passing over the Appalachian Mountains due to the extremely difficult environmental conditions that these mountains posed. The early colonists had to endure harsh and brutal surroundings (that they often didnt survive) in order to be able to reach the other side. The Appalachian chain is a barrier to east-west travel as it forms a series of alternating rigidness and oriented in opposition to any road running east-west (Wisped, 2013). This cross- mountain trek was imperative in order for early settlers to migrate westward and thus expand the united States. As a consequence of the serve conditions, the Appalachian Mountains kept westward expansion from occurring at a faster pace and is actually one of the reasons why colonies developed more rapidly in the east while the west came to be seen as a hostile territory by most colonists. This all changed with the discovery of Cumberland Gap. On the boards of the U. S. States Kentucky[->2], and Virginia[->3] is Cumberland Gap which is a pass through the Appalachian Mountains. : The moment colonists discovered the Cumberland Gap turned out to be an essential time in American history. With the formation of the United States, an important first phase of westward expansion in the late 18th century and early 19th century consisted of the migration of European-descended settlers westward across the mountains into the Ohio Valley through the Cumberland Gap and other mountain passes (Wisped, 2013). Even though the fact that the Cumberland Gap was guarded by Native American tribes when it was first discovered did not deter the westward bound migrants. This pass through the Appalachian Mountains was nonetheless proof that expansion westward was to as difficult as it had been previously and then the floodgates were opened to the migration of the colonists. It is estimated that between 200,000 and 300,000 migrants passed through the gap on their way into Kentucky[->4] and the Ohio before 1 810 (Wisped, 2013). The second environmental or physical geographic factors that contributed to the development or expansion of the United States were the Mississippi and Ohio rivers. Although many colonists wanted to go farther west, after finally making it to the other side of the Appalachian Mountains, in order to reach he Pacific Coast, some realized that the mid-west region of the United States represented an intriguing location. The area consisted of valuable nutrient rich lands that could be used in growing large areas of grain and raising of livestock. Concomitantly, colonists were impressed with the fact that they could also utilize the Mississippi and Ohio rivers for transportation fifths grown agriculture, for transportation of people, and for food for their tables. The colonists took into account that they could provide basic necessities for numerous individuals and multiple usages by monopolizing the Mississippi and Ohio rivers. By the sass, cotton, grain, pork, and other agricultural products floated down the Mississippi River to the citys docks. The rise of the steamboat brought trade upriver and opened the Midwest to settlers and goods (River Towns, River Networks, 2012). Settlers thus expanded long these rivers and built settlements. The Mississippi, Ohio, Missouri, Illinois, and other rivers knit together the American nation over the course of a century. In an era before widespread highways and railroads, the farms and industries of the Midwest poured their goods downriver to markets around the world (River Towns, River Networks, 2012). This made it possible for the colonies to experience rapid expansion westward and for colonists to significantly contribute to the development and expansion of the Un tied States. The geographical and environmental factors such as the Appalachian Mountains with its Cumberland Gap and factors such as the Mississippi, Ohio, Missouri, and Illinois rivers have significantly contributed to the development and expansion of the United States. The geographical features of the Appalachian are extremely important because of the literal barrier and roadblock that these mountains originally posed to be and then once Cumberland Gap was discovered it literally opened a floodgate to the westward expansion of America. The major river systems of the Mississippi, Ohio, Missouri, and Illinois rivers made possible the growth, development, and facilitated the explanation of the U. S. Because, People followed waterways, from canals to great rivers, to build businesses, communities, and new lives (River Towns, River Networks, 201 2) The most significant environmental or physical geographic factors that contributed to the development of the history and culture of the, Mesopotamia civilization is inextricably connected to the ebb and flow of the Tigris and Euphrates Rivers (Krebs, 2006). History shows that a citys or a civilizations geographic position always plays an important part in its ability to thrive and grow. The area of Mesopotamia neighboring the Euphrates and Tigris rivers provided people with the opportunity to settle in the territory and to build one of the most complex civilizations that existed until that time. In fact, the Mesopotamia civilization is responsible for establishing, developing, and implementing such things as higher social thinking, original agricultural technological methods, and development. This society is responsible and known as the birthplace of civilization; the original place for such things as religion, art, literature, science judicial order, agriculture and so much more. The most significant environmental and physical geographic factors that contributed to the development of the civilization of Mesopotamia were the Tigris-Euphrates river system. Because of its proximity and placement near these rivers, the society developed and grew primarily into a thriving agricultural society. As the muddy Tigris-?Euphrates river system flooded and receded, their silt built a plain with rich soil, ideal for agriculture in which this society of Mesopotamia flourished and capitalized on. Agriculture, thanks to the construction of irrigation ditches, became the primary method of subsistence (for Mesopotamia). Farming was further simplified by the introduction of the plow (Krebs, 2006). Because the rivers provided the environment ideal for agriculture, the Mesopotamia society developed into a rich, prosperous, and influential civilization that passed these developments on to other societys and groups of people. As humans, We are shaped by the world around us. The food we eat, the clothes we wear, even the languages we speak all have a connection to the geography of the world around us. From the first civilizations and cultures throughout history to our world today, people and their environments form complex relationships that can have a profound influence on every aspect of our lives (Geography and Development: Diffusion of Human Societies, 2006-2012). Some of the most important tools in history were first developed in Mesopotamia. The Sumerians were the civilization of people who lived in ancient Mesopotamia and developed tools for a variety of projects, from farming to fighting to transportation (Gabriel, 1999-2013). Through cultural diffusion over time these tools, such as the plow, and other agricultural concepts from the Mesopotamia society reached other regions. An area that these agricultural tools migrated to was the Nile River area (later known as Egypt) by migrations f people through different methods like trade routes and other cultural diffusion methods. Early tribal peoples migrated to the Nile River where they developed a settled agricultural economy and more centralized society (Egypt, 2012). The evolution of these concepts, tools, and knowledge were a significant to the development and growth of, first, the Mesopotamia society and then later the Nile River regions and societies. From there the agricultural concepts and ideas were then carried, spread, and diffused throughout the world.

Management Article Example | Topics and Well Written Essays - 250 words - 3

Management - Article Example Eisenberger, Jones, Stinglhamber and Shanock (2005), explain the impact of need for achievement on motivation from the point of the opportunities for an employee to be able to increase positive mood and task interest at work, as well as organizational spontaneity. Need for power within the working environment influences motivation in terms of person’s satisfaction after one’s will is listened and wants fulfilled by others. Such employees and often managers are motivated by the need to self-esteem and building their reputation (McClelland  & Burhman, 2003). It may seem as a negative aspect to be motivated by power to manage situations and other people; however, for manager such need leads to setting clear targets and achievement of goals. Unlike need for power, employees’ need for affiliation appears from the desire to have a friendly environment within work and it is followed by motivation to effect team in a more supportive way. Greater level of affiliation ensures greater personal interaction and motivates employees to achievement of common goals in a friendly

Writing an Argumentative Essay - How to Prepare For an Argumentative Essay

Writing an Argumentative Essay - How to Prepare For an Argumentative EssayIf you want to write an argumentative essay for your 8th grade English class, you may have a lot of questions. Below are a few tips on how to prepare for an argumentative essay.A very important skill when writing an argumentative essay is that you are writing about facts, and not opinions. You must be able to construct sound arguments that will convince the reader.The final step in preparing for an argumentative essay is to be sure that your points are well supported. You should know the background of both sides of the argument before you begin to write your essay. Start with some background reading to understand the argument and what it is intended to accomplish. Make sure to present both sides of the argument.The next step is to write the argumentative essay. Your essay will most likely be limited to an argument based on the facts you gathered. Remember that your essay should be written so that your reader wi ll be convinced that they agree with your viewpoint. The thesis statement and conclusion must always be positive and constructive.End your essay with a reason why the reader should agree with you. Use words such as you. While your essay is on a topic you are passionate about, use short sentences and paragraphs that get to the point. Be brief but bold when writing. If you give your essay too much space it will be difficult to convince your reader that you have something to say.It is very important that you follow the 'How to' lesson plan in preparing your essay. The goal is to come up with a topic that interests you, gather as much information as possible, and then write a well-reasoned essay that appeals to the reader. By following the directions from the 'How to' lesson plan, you will have a topic that will appeal to a large audience.Writing a perfect essay requires experience and knowledge of the English language. Once you learn the right way to write a persuasive essay, you will also have a more powerful argument to make in your arguments. While a proofreading assignment or even a fresh assignment can correct errors in your essay, the only true way to learn is by doing.

The New Angle On Debate Topics Probably on the Act Essay Just Released

The New Angle On Debate Topics Probably on the Act Essay Just Released Most Noticeable Debate Topics Probably on the Act Essay Utilizing the aforementioned criteria as a simple guideline should make it possible for a writer to locate an acceptable topic. Since you may see, finding an appropriate topic is not quite as simple as it might appear. To discover argumentative essay topics easy on various platforms, you want to comprehend about the argumentative essay. A persuasive essay is a powerful tool when you want to supply a new vision of a specific topic for the reader. Argumentative essay topics are so important since they are debatableand it's important to at all times be critically considering the world around us. Moral argumentative essay topics are a few of the simplest to get carried away with. You don't need to find super technical with legal argumentative essays, but make sure you do your homework on what the recent laws about your preferred topic actually say. So you must have a thesis before you may write your topic sentences. A manageable topic is one which can be successfully performed within the page needs of the essay. You will likely find a different and terrific topic you will love to write about. Whatever They Told You About Debate Topics Probably on the Act Essay Is Dead Wrong...And Here's Why To defend your subject, you might recall the effect of overloaded schedule on college grades. College loans are frequently the very first major financial dealing that individuals work with. All you will need is to select the field you're good at. To begin with, it can be hard to gauge how colleges utilize the ACT essay score because the score isn't utilized to. So here it has come to be one important job. Writing about widespread problems such as national or global problems is often unmanageable in just two or three pages. A. It is not your choice to make. Prior to going to a debate, it's ideal to orient the students on the process. There are lots of aspects about a sport which can be argued in an essay. What's more, a verbal argument often focuses on who's right regarding a particular issue, though a well-written, researched argument essay focuses on what's the proper side of a specific issue. An essay on bullying isn't restricted to defining the term. It's possible to incorporate a huge quantity of recent research, developing a well-thought essay. A student ought to keep in contact with the hottest trends and know which persuasive essay topics are related to sound convincing in regards to defending personal opinions. Controversial topics work nicely for speeches and essays, since they typically evoke strong opinions on either side. It's important to select debatable argumentative essay topics as you need opposing points you can counter to your own points. A great guideline is to locate some effortless debate topics to research. All you will need is to select the one which reflects your private interest and acknowledgment. It is essential to opt for a great topic so as to compose a wonderful paper. You can witness the spirit whenever the students are participating in school activities like competitions outside the school. Students need more practical subjects to learn the way to use unique things. They should be allowed to pray in school. They need recess to interact with each other and make friends. Using technology and the web has had an enormous influence on society and the modern generation, which makes it the most progressive up to now. Advertising and the media are now nearly inseparable from society for a whole. Google News is an excellent first step as it can provide you a notion about the most recent topics. Up in Arms About Debate Topics Probably on the Act Essay? Government should think about allowing euthanasia . The Basics The Constitution is the maximum law in the usa. The 27th Amendment is in fact one of both left-over amendments from 1791. Senators should represent the interests of all the folks.

Why People Arent Talking About Examples of Graduate Level Research White Papers and What You Should be Doing Today

Why People Aren't Talking About Examples of Graduate Level Research White Papers and What You Should be Doing Today Attempting to compose a graduate-level research paper at the last minute is near impossible if you desire a great grade. The white papers we are going to be speaking about today are different. The more you fully grasp the simpler it's for you to compose a thriving research paper. Writing a research paper even though may appear challenging is a considerable portion of routine student life. The Tried and True Method for Examples of Graduate Level Research White Papers in Step by Step Detail Vary the sorts of data visualizations you use based on the kind of information. The article's list of cited references will be supplied at the close of the short article. 1 page could have a featured image, another a massive quote, and the upcoming only including written content. Dividing your page into columns is a superb means to organize your information and help you save space on the webpage. New Ideas Into Examples of Graduate Level Research White Papers Never Before Revealed Using informal or conversational wording needs to be avoided. As soon as you've made all the changes, read it over yet another time. For additional information about the course and the process don't hesitate to get in touch with our administration team. The solution is with a thorough promotion program. Examples of Graduate Level Research White Papers Can Be Fun for Everyone Acknowledging the effect of returns on other regions of the company means making relevant small business units conscious of the valuable information readily available to them. Connecting returns data to other sections of the company means you've got to have good data collection capability. 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The report emphasizes that in too many scenarios, higher school just does not prepare students for the rigors of college life, including most especially all the writing they must do in order to succeed. An excellent teacher will provide you with th e tools to create your problem solving easier and more effective. As the writer, you must state what it is you're attempting to accomplish in the start of the paper in order for your audience may read the remainder of your paper through the lens of your initial intentions. If you create your white paper design engaging, far more folks are going to need to read it. By being prepared, you will be more reliable. You might actually discover that something you might not like will prove to be incredibly rewarding. Examples of Graduate Level Research White Papers You'll have more perspective on various interpretations of the dots and lines you see before you. When a paper is suitably organized, it is going to flow from section to section making the transitions easy to follow along with. There are various characteristics of graduate writing that aren't found in different kinds of writing. While writing, consider what sorts of images you'd like. The Examples of Graduate Level Res earch White Papers Trap You must write a minumum of one research paper in a semester for most the subjects. Without research, there isn't any topic. The entire research should be constructed around or from the subject. Research at the master's degree level is largely based on trying to develop a topic that's narrow in scope, but answers a substantial question which exists in the scholarly literature. A strongly written introduction and conclusion are unquestionably impertinent in regards to quality graduate work. Play as much as possible in every potential situation it is possible to end up in. Vast majority of the respondents also have a yearly gross household income that doesn't exceed P50,000. You will complete our foundation courses with increased confidence in your capacity to obtain a fantastic degree and progress to a prosperous career. Our crew of experienced professionals will give you individual attention and exceptional guidance throughout your procedure for application. Many mistakes most students make is they think their university certificate is truly worth more than the knowledge they've applied or the experiences they've gained. A number of the mistakes that professors would allow at the undergraduate level aren't tolerated when the graduate level was reached. Where to Find Examples of Graduate Level Research White Papers There's well-known that you aren't going to have the ability to compose a great insightful research paper if you're not interested in the subject overall and in this issue specifically. As you will need to do lots of research later, we advise that you decide on a topic that's of interest to you. You must be certain to understand every thing clearly once you go for an essay topic. Your paper topic should meet up with the course requirements, but it also ought to relate to your very own scholarly interests.

Writing and Environment Essay Example | Topics and Well Written Essays - 500 words

Writing and Environment - Essay Example Jared Diamond’s article titled The Last Americans: Environmental Collapse and the End of Civilization issues a warning to those living in advanced economies (including the United States) that great civilizations of the past inevitably decline and perish after hitting their peak. He suggests that being complacent currently can lead to irreparable ecological catastrophes in the near future. The article Am I Blue by Alice Walker touches upon an allied concern, namely the issue of animal rights. She suggests that human have for too long exploited animals for their own selfish ends and that this is a symbol of human conflict too. So in order for humans to flourish, they have to start treating animals ethically. All three authors discussed above raise several valid points and their observations validate each other’s arguments. Rachel Carson’s article titled The Obligation to Endure is gives an in-depth analysis of the state of chemical pollution in our environment. Carson asserts that the rate at which new synthetic pollutants are let out into our environment is too fast for life-forms to adopt to and evolve accordingly. As a result our planet is now at a cusp of a fatal disaster. Given the gravity of the issue, Carson does not employ humor or sarcasm. Instead, her prose is of a serious tone, infused with dark irony and earnest imploration. Her appeal to the reader is quite powerful, for it comes at the back of a detailed and factual analytical presentation. One chemical problem that Rachel Carson focuses on is that of the insecticide. This seemingly beneficial device to keep insect pests has caused unforeseen consequences of vast proportions. Insecticides such as DDT, while providing immediate improvement in agricultural productivity, have caused severe collateral damage. For this reason, Carson asserts that

Bullwhip Effect In Healthcare Sector

Bullwhip Effect In Healthcare Sector In Supply Chain management, Bullwhip effect has attracted some considerable importance in the FMCG sector in the last 20 years. The phenomenon Bullwhip Effect shows how small changes at the customers end have tremendous impact on the operations back there in the chain. The cause behind this effect is mainly attributed to the increasing demand variability in the supply chain. We consider the number of companies taking part in a single supply chain. Each of the company gets the order from its immediate downstream company to be fulfilled. In Bullwhip effect the orders to the suppliers tend to have a larger variance than sales to the buyer. This demand distortion then gets amplified while propagating upstream. The paper mainly focuses on how the Bullwhip effect the matching of the demand and supply and the main causes leading to this. It also focuses on the PG case study to understand the Bullwhip effect and the steps taken to dampen the bullwhip effect. Further it aims at quantifying the bullwhip effect and reducing its impact on the supply chain. Acknowledgement I am thankful to Mukesh Patel School of Technology Management and Engineering (MPSTME) for giving me this opportunity to understand the Bullwhip Effect and the major causes and the PG case. Furthermore helping us understand the various techniques and procedures for writing a research project. I would also like to express my sincere gratitude to my college mentor Prof. Jinu Kurian for her continuous guidance and support and being available at all times whenever the need may arise. I would also like to thank Prof. Prasad Chakrabarty for his help and support in the project. Table of Contents Introduction The bullwhip effect occurs when the demand order variability in the supply chain is amplified as they moved upstream in a supply chain. Distorted information from single end of a supply chain to the other may lead to tremendous inefficiencies. Companies can effectively deal with the bullwhip effect by thoroughly understanding its underlying causes. Organizational leaders are implementing various innovative strategies that pose new challenges: integrating new information systems defining new organizational inter relationships implementing new incentive and measurement systems. At macroscopic level, Bullwhip Effect generates inefficiencies in production scheduling, sourcing, capacity utilization, distribution and the profit generation. While if we take a look at the operating level it induces additional inventory which is placed inappropriately to maintain the service levels. It also reduces the performance level by decreasing the incoming cash and the potential revenue. It can even dilute any companys competitive strategies. 2 factors have changed the landscape of supply chain management in the last few years significantly. Availability and use of the technology and software applications to allow capture and sharing of information across a supply chain mostly through extranets Increasing indulgence of members of the supply chain in order to move towards to put aside the traditional arms-length relationships amongst each other and in its place move towards closer, partnership-type arrangements. Again, the networks over which these collaborations take place must include the necessary levels of performance, scalability, security and reliability to realise these benefits to their maximum potential. Problem Statement To analyse the Bullwhip Effect in healthcare sector and to find out its causes, consequences and cures. Significance Global competition in the world market today contains many challenges to achieve a degree of predictability in the supply chain and remove the impact of Bullwhip Effect. Researchers have examined the bullwhip effect and some models to reduce it, however a very few research has been done on analysing the Bullwhip Effect in healthcare sector and to find out its causes, consequences and cures quantifying the effect of bullwhip and its Measurement still remains an exigent research path. Research Methods A case-study based approach was employed to conduct the research. Data were gathered primarily through interviews, observations and archival sources. At the hospitals, Interviews were conducted, in person, with doctors, nurses, administrators, and other hospital staff. At the diagnostic laboratory, personal interviews were conducted with the CEO, pathologists and other lab technicians. As far as data gathering is concerned, we decided to employ an informal, minimally structured, non-directive interview approach, enabling to minimize the influence of the assumptions. . Literature Review Fluctuations in demand have a varying graph when we compare from industry to industry. Driven by seasonal demand and business cycles, apparel industry faces major demand adjustments, while the diaper market is subjected to constant demand in the market arena. Due to misjudgement of demands, the big players in the retail market can be subjected to inventory shortages or surpluses. But given the consistency of demand in the diaper market the diaper supply chain should be more efficient and accurate. But it isnt the case. The diaper market even with the reliable demand patterns isnt able to match the demand-production matching. The major cause to this supply chain inefficiency can be subjected to Bullwhip Effect. The term was coined by Procter Gamble who noticed amplification in the information distortion as the information of the order travelled upstream in the supply chain. Bullwhip effect or Whiplash effect can be majorly seen in the forecast driven distribution channels. It indicates a lack of synchronization among the members across the supply chain. Even if there is a small fluctuation in the customer sales, it reflected upstream in an amplified form. Because of this supply patterns does not match the demand patterns resulting in inventory surplus at various stages of the supply chain.C:UsersIndiaDesktopblwhp.jpg As the customer demand would be rarely perfectly stable, businesses should forecast demand in order to match the demands with the production and managing their inventory levels. Some of the major reasons behind bullwhip effect are:- Forecast Errors Overreaction to backlogs Lead time variability No communication and no coordination along the supply chain members Delay in information and material flow Price fluctuations Product promotions Order batching raw material orders from ProcterGamble to its suppliers fluctuated over time. On further noticing it was found that farther down the chain, when sales at retail stores were studied, it was found that the fluctuation which was present, were small. It is reasonable to assume that the consumers of the diapers at the last stage of the supply chain used them at a steady rate. Although consumption at the end product was stable, orders for raw material were highly variable, increasing costs and making it difficult for supply to match demands. Lack of coordination between supply chain members also results if information distortion occurs within the supply chain. Considering the Bullwhip effect PG observed in the diaper supply chain. As a result of the bullwhip effect, orders PG receives from its distributors are much more variable than the demand for the diapers at retailers. The lack of the supply chain coordination between members has an adverse effect on manufacturing cost. It increases the manufacturing cost in the supply chain. PG and its suppliers must satisfy a stream of orders that is even more variable than customer demand. ProcterGamble responded to the increased change by either building excess capacity or by holding excess inventory, both of which increase the manufacturing cost per unit produced. It even increases the replenishment lead time in the supply chain. The increased variability due to bullwhip effect makes scheduling at PG and supplier plants much more difficult as compared to a situation with level demand. There are times when the capacity which is available and inventory cannot supply the orders coming in. This results in higher replenishment lead times in the supply chain from both PG and its suppliers. It even hurts the level of product availability and results in more stock outs in the supply chain. Very high fluctuations in orders make it difficult for PG to supply all distributor and retailer orders on time. This increases the likelihood that retailers will run out of stock, resulting in lost sales for the supply chain. It also leads to an increase in the inventory costs. To handle the increased variability in demand PG has to carry a higher level of inventory than would be required if the supply chain was coordinated. As a result, inventory costs in the supply chain increase. The high levels of inventory also increase the warehousing space required and thus the warehousing cost incurred. It impacts the transportation cost in the supply chain. The transportation requirements over time at PG and its suppliers fluctuate with the orders being filled. As a result of bullwhip effect, transportation requirements fluctuate significantly over time. This raises transportation cost because surplus transportation capacity needs to be maintained to cover high demand periods. It also leads to the increase in labour costs associated with shipping and receiving in the supply chain. Labour requirements for shipping at PG and its suppliers fluctuate with orders. A similar fluctuation occurs for the labour requirements for receiving at distributors and retailers. The various stages have the option of carrying excess labour capacity in response to the fluctuation in orders. Either option increases total labour cost. PG estimated that due to the manual interventions required in their process of ordering, billing and shipment systems, each deal to its customers cost between $35 to $75 to process. Sharing point-of-sale (POS) data across the supply chain can help reduce the bullwhip effect. A primary cause for information distortion is the fact that each level of the supply chain uses orders to forecast the future demand. Given that orders received by different levels vary, forecasts at different levels also vary. If retailers share POS data with other supply chain stages, all supply chain stages can forecast future demand based on customer demand. Sharing of POS data helps reduce information distortion because all stages now respond to the same change in the customer demand. Sharing aggregate Point Of Sale data is sufficient to reduceinformation distortion. PG has convinced many retailers to share demand data. PG in turn shares the data with its suppliers, improving coordination in the supply chain. In a continuous replenishment programs (CRS), the wholesaler or the manufacturer replenishes the inventorey regularly based on Point of sale data. In its simplest form, CRS seeks to allow more accurate production planning of inventories and also matching of supply and demand. Success with continuous replenishment programs is achieved when production planning has become demand-driven on an end-to-end basis throughout the supply chain. . Vendor-managed inventory (VMI) is a family of business models in which the buyer of a product provides certain information to a supplier of that product and the supplier takes full responsibility for maintaining an agreed inventory of the material, usually at the buyers consumption location (usually a store). A third-party logistics provider can also be involved to make sure that the buyer has the required level of inventory by adjusting the demand and supply gaps. PG now employs vendor-managed inventory (VMI) in its supply chain, starting with its supplier, 3M, and its customer, Wal-Mart In VMI, packaged-goods behemoth Procter Gamble (PG) initiated a value pricing scheme for sales to retailers. Value pricing was PG label for everyday low pricing (EDLP), a pricing strategy under which retailers are charged a consistent price rather than a high baseline price punctuated by sporadic, deep discounts. PG had many reasons for converting to EDLP. Its sales force had grown to rely on discounting to drive sales and the use of deep discounts had spiralled out of control, cutting into earnings. Background SMS Hospital, operating in Jaipur, is one of the largest government healthcare providers in Rajasthan. It consists of more than 500 beds and offers healthcare services ranging from a 24 hour accident and emergency service, to acute medical and surgical care, operating theatre suites, intensive care, ocus on cardiac and orthopedics areas and head injury and orthopaedic related trauma and community care. The hospital services more than 40,000 patient admissions and an average length of stay of 3.62 days for all patients. There are10 operating rooms (OR) with state of the art equipment, in-patients have hospital wards, acute cases beyond normal post-operative hospital care have rehabilitation unit for recovery and related ancillary services in the hospital facilities. These rooms are being used for major inpatient procedures. On an average of about 27,000 operations are performed in these rooms in a year. Specialty and staffed with suitably qualified nurses and technicians organizes 500+ beds in the hospital. The Operating Room Management Department (ORMD) is the central division, which faces daily challenges of managing and allocating the staff and equipment so that surgeries can be performed in an efficient, cost effective, and safe manner. The equipment that is owned by the hospital may either be dedicated to a theatre or be shared across theatres. The Operating Room staff is comprised of registered nurses, nursing assistants, scrub technicians and unit secretaries and an Operating Room nurse super vises all these. Equipment to be used for Operating Rooms may either be owned by the hospital or be procured from outside on a loan/hire basis. The Operating Room Management Department is responsible for assignment of theatre suitable for the scheduled surgery and ensuring the availability of staff and equipment when needed. Quality and cost of patient care implications are on overstaffed, undermanned, and unbalanced nursing teams. The hospital has adopted a hybrid strategy to meet its nurse requirements in both wards and Operating Rooms. The hospital has employed a group of permanent, full time nurse staff, which is also, complemented by a bank of casual, part time nurses which are available at short notice. Also, the hospital also has made some arrangements with several private agencies, which are known for providing qualified nurses for short periods to hospitals, on a temporary basis. Fifty % of the hospitals requirements) in the terms of nurse requirements are usually been met by permanent staff, thirty% by part time nurses and twenty% from agency staff. The hospital havent employ any specialist/surgeon, but only has a small group of physicians for overall supervision of the wards. Instead, it has arrangement with a large group of consultant surgeons who hold privileges to avail of the hospital facilities for treatment of their patients. The hospital derives its revenues from the fees charged for the use of its facilities ORs, hospital beds and other services from the patients. In most cases hospital charges are borne by patients medical insurance providers and the hospitals revenue is based on negotiated rates with these firms. Value Chain Figure 1 illustrates a schematic description of SMSs service value chain. As shown in the figure, the multi-stage process begins with the patients consultation with his or her primary care physician. Upon receiving a referral from the general practitioner to visit a medical specialist, the patient will then be assessed by a specialist. This stage does not involve the hospital and may consist of several visits to the doctors office and diagnostic laboratories, deals with the assessment of patients condition and treatment options. A determination of the need for surgery results in the addition of the patient to the doctors list of patients requiring surgery/hospitalization. Typically, specialist doctors have privileges at several hospitals in the area, and the choice of hospital for surgery is determined by a number of factors that include cost, patient preference, case complexity, wait involved, facilities and other services provided by the hospital. Following the choice of hospital, the patient is scheduled for surgery by assigning a slot in one of the doctors theatre sessions at the hospital. It is not uncommon for elective surgeries to be scheduled several weeks to a few months in advance. The schedule for each session along with patient and surgery details is expected to be communicated by the doctors office to the hospital well in advance to enable the hospital to make adequate arrangements. The surgeons operating list is not frozen and is dynamic with additions possible at a later stage (in some cases a few hours in advance) and the hospital is expected to be responsive and be able to provide the requisite support of staff, equipment and supplies. Surgery represents the third stage of the value chain and Saint Marys hospital is responsible for providing required support services. These include staffing the theatres with qualified nurses and technicians, and making available all equipment and supplies needed. The hospital is also responsible for pre-operative care of the patient and getting the patient ready for surgery and for post-operative care. Insufficient capacity and delays in these phases can result in blockage and starving of theatre resulting in underutilization of ORs with consequent adverse impact on hospital costs and efficiency. Post-operative care in hospital wards and in subsequent rehabilitation areas, if necessary represent the fourth and fifth stages before the patient is discharged and exits the hospital system. Constraints on bed capacity in wards can lead to fewer surgeries being scheduled resulting in lower theatre utilization. This is in contrast to the rehabilitation services, where capacity shortage may only lead to patients being off-loaded to other facilities owned by competitors, thereby resulting in loss of potential revenue. Planning and Scheduling at SMS Hospital Planning and scheduling at Saint Marys hospital is similar to other hospitals in Australia with annual theatre plans forming the basis for hospitals activities. The theatre plan involves assignment of theatre sessions to consultant surgeons and essentially defines the demand for hospitals services. A half-day slot is considered the basic unit for this purpose and thus each theatre has a capacity of 10 sessions per week, based on a five day week. As described earlier, surgeons expect hospitals to provide complete flexibility in organizing the activities within their sessions and hence assignment of a theatre session to a surgeon commits the hospital for providing the necessary staff and equipment for operation and post-operative care, and hence the hospital workload is a direct consequence of the theatre plan. In practice, theatre planning at Saint Marys begins three to four months in advance, in September/October for the following year. The plan is developed in consultation with the surgeons and varies little from year to year, except for changes to accommodate vacation periods of surgeons and other planned absences. The plan can be characterized as cyclic with effort to evenly spread out sessions assigned to individual surgeons. Further, to the extent feasible, weekly schedules are adopted. For example, a surgeon with 50 sessions would be assigned one session per week, usually in the same time slot every week (say, Monday morning). One feature of session plan at Saint Marys Hospital that merits special mention relates to the practice of concentration of sessions assigned to particular specialty. As a result, we find, sessions corresponding to different specialties peaking on different days of the week. Such practices are not unique to Saint Marys and are quite common at other hospitals i n Australia. The annual session plan forms the basis for nurse and technician staffing in the hospital. The labor cost of nurses and technicians is perhaps the most significant controllable operating cost at Saint Marys and directly impacts the hospitals financial viability. Staffing plan for nurses in the OR theatres is prepared for each calendar month on a monthly basis, two weeks in advance to conform to regulatory requirements. The initial plan is developed on the basis of the session plan. The nurse schedule is revised and frozen only a day in advance, at which time the requirements are assessed based on surgery lists available in the hospital. Besides adjustments for providing the required number of qualified nurses, the final schedule takes into account deviations from the initial plan (for example, absence due to sickness, or inability to schedule the nurse due to excess overtime on the previous day etc.) At this stage there is only very limited flexibility in respect of permanent, full t ime staff and the nurse scheduler relies on part time staff, supplemented by supply from external agency to meet the requirements. As mentioned earlier, current practices at Saint Marys hospital result in 20-25% of nursing needs being met with agency sources. In monetary terms, the proportion is higher due to higher rates paid for the temporary staff. Nurse staffing in wards is similar and schedules are frozen only a day in advance. Observations Our interviews with doctors/surgeons indicated that in a majority of specialties there is no discernable pattern in the demand for elective surgeries. This is in contrast to illnesses such as flu, hay fever that exhibit pronounced seasonality. Thus, daily demand for elective surgery end customer demand can be reasonably be described as fairly uniform with no seasonality (day of the week, month etc.) and low to moderate variability. Figure 2 describes the pattern of admissions (which corresponds to demand) for orthopaedic surgeries at Saint Marys hospital by day of the week. The figure is based on data for one year and excludes the holiday period (mid-December to mid-January) in Australia during which most doctors avoid scheduling elective surgeries. The data in Figure 2 shows mild seasonality by month (admissions range from a low of 332 to a peak of 512 with mean of 470) and high variability by day of the week. Excluding the weekends, the average daily admissions range from a low of 58 on Fridays to a peak of 123 on Wednesdays. The pattern is similar for other specialties, except for the location of the peak. While in Figure 2 the peak occurs on Wednesdays and Thursdays, for other specialties it might occur on other days of the week. Taken in conjunction with our premise that end customer demand is fairly constant, Figure 2 suggests strongly presence of phenomena similar to the bullwhip effect. In the remainder of this section we discuss briefly the impact of this pattern on hospital performance operational and financial. First, increased variability in the number of surgeries performed directly impacts the demand for post-operative services in the wards. Consequently, on peak days, shortage of beds makes the wards the bottleneck, thereby restricting the number of surgeries and reducing the theatre utilization and hospital throughput, which in turn leads to lower revenues and lower operating profits. While the hospital is a not-for-profit organization, operating profits represent one of the key funding sources for financing investments in equipment and facilities, and lower levels or absence of operating profit can severely restrict the hospitals ability to provide state-of-the-art high quality service. Second, the demand for nursing services both in theatres and wards is directly affected by higher variability and results in higher labor costs. With Saint Marys strategy of meeting the nursing demand with a mix of full time, part time and agency staff, higher variability of demand translates to the need for higher levels of flexibility and larger proportion of casual and agency staff. Higher wage rates for these categories increases operating costs and leads to lower profits. Third, SMSs reliance on flexible (part time and agency) staff affects the hospitals operating performance in more subtle, but significant manner. Higher levels of temporary staff leads to frequent changes in the composition of support staff assigned to each theatre, thereby inhibiting development of cohesive support teams. Consultant surgeons in our interviews mentioned this factor repeatedly as the primary cause of inefficiencies in theatre, requiring more operating time and reduction in efficient use of theatre capacity. The role of cohesive support teams in improving OR efficiencies is well known and has been noted in many other hospital environments. In the absence of such a support team, the surgery list scheduled for each session tends to be shorter (thus reducing hospital revenues). Alternately, with normal list the theatre time will be higher than planned, resulting in overtime and increasing operating costs. In either case, this practice adversely affects hospitals profits. Furthermore, this factor influences the doctors choice of hospital, prompting use of Saint Marys for more complex cases requiring its facilities. For simpler cases, the doctors tend to choose other hospitals with more efficiently organized OR theatres, perhaps with more limited range of services. As the more complex cases typically involve higher costs, this behavior has an adverse impact on Saint Marys finances. Under the Australian system the fees payable (to the hospital and doctor) are based on predetermined rates for each class and do not depend on the case complexity within each class. To summarize, increased variability in the demand for elective surgeries at Saint Marys hospital results in lower efficiencies, higher operating costs and lower revenues leading to lower profits. Thus, the presence of bullwhip effect leads to degradation of performance as in the case of manufactured goods reported in the literature. While this is intuitive and not surprising, it is interesting to note the dynamics are different from those observed in manufacturing higher levels of inventories and shortages. Macintosh HD:Users:vasvigakkhar:Desktop:Screen Shot 2012-12-29 at 2.09.56 AM.png Macintosh HD:Users:vasvigakkhar:Desktop:Screen Shot 2012-12-29 at 2.13.36 AM.png Methods for coping with the Bullwhip Effect The preceding section highlighted the different causes of the bullwhip effect in the healthcare sector and identified strategies to mitigate the detrimental impact of the effect. We briefly summarize the strategies (see Table for a summary): (i) Reducing uncertainty In order to minimize or eliminate bullwhip effect, it is important to reduce uncertainty throughout the service value chain. If information about customer can be centrally managed and if each stage of the service value chain can be provided with latest information in a timely manner, it will help eliminate duplication of effort at different stages and also ensure data consistency across all groups that require that data. It is also critical that dynamic updating of information is performed which will greatly help reduce uncertainty. (ii) Reducing variability There is inherent variability in the customer demand process and any effort that can be taken to minimize this variability will help reduce the overall bullwhip effect. Also, localized practices that lead to increased variability in demand at any of the stages should be eliminated with better coordination. Use of good forecasting methods will also assist the reduction of variability. (iii) Developing strategic partnerships The bullwhip effect can be minimized by developing key strategic partnerships with different links in the service value chain. For example, in case of hospitals, the hospital administration has to forge strategic alliances with medical specialists. These partnerships will change the way in which the information is shared and will help foster better coordination between the two parties. Although this may not fully eliminate bullwhip effect, it will go a long way in reducing the effect. (iv) Realignment of incentives One prime reason for the lack of coordination and meaningful information sharing is that the different entities are evaluated on the basis of different criteria and receive rewards for different activities. The evaluation and reward system should be modified to stress cooperation across stages and so that the planning is performed on system-level objectives and not on division/local level objectives. (v) Improving coordination across stages of service value chain To reduce the bullwhip effect, it is also important to ensure coordination across stages that are facilitated and improved. Summary and Future Research In this paper we have identified and described a phenomenon in healthcare industry that is similar to the bullwhip effect observed in the manufacturing sector which results in amplification of demand variability upstream in the service chain. Not surprisingly, this distortion likewise leads to performance degradation. However, the similarity with the manufacturing sector does not extend much further since the causes and the impact are somewhat different. For example, while bullwhip effect in manufactured goods results in higher levels of inventory and shortages, in hospitals it leads to lower levels of throughput, higher operating costs and longer patient waits. Hence, initiatives and strategies for minimizing the bullwhip effect and its impact require a different approach that addresses directly the root causes. Our study also indicates that the potential for performance improvements is quite significant. While our study focused on hospitals and other allied institutions in the health sector, we conjecture that a similar phenomenon may be present in other service industries. For example, billing practices in consumer utilities (electricity, gas etc) and credit card services with monthly cycles leads to variable unbalanced loads in certain segments. Similarly, scheduling practices in auto repair industry result in some variability amplification. Together this suggests that a more detailed study of the bullwhip phenomenon in services is warranted and may lead to order-of-magnitude performance improvements similar to those realized during the past two decades in the manufactured goods industries.