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Wednesday, April 09, 2008
We Don't Want You to Get Hurt
A 'protection racket' is an age old scheme whereby individuals are strong-armed into paying money to crime syndicates or gangs to, ostensibly, avoid harm at the hands of "real criminals". Of course, the deal is that if you don't pay the protection money to the gang or syndicate then you are targetted and then, if you live, you have a real reason to pay the money, namely your broken arm or busted nose and the desire to, well, live.
Even though the kind of 'protection' we pay for with JCAHO and Press-Gainey has nothing to do with physical harm, doctors and hospitals have become dependent on getting good scores so they can advertise their "five star rating" or whatever, and individual ER groups often base bonus pay on a physician's Press-Gainey scores. These scores and the methods used to obtain them are NOT TRANSPARENT, and have the science of statistics behind them to be sure, but really, how much sense does it make to ask patients whether they received good care? First off, if you are answering the survey, you lived! Awesome. Secondly, it is an unfortunate axiom of the ER that if you are not really sick you are probably going to wait a long time and why the hell would you then want to fill out a survey telling someone how great your experience was?
How reliable is the data that is put into their equations to generate 'patient satisfaction scores'? Do they control for education level? Cultural bias? Whether the patient got free care or had to pay? And most importantly, do they actually ask if the patient, whatever the perception of their care, was treated appropriately from a medical perspective? No, they don't. Again, correct me if I'm wrong, and then explain to me and our readers, in terms we can understand, why Press-Gainey scores should be obtained to begin with. Why pay for information we can get anyway? For their 'lack of bias'? Well, PG is biased to keep their jobs so WTF?
It is not as if we are selling cars here. You may know jack shit about cars but you damn well pay for them when you buy one. In this context I understand, really, why being all about customer service will increase your business' success as you definitely want repeat customers. Also, while someone may lie to a car salesman about their income in order to get a better price, they have no other reasons to fabricate stuff outside the financial because the car salesman can not prescribe narcotics.
Next, and to tie the two together, I am unaware of any double blind placebo-controlled trial that shows that getting good JCAHO scores OR good Press-Gainey scores correlates with good patient outcomes and hence excellent medical care. Again, I may be wrong and stand to be corrected so please do tell me.
Etotheipi has already started in on these guys so please check out his previous post with the neat sharp sign.
Here's what happens in real hospitals with JCAHO and Press-Gainey. When JCAHO comes to town everyone goes into a tizzy. The most important things in the ER are, evidently, that we keep coffee and soda out of the nurses and doctor's areas. Coffee, soda, and food are still allowed in the patient's rooms though. Also, all the nurses and doctor's get handed little cards that we can read from in case the JCAHO flunky asks about what we would do with a blood spill on the floor. I want you all to walk in a straight line all the way to the lunchroom and everyone be quiet!
"Core measures" are an attempt to graph the ungraphable, and an attempt to put numbers on "quality care". They are also worthless. For instance, even after we knew that drawing routine blood cultures on patients with community acquired pneumonia DID NOT improve outcomes or change care in all but the sickest of the sick, JCAHO implemented this core measure and added $500 or so to all patient's bills by mandating this lab test. Art of medicine? Dear readers, ever hear of the New England Journal of Medicine? The Journal of Trauma? See, we already do this with rigor and thoroughness and JCAHO is, well, it's fucking JCAHO.
Press-Gainey gets us all worried fielding complaints from patients. The ER is "too noisy" or we "ignored them" and "spoke harshly" to them while they were here. This translates, often, into loss of income for us or even loss of our jobs. Only 1/3 of our "customers" pay for our services. Since most people who answer the surveys are already pissed off about their six hour wait guess what comes in on the survey? A lot of pissed-off patient complaints. Also, and again correct me if I'm wrong, admitted patient's are not surveyed so there is a preselection bias towards ER abusers.
To continue the analogy, while not knowing jack-shit about cars might make you prone to buying a bad car, outside of medicine no one knows an iota of jack-shit about why we do what we do and why we order the tests and studies we do in the ER. Getting that JCAHO star therefore means lots of money to our bosses. Protection racket.
News flash! Even though you are a nice person and are sure you are not having a heart attack I have to look. You came to me with chest pain, I've never seen you before, I have no records on you, and I can not, without committing malpractice, just write you a work note and tell with my hugely developed clinical acumen and Xray vision that your "indigestion" is "nothing serious" and "not your heart".
But here's a kicker, guess what we do after a bad patient outcome or with problems in how we deliver excellent care in the ER? We ask each other and do research and go to conferences and see what the pointy-headed academics are doing. We never say, "Hmm, why not ask JCAHO or Press-Gainey about this?"
JCAHO and Press-Gainey are parasites. They are solutions in search of a problem. With rare exception none of the JCAHO or Press-Gainey folks are practicing physicians. These companies have grown eighteen heads and can not be killed. They are feasting off the detritus of the piles of money that get shuffled around in the medicine game. Unfortunately, hospital CEOs and ER group directors have signed on because, I guess, having some information (however shitty it might be), or some way to put intangibles on a graph (and to show the upward trend), is worth something to someone.
Finally, it's nice to have a bullet in your gun when coming to the table to negotiate a contract with your ER group or when you want to ride herd on your nurses. Press-Gainey and JCAHO provide the bullets. Then, when they are fired, just like the Chinese, those who are executed have to pay for the bullet.
65 comments:
- Anonymous11:02 PM, April 09, 2008
I'm curious about something: Why does your average inner-city trauma center give a &$&# about getting a five star rating? You guys have talked a lot about your typical patient population. Something like: 10% critically ill/injured. Those guys aren't shopping around for care, they're going straight to the closest place that can help them. 50% using the ED instead of primary care because it's free. Those guys also don't care -- free medical care is free medical care, never mind its rating. 10% looking for drugs. Those guys definitely don't care about ratings, in fact the lower the better.ReplyDelete
So if this is right, your "customers", for the most part, don't care about JCAHO/Press-Gainey ratings. So why do the providers care? I'm serious -- at least for major, maybe non-profit, large urban trauma centers, why don't the hospitals turn around and tell JCAHO where they can stick it?
great question. i think the answer is twofold. first, some hospitals do tell jcaho to stick it. i have heard that mayo in MN told them to fuck off. i hope that's right and not a rumor. secondly, in order to make money to pay for those who don't pay i guess the 'five star' ratings matter.
UGH! That's just more depressing. I have no clue how to help the problem either. How do you dislodge deeply entrenched beaurocrats from their positions of power? With a crowbar?ReplyDelete
If I ever got a survey, I always threw it away because I only felt like filling them out when I was pissed off about something. Like when I had a pediatric ER, I'm assuming resident, eyeball my 3 day old daughter and tell me that her bilirubin was probably a 12.8 or so. Being a former labbie, I debated mocking him to his face, but then just said, "But you WILL test it anyway, won't you." Because I'm polite like that. It ended up being 16.9, so they admitted. We brought her in because she quit breathing while I was nursing her, and turned blue as a blueberry.
Ugh, sorry for the randomness. THat's the only time I've ever been pissed at the ER.
Press Ganey sucks and so does JHACO, and I think your arguments are completely spot on. Your scores and paychecks should ABSOLUTELY be based on outcomes. And even then, you can't save everyone, nor are you perfect. My lab director used to say that even the most proficient person will screw up 1 time out of 1000. Outliers happen.
The measure of blowing sunshine up someone's ass isn't exactly correlated to health outcomes now is it?
*sigh* why can't you/people like you be in charge?!ReplyDelete
none of this bodes well for those of us looking for a future in EM...
- Anonymous12:00 AM, April 10, 2008
So, I've been lurking on medical blogs, and far as I can tell, you are all full of shit. Jack-shit, bullshit, horseshit, farts... there is more to medicine than the back end, people!!! Ever heard of a stethoscope?ReplyDelete
- Anonymous12:13 AM, April 10, 2008
I have taken patients via ambulance to the Mayo clinic. While I, as a paramedic, am picking through the gutter in terms of how other medical people view me, am not a patient, I have realized that hospitals which treat us like shit tend to treat their patients and coworkers like fucking slime.ReplyDelete
When you transfer into Mayo, at least St. Mary's in Rochester, which really is the mayo in the Mayo, there's a lovely charge nurse in black scrubs standing by the door greeting each ambulance patient. You are provided with a greeting, a room assignment or disposition, and an escort to the patient's room if its in a far flung area. It is by far one of the most wonderful experiences. From the second a patient walks in the door, people act like they know what the fuck is going on. They take care of shit and keep things moving. Things are ready. Beds are in place. IV pumps are set up with the tubing primed. It's not some mickey mouse bullshit where you stand around.
That is what it's like to have your shit together.
But, they still use Press Ganey. And they're ranked quite highly.
Theres another major hospital I go to routinely. Big academic hospital. Level 1 trauma center, famous school affiliation. In a big city. They're the biggest bunch of cunts in the world. Absolute fucking whores. I wouldn't take a fucking dead gold fish there to be flushed down the toilet, let alone an actual human being. When I find some gorked, pissed covered, shit stained, toothless, violent, drunk dirtball of a patient, the kind who spits HIV infected blood on the floor, I always find a way to take them to this particular hospital. You know, because they're so academic and have wonderful services for this down and out fellow.
Yeah that shitbag place also ranked super dooper high on the Press Ganey scores. So I haven't really figured out what exactly is being measured. People hate going to this hospital. I have yet to meet a patient who actually wants to go to this ER. Yet, they claim these wonderful scores on par with the Mayo.
please explain. are you yelling at us or at the people we are yelling at?
- Anonymous1:37 AM, April 10, 2008
Both. (I like to yell.) And then when I get tired of yelling, I'll talk to both of you. sweet nothings apparently - because apparently I'm an ignorant, uneducated, asinine(!), etc. etc., you get the idea, with nothing much worth saying. You may as well ban me from your comments now - save us both time and trouble.ReplyDelete
you don't seem to be ignorant or assinine but i'm afraid i still don't get it. we don't ban anybody from our posts. come by anytime.
I think we all should just say No to Jcaho. I would love for my hospital to tell them to take a flying leap. I think the DPH should make surprise visits. I have never seen Jcaho make surprise visits. The Jcaho folks cannot stay up that late.ReplyDelete
One of the joys of working all overnights is the special feeling I get when I hear that JCAHO "will be coming by the ED...tomorrow morning."ReplyDelete
We spend all night giggling and cheering, knowing that we're spared the inspectors yet again, because they don't get up early (or stay up that late) to play with the night owls.
- Anonymous7:52 AM, April 10, 2008
More reason for a doctors union. You don't see any JCAHO going into the Ford factory to make sure all the lug nuts are tightened. If they tried they'd get a monkey wrench upside the head from Guido or Tommy and 50 pounds of dynamite in the trunk.ReplyDelete
- Anonymous8:25 AM, April 10, 2008
Excellent post.ReplyDelete
I think the idea of a randomized double-blind clinical trial to measure the effectiveness of JCAHO and P-G on outcomes is brilliant. I would bet ALOT of money that it doesn't make a micron of difference.
I can only see downside to the function of a hospital when the efforts of those in charge are focused on jumping through hoops and manipulating patient perception.
If we ACTUALLY think that a hotel-like experience is the ideal for a hospital then we should hire a Hilton executive (not Paris) to run the place. Let's give the patients mints on their pillows and a personal concierge. My guess is that the PG scores would be through the roof. I would also guess that more people would die or get marginal care because WE ARE CONCENTRATING ON THE WRONG THING!!!
I had a kid in a UC trauma ward for weeks last year with horrifying pelvic injuries and I think I know why they get good scores. I'd bet that 9/10 of the patients treated don't return surveys, as they're busy setting up their next meth lab. The ones who do, like me, are grateful that their kid was somehow patched up and saved. I'm sorry you were treated like crap--I didn't even see that entrance to the facility, as my kid was coptered in.
It was filthy and chaotic (I mopped the floor myself), but the medical care was excellent, if a bit excessive. My son said, "Jeez, there are, like, hundreds of medical students and doctors who want to see my junk". We subsequently were sent to another private, highly rated hospital, which was very clean, but the medical care was practically actionable, and the kid was constantly discharged and returned via ER. Cleanliness and politeness are secondary to good medical care, and I'd take the filthy UC hospital anytime.
- Anonymous10:11 AM, April 10, 2008
"When JCAHO comes to town everyone goes into a tizzy. The most important things in the ER are, evidently, that we keep coffee and soda out of the nurses and doctor's areas."ReplyDelete
So true, 911Doc. Oh, and don't forget the importance of not using the "do not use abbreviations". Such stupidity is hilarious.
- Anonymous10:37 AM, April 10, 2008
When mobsters run their protection racket, part of their strategy is to break the bones of anyone who rats them to the police or speaks out against them. In this case, there are no police to ask for help because it IS the police who are running the racket. You are doing the only thing you can and that is to try and educate the voting public. Thank God for anonymous sites like this. Can you imagine the JCAHO/PG folks reading these great whistleblowing blogs, feeling threatened about losing their power and targeting the doctors who write them for an upcoming "extra diligent" inspection visit?ReplyDelete
- Anonymous10:40 AM, April 10, 2008
Devorrah: I feel your sympathy, and I appreciate it. Also, I hope your kid is doing better. And, I'll take your hint and look for a chaotic and filthy (UC) hospital. (What is a UC hospital? Is that a specific type of hospital that you are also recommending? TIA.)ReplyDelete
I could not agree with you more. Everywhere else in medicine we are being pummeled with the "evidence based medicine" mantra --- why not with JCAHO mandates? Is there any data that a 52 point "time out" check list in the OR does anything other than cause frustration, or that keeping coffee cups away from ED physicians and nurses is good for patients? In a word, no. I think it is high time hospitals across the country started chanting "Hell, no, we won't JCAHO."ReplyDelete
911 doc. . .amen.ReplyDelete
- Anonymous11:27 AM, April 10, 2008
Must get coffee cups out of nurses station and stop abbreviating morphine as MSO4 (I think I'll switch to MoSO4!).. blood pressure rising.. homicidal urges building..
- Anonymous11:34 AM, April 10, 2008
Aggravated docsurg: At this point, I'd like to see some evidence that you would be able to recognize/and/or/evaluate a clinical study. I think it's fucking scary that people who are obviously mathematical and statistical illiterates keep calling for evidence based medicine. I say that you would not know good statistics if you met any in a dark alley. You wouldn't know good statistics from Adam. Richter is aggravated this morning.ReplyDelete
To Richter:ReplyDelete
I am quite sure that most every medical professional posting here can and do not only recognize and evaluate a clinical study, they also use the results in their daily practice. And that, my friend, is exactly the point. There is NO study to evaluate whether or not JCAHO or PG are doing any good at all!! As a matter of fact, I believe with all my soul, as a practicing Peds ICU RN, that they do nothing of benefit. In actual fact, I think you would find, if you could ever get a study of their effectiveness funded, that they actually do more harm.
Overall, I couldn't agree more with this post. I wonder what it does to the PG scores when you are asked the same questions at least 4 times in the space of an hour. Let's see: triage fills out their questionnaire, then the ER doc asks many of the same information, then you come to the ICU and we, the nurses, have to ask everything again, then the ICU doc asks many of the same things...after that, if you also need a specialist consult, you get asked everything yet again. Why do you get asked all these things over and over again? Because JCAHO says we have to!! We can't trust our coworkers, it seems.
One last point about statistics...no matter the numbers, they can be used to prove your point..any point..no matter what your point might be.
One last thing, if anyone knows, FOR A FACT, of any hospitals that have kicked JCAHO out on their ass, I would love to know about it. I hope to put together a list of those hospitals and see whos who. I heard a rumor sometime back that both Hopkins and Vanderbilt have kicked them out, but have been unable to confirm it. I think a list of this sort could be invaluable for any of us trying to convince our employers to do the same.ReplyDelete
- Anonymous2:00 PM, April 10, 2008
So, it's put up or shut up time now. I've got a friend who's an epidemiological statistician and I'm going to try to convince her to do a comparison between P/G scores and reality. However, I'm a Ph.D., not an M.D., so I need help with what reality is. What objective measures of patient care should be collected? How would you identify the deadwood and the 007s? How do you tell the difference between a bad ER and one that's being crapflooded with patients that are beyond the scope of emergency medicine?ReplyDelete
Ya'll know that Richter only came over here because he/she just got banned for awesome trollness over at Pandabear's right?ReplyDelete
How's High School Richter?
richter huh,ReplyDelete
was nice to him last night then he goes on some psychotic rant that makes about as much sense as a psychotic rant would make then mentions that he has a hairdresser. hmm. a hairdresser. he may be the first banned from our blog too. richter, straighten up and fly right or be banned you asshole.
- Anonymous2:28 PM, April 10, 2008
if you're such a statisctical expert tell everyone how you calculate a pitchers earned run average. Hint, its a brief one line equation but your hairdresser probably won't know it. No fair looking it up.
it seems like there's a lot of agreement among health care providers concerning this issue, and a lot of evidence that the joint commission and p-g scores are doing more harm than good...so...ReplyDelete
what's to be done about this?
Someone said something about a "doctors union", but the AMA seems like it already has a lot of clout (too much, I'd argue), and it seems to me that change would have to come from the lobbying priorities of the professional organizations that health care providers belong to.
Additionally, as diluted and unreliable as the peer-review circuit has become, publishing research either contradicting current practices or supporting alternatives might help?
The thing is, it's going to take more than just one segment of the health care delivery sector to undo this bureaucratic nonsense.
A "legal" option might be lobbying to revoke the salient corporation's "corporate personhood", effectively dissolving the offending organizations directly.
Oh 911doc, please, please don't ban Richter! I think that he is just so cute when he gets all in a tizzy!ReplyDelete
Re: "you would not know good statistics if you met any in a dark alley;" well, of course not! Dark alleys are too dark to see your Texas Instrument calculator screen while you are verifying the accuracy of the researcher's chi square calculations. Anyone knows that.
I was a charge nurse during a hospitals initial JCAH accredidation. It was like being a bit player in a bad situation comedy. The floors did get mopped more frequently, which was nice, but otherwise it was a matter of stroking the egos of the inspectors and trying to keep a straight face while answering their questions (absolutly none of which had anything to do with patient care). We did as we were told, got our accredidation, and breathed a sigh of relief when we could stop wasting time and return to the care of our patients.
I do miss those nice floors, however.
(Note to Richter, we now have treatments for Tourette's Syndrome. There is no cure, at least not yet, but there is treatment, and hope!)
Maybe Richter is just "The Dawn" reincarnated?ReplyDelete
oooooooooo *insert Twilight Zone music*
what kind and compassionate people you all are, to feed the trolls as you do! heheReplyDelete
- Anonymous4:51 PM, April 10, 2008
Amy: high school is busy and stressful right now.ReplyDelete
Countryrat: I'm flattered that you think I'm cute, when I'm in a tizzy. (Which is most of the time.)
911doc: no fair banning me from my first comments post. That's not fair. So, I'll try to behave. (straiten up and fly right? could you clarify that????)
Everybody: I don't know that much about statistics. I'm not that educated, yet. (I'm just thinking about being pre-med, maybe.) I'm just trying to say that it's pathetic how little all of you know about statistics. that's all.
UC means Univ. of California, (at Davis and San Francisco, both pretty close), and my kid is doing great. Now quit running with scissors please and play nice. Oh yeah, school is out for the day...
- Anonymous5:10 PM, April 10, 2008
Our Hosp does not belong to JACHO but they sure are uptight about those freaking "Press Gany". The we do not give a crap if the pt is lying , you have to because they would never lie, whine or say so otherwise."ReplyDelete
This comment has been removed by the author.ReplyDelete
Yay, Trolls!ReplyDelete
*sniff* I kinda miss The Dawn.....
"I'm just trying to say that it's pathetic how little all of you know about statistics. that's all."
If you can't tell statistics from your...ahem...eyebrow, how on earth will you be able to determine if docs know statistics or not? Stats is a pre-req for med school.
Some of these doc dudes are pretty mathy. And geeky. That's all I'm sayin. Etotheipi and S Cat and p value and all.
- Anonymous5:48 PM, April 10, 2008
E.R.A.(Earned Run Average, not that pinko/commie Equal Rights Ammendment)= (Earned Runs Allowed/Innings Pitched) x 9.ReplyDelete
Major League Average is around 4.5.
- Anonymous6:27 PM, April 10, 2008
How DO you put a metric on Emergency Department? Clearly one would be if you left in better shape (I'm not dead yet!) than when you came in. Speaking as one who has recently visited the ED with an injured loved one, I found that a little simple politeness really goes a long way and we were treated with a lot of respect and with the necessary attention given the severity of the injury.ReplyDelete
- Anonymous6:54 PM, April 10, 2008
Devorahh: "I'll be your friend" - thanks, that is bighearted of you.ReplyDelete
But as for the rest of your advice:
"First, no name calling.
Second, you can express an opinion without flaming out of every orifice.
Just curb your enthusiasm a bit"
I don't think I can. I just don't think I can. Not even the curb my enthusiasm part. Not even a little bit.
"Everybody: I don't know that much about statistics. I'm not that educated, yet. (I'm just thinking about being pre-med, maybe.) I'm just trying to say that it's pathetic how little all of you know about statistics. that's all."
first, take logic 101.
secondly, and quite seriously, are you on medication? who exactly are you angry at?
come here with an opinion, defend it with logic, and we can have a discussion. otherwise, go get your own blog and quit bothering people with your nonsensical ramblings.
OOoohhhh! I just got called with one of those surveys, about my son's procdure he had 2 weeks ago. They asked me all sorts of questions like:ReplyDelete
Did the surgeon do anything to make you think he didn't know what he was doing?
Were you afriad at any time that they might screw things up?
Did you hear any staff bad mouth any other staff?
And the usual was the joint clean, etc?
And this one was strange: Was your son given any medications that he hadn't had before?
Now how would I know that? I did recieve an itemized list today of the meds and their costs today, but I have no clue as to what they doped him up with his last surgery besides demerol because he growled at the nurses.
If only the crackheads just knew that they needed to growl at the nurses. Course they don't want demerol do they?
FYI: It wasn't Press-Ganey, I asked. It was something and Jansen.
Actually, I do have a big heart, and you don't even have common courtesy. Please go find another outlet for your out-of-control anger, and don't expect anybody at hospitals or blogs to be nice to you when you're spewing malice every time you open your mouth or browser.
You can search online on at www.qualitycheck.org to see which hospitals are accredited. Mayo is not only accredited, it has the "Gold Seal of Approval." SIGHReplyDelete
"I'm just trying to say that it's pathetic how little all of you know about statistics. that's all."ReplyDelete
Oh, my dear, young friend, you do not have any idea what we know, or where we have been, or what we have done to earn the privilege of membership in our various professions.
Thinking about medical school, eh? Good for you! That is a noble ambition, and I wish you well. Maybe, in a few years, you will have experienced what it means to be responsible for the life of a human being who is depending on you to help them. On that day, you will, I am sure, have many interesting and informed insights to share with us. I would like to hear from you again, if that day should ever come.
Very best wishes,
I'd like to go on record saying that it's much more fun when you guys dissect the JCAHO charlie foxtrot than watching the fairly thorough gangrape of whoever the fuck "richter" is. It's fun, he's annoying, and it feels good, I know, but JCAHO's a little more....uh......relevant.ReplyDelete
Is space limited?ReplyDelete
"JCAHO charlie foxtrot"ReplyDelete
OMG. That's funny. It's like a secret code...and this time I GET IT!!!
Yes I am slow. I speak toddler all day.
Devorrah- Nope, but if we don't stick with some semblance of the topic, eventually somebody's gonna go whip us all into a mad hockey frenzy, and we'll forget all about hospitals for a while. Outside of Siberian bloodsport, hockey's maybe the best place to see two pale honkies turn each other's faces into Pollock paintings.ReplyDelete
I have a feeling you didn't just shoot out of your chair, furiously fist-pump the sky, and scream "AWESOME!!!" Maybe it's a guy thing.
Amy- Oh yeah, the old CF, a military term. I think it dates back to WWII, maybe even before. I'm going to base this on the loosely anecdotal fact that my grandfather (B-26, later C-130 pilot) used the term frequently when describing events from long ago and across the pond. JCAHO is pretty much your typical CF; a ton of people running around doing, well, not a whole lot of good.
For those of you who find yourselves curious, yes, this post has been approved! It's so comforting, like a warm pile of linens fresh from the dryer. Or just a warm pile.
Ruby, sorry to digress. And you're right, hockey leaves me...cold. We don't do hockey in California.ReplyDelete
Richter: Last thing. I can't sleep worrying about a teenage girl who is so angry, I have a foster son your age, and I'd be very concerned and sad if he had this much anger that he couldn't control. As a public school teacher and a Mom, I hope you'll go see your counselor (it's free!) I'm sorry for whatever has made you so angry: You don't want to stay this way, for your own sake. Life gets better after high school, you want to be able to enjoy it.
Good luck, and yes, I know, I can go fuck myself. Take care.
- Anonymous8:43 AM, April 11, 2008
Anger is the natural state of teenagers of all species. The laid back friendly Tyranosaurus simply couldn't have enough kids to survive so eventually you end up with meanies. My own daughter makes those Columbine kids look like the Dali Llama, happily she takes out her aggressions on the softball diamond. I feel sorry for the instructor pilot who gives her a bad grade 5 years from now.
Must be a girl thing--my boys are pretty tame in comparison! I'm glad I never had any girls. I was, of course, a horrible teenager myself.ReplyDelete
- Anonymous12:30 PM, April 11, 2008
I'd like to go on record saying that it's much more fun when you guys dissect the JCAHO charlie foxtrot than watching the fairly thorough gangrape of whoever the fuck "richter" is. It's fun, he's annoying, and it feels good, I know, but JCAHO's a little more....uh......relevant.ReplyDelete
(Richter is amused. Richter is also trying to practise "safe commenting." Because, if Richter was banned, Richter would be bored, and Richter does not want to be bored.)
Richter: Even my boys don't know what roflmao is. They knew the others. Help?ReplyDelete
Our hospital almost told JCAHO to shove it with the prospective medication review in the ER requirement business, but, oh, well, okay, I guess we'll make the staff wait 20 minutes for a pharmacist to approve an ibuprofen order from the triage nurse for a person who broke their hand and not tell JCAHO to shove it because JCAHO is God and doctors need help prescribing stuff.ReplyDelete
- Anonymous4:07 PM, April 11, 2008
lol: laughing out loudReplyDelete
roflol: rolling on floor laughing out loud
roflmao: rolling on floor laughing my ass off
Other acronyms as E.V.E.N.T.S. warrant.
Hi Richter and Amy: OIC, and W/B. BTW, I'm glad Richter is NAD. Glad you decided to D/C the unsafe commenting, which was clearly AMA. Your comments are WNL. BTW, I'll BRB. We're off to the ED (really) because my son's been hiding an infected tattoo.ReplyDelete
- Anonymous9:37 PM, April 11, 2008
Not to mention that you're more likely to get favorable patient satisfaction scores if you are a white male. The LOLs in NAD will take the time to write the hosptial how wonderful 'their sweet dear doctor' was when he looks like their grandson (or the grandson they WISHED they had).ReplyDelete
OTOH, the black and latino patients (if they can even write English) will likely NOT write anything, even if you were the bestest doctor ever.
My point is, if you happen to be someone other than a white male, you're not as likely to impress the type of people who will likely take the time to write a positive review.
I think that the PG scores are inherently racist, sexist, and biased!! Maybe I should do a study proving this to be true...and due away with all of the bullshit!!
dear anon,ReplyDelete
you may have a point, but proving racism or bias is impossible unless you are psychic and i would argue against this plan and attack PG scores based on waste, fraud, and abuse. especially in the ER, let's rate physicians on patient outcomes and the like and stop there.
- Anonymous10:24 AM, May 18, 2008
Something more to ponder:ReplyDelete
TJC/JCAHO and CMS standards are becoming more and more similiar. Apparently there are several hospitals/facilities that are "subscribing" to the adherence of CMS standards/elements of performance in lieu of JCAHO/TJC-- which are, as a generality, more strict than JCAHO/TJC. Interesting.
If you've ever read the specific JCAHO standards you'll also note compliance to meet the standards is relatively easy as a whole... facilities often seem to make the simple more difficult. ;)
Lastly-- perhaps a better measure of "medical effectiveness" without measurement of "soft skills" (e.g., interpersonal skills-- which has been researched to demonstrate that it is a core component in clinincal competence) would be the IHI tools?
PS: I do agree that Press-Ganey in the ER is simply and succinctly, retarded for the reasons someone has already stated. :)
- Anonymous11:18 AM, October 16, 2009
As a note, I work for Press Ganey. It is indeed the evil empire. I can tell you clearly that their focus is on money and not on improvement. This company works on a 40% gross margin on all products. The earned over $90 million last year alone on the mailing of surveys. It is hard for an ED to EVER get enough back to really be able to have valid and reliable data. National response rate averages for EDs is about 10%. Realistically, in most areas, it runs 6-8%. Most facilities simply cannot afford to get a valid sample.ReplyDelete
Something to keep in mind when looking at the data. Benchmarking is effective to see where you stand on the grading curve. On the other hand, it is something you cannot control. Your percentile ranking falls into the "area of concern". Your mean score falls into the "area of control". You can only work on your own facility, you cannot effect the outcomes of another. Administration needs to understand this basic fact and tie performance to that which can be controlled and effected. It is demoralizing to staff when they do not make their percentile rank goal. Take two facilities and say one has more buy in at the top and more resources to make things happen. Both have the save level of committed staff members. Logically, the greater resource facility will improve faster with all else remaining equal. Hence, the other facility see a lowered percentile ranking in comparison, even with the same amount of effort. Be aware of the benchmark, but focus on you!
Let's be completely honest here, ALL survey companies fall into this boat. They have used statistical manipulation to pad their pockets and hold healthcare hostage. In the end, data is data. This is another commodity product. With Press Ganey you pay for a 23 year old college grad in South Bend that has little to no healthcare experience. What they provide cannot be justified at the price point you pay. For a hospital that has in excess of 100 beds the ED contract price is over $8000. Want to get the patient's comment? Add another $4100+ As far as mailing, to get the bare minimum for a report, add another $15-$18,000. Suppose you had 10 ED docs that you wanted breakout data. Hold onto your seats, but it would cost over $54,000 just for the mailed surveys! Over $66,000 a year just for data. Do yourself a favor, hire another nurse and find a cheaper provider.
This company is changing by the day and its reputations is far from what it was. You can do better and you all deserve better!
- Anonymous10:00 PM, October 28, 2009
SPEAKING OF PROTECTION RACKETS! Yesterday every Press Ganey employee received a "Drive to 500" shirt. We are expected to grow this thing from $150MM a year to $500MM within 5 years! If you think you are paying a lot now for these surveys, think what this is going to do to your pricing on the next contract cycle! Can you say massive increase?ReplyDelete
Amen, brother/sister. I f-king hate how they hire extra housekeeping to polish the lobby before a surveyor comes, but let the needle boxes ( sharps) overflow the rest of the year, because there is only one housekeeper per two floors, and looking at them is like watching a drowning person.ReplyDelete
We now have posters up saying if "you are not ready to mark us as outstanding , please call 1 800 administrator so that we may improve our service" Service? I'm not giving you service, I taking care of you, whether you like it or not. If you didn't want an IV, why did you come to the ED? If you didn't want to be "bothered" every hour by your blood pressure cuff, then why are you in the ICU?
- Anonymous3:19 AM, December 06, 2009
Well, TJC is supposed to show up any day now, and we have all been basically informed that our jobs are on the line if we do not produce change in the satisfaction scores... Being a large suburuban teaching hospital that ranks at the top in quality, is just not good enough. If nurses don't push the dilaudid quickly enough, another poor score. If the fan control only goes to a 4, not a 5, another poor score. Think I am kidding here? Come on down and view the real world executives, if you think you can handle it.In the past, I never understood why people who were passionate about healthcare would just pick up and walk away.....now I know.ReplyDelete


text:
On November 16th, at events in 265 cities in 43 countries, thousands of people take part in a day of solidarity to mark two months since the Arctic 30 were detained following a peaceful protest against Arctic oil drilling on September 18.
A Russian court has charged the Arctic 30 (twenty-eight Greenpeace International activists, as well as a freelance videographer and photographer) with both piracy and hooliganism. No official confirmation has been given by the Russian authorities that the charge of piracy has been dropped, which carry a maximum sentence of 15 and 7 years, respectively.
To show your solidarity, please visit greenpeace.org/freethearctic30
Christine Russell, wife of detainee Colin Russell and their daughter Maddy release 30 doves at an event on the Sydney foreshore to show support for the Arctic 30. 2013-11-16
© James Alcock / Greenpeace
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Monogrammed Steak Brand, Triple-Initial
Backyard chefs who take pride in their grilling can now sear their own initials into steaks and chops using this iron brand that's hand forged by a Texas cattle rancher.
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- If the brand becomes rusted or dirty, clean it gently with steel wool or a wire brush, or rub it lightly with sandpaper.
- Dry thoroughly after cleaning to prevent rusting.
Shipping Information
This item will be shipped directly from the manufacturer and is not eligible for rush shipping. Please allow one to two weeks for delivery.
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The shipping rate varies depending on your order total and shipping destination. View Shipping Options and Charges.
Return Policy
At Williams Sonoma, we take great pride in the quality and craftsmanship of our products. Attention to design, materials, safety and construction are our priority. Upon receipt, please inspect your purchase and notify us of any damage; we will arrange for a prompt replacement.
If within 30 days, you are dissatisfied for any reason, you may return your purchase for a refund of the merchandise value. An original receipt or gift receipt is required for all returns and exchanges. Returns with a gift receipt will be refunded in the form of a Merchandise Credit for the amount indicated on the gift receipt. Returns with original receipt will be refunded in the original form of payment, cash and check refunds over $100 will be issued as a company check (may take 14 business days from time of request).
For all cutlery returns (knife sets, single knives, cutting boards, knife sharpeners, and knife storage) please contact us at 888.922.4108 to initiate the return.
We cannot accept returns on monogrammed, personalized, special-order items, custom upholstery, food, items shipped direct from the vendor, or on items damaged through normal wear and tear. Final sale items ending in .97 or .99 cannot be returned.
For returns of items purchased from your Williams Sonoma Gift Registry, we will gladly provide a refund or exchange for the merchandise within 90 days of your event or within 90 days of purchase, whichever date is later. View Full Returns Policy.
Monogrammed Steak Brand, Triple-Initial
|Delivery Surcharge
|Monogrammed Steak Brand, Triple-Initial
|Monogrammed Steak Brand, Double Initials
|Monogrammed Steak Brand, Single-Initial


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Because it seamlessly collects retail sales data spread over multiple applications, channels, and formats – and prepares it for analysis. Take advantage of lightning-fast SAP HANA in-memory technology for real-time inventory visibility, POS data transfer, sales analytics, and demand forecasting.
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Personal computing discussed
Moderators: renee, farmpuma, just brew it!
arpstorm wrote:...We have our set our gaze upon drfish (the doc) of course but see that TheBank is a force of over 100 CPUs to be reckoned with. The doc is already sweating them I hear ...
drfish wrote:...Regardless, I eagerly await the day you challenge me, regardless of what place I'm in at the time... I may drop to 2nd or 3rd, but I will defend it as if it were the holy throne of 1st place.
arpstorm wrote:BTW our user name is borrowed from networking and security. See http://www3.ca.com/securityadvisor/vulninfo/vuln.aspx?id=32460
emkubed wrote:...Yeah, when I first saw your name as a new folder, I recognized it and thought it was a bad-ass folding nick....
arpstorm wrote:Greetings mighty Leor. Thanks for the come-back
We're not sure who the faithful Stubb might be though ..
Good Folding!
emkubed wrote:
jeffry55 wrote:emkubed wrote:
Nice catch.
redmouse wrote:
arpstorm wrote:redmouse wrote:
I guess while setting up over 50 Folding CPUs the guys and gals of arpstorm are drinking too much Red Hook in celebration of their sucessful launch. We're now 50 CPUs strong and we recorded our best day ever - 3095 points. Waitress! More RedHook for me and my Folders! Ahhhh. Thank you
jeffry55 wrote:Never fold under the influence.
arpstorm wrote:Wohoo!
arpstorm has managed some consistent momentum huh? We're consistently in the top 20 producers. Good job everybody! Next term we should be able to swell our numbers by recruiting members of the next class.
So far we are still no threat to LordIcon, who has taken first place from drfish. And emkubed, Nulfire/Druid, TheBank and mighty Leor remain unimpressed and unthreatened by our progress.
But even though we threaten TheJuggernaught, ichafee, Steel, and cass, they are light years away from us. We must remain true to our cause.
Warp speed ahead!


text:
Description:5 x 300GB 15000 RPM 80-Pin Hot-Swap 3.5-inch SCSI Dell Hard Drive in Dell 9D988 3.5-inch Hot-Plug Hard Drive Tray (as pictured)Genuine Dell serial number and firmwareGenuine Dell Certified Enterprise Class Hard DrivePart Number(s):Manufacturer Part# JU654
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Pioneer Credit keeps calling for a debt I already paid off. Leave me alone!
Owner: Pioneer
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I chat with and hear from many other people who live with chronic pain. Like any other jolt in life, we each react differently when we're shaken up, according to our attitude, our families and our physicians. I am constantly amazed by the reactions, the sorrows and the amazing joys in my own life and in others.
These vessels, these bodies we walk around in are fragile and destined for extinction. Once we accept that fact, it makes the whole process of suffering chronic daily pain so much simpler to deal with. The suffering is not going to last forever; neither are the joys, the opportunities and experiences. There is a tiny secret in all of this misery many of us share and one I'd like to share with you, just in case you haven't found it yet.
The secret is like finding a key to a locked treasure box. It's not a bit complicated; it costs nothing and is universally available. It doesn't care what kind of insurance you have, where you live, whether you are rich or poor, male or female and your age is of no significance. No, it's not chocolate. Therefore I must add, it is not fattening, although it can be a bit addictive.
The key is to keep your pain in its proper place. It is only pain. It isn't your loved one, your master or servant and definitely, it is not your friend. It can; however be your teacher, if you allow it to be. I've learned so much from 25 years of chronic pain and for that, I am thankful. You have to be careful and keep it in its place and not make a "meal" of it.
One of the sad experiences I have often witnessed with friends, strangers and loved ones is how they allow this awful thing to take over their lives. They talk about it all the time. They give it their time, their interests and their lives to the exclusion of all else. We have to be constantly reminded it's a marvelous world we live it. Trouble free? Certainly not. But if you go through life and see only the pain, you're blocking out so much else. Days, weeks and endless months pass by and some of us only see our own problems and give credence only to the pain.
One of the things I love about Dr. Ben Carson's books is his ability to see all people as equal. It would be almost "natural" for a world famous neurosurgeon with his skills and the distance he has traveled, to be arrogant; but he is not. In his book THINK BIG, he describes one night when he had a realization about his place in this world. It occurred one quiet night while he was on duty at the hospital. If I may, let me quote from that book: "One particular night, after I had enjoyed a really good conversation with the janitor, a cleaning woman and two nurses' aides, I reflected on the evening. Being a doctor at Johns Hopkins does not make me a any better in God's sight than the individual who has not had the opportunity to gain such an education but who still works hard."
You and I have been given an opportunity for growth but we need to be very cautious how we handle it. We are not better than those who do not suffer nor are we worse. We are just unique. Some of us are more unique, quirky and yes, interesting than others but that was already there before the pain arrived.
I'm certain you have also met other individuals who "make a meal out of it". They drive others from them with their immersion in their problems. It's the old, "If you have a headache she has a brain tumor" analogy. Flee from these folks until they wise up. Such wisdom has to come from within.
All I have to do when filled with the occasional round of self-pity is to look around and see friends fighting cancer, loss, problems with their children both grown and small and realize, life is for the living. It is to be lived. I noticed this morning some tiny bulbs are popping up in the back yard. It happens to be occurring in an area where the dogs leave their little messages therefore, I am more convinced than ever that a little bit of poop in life is good for us and all living things. Fertilizer my aunt Fanny…let's call it what it is and see the good in it.
I love all living things. I have plants all over the house and getting light to them in soggy old Oregon is often a challenge. My dear man is always complaining about me leaving lights on but there is a method to my madness. Plants need light. Some of my most beautiful African violets live near and have a love affair going with a lovely lamp. You can always see the clues as the plant leans into the light to catch each flicker. Now that's love. I usually remind my spouse that plants are living things. I'm afraid we've a way to go to convince him to care about plants, but he cares about me, and that's enough for now.
My friends don't make a "meal" of your pain. Get good medical care, do what you must to be as comfortable as possible, embrace change and learn from it but don't drown in it.
Sue now has a Facebook page — check it out and "like" her now!


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text: NaturaLawn of America Lawn Care Service InPortland, ME Topsham, Augusta, Lewiston-Auburn, Boothbay Harbor, Cape Elizabeth and surrounding areas Franchise Description Have a lush green lawn, naturally, and with fewer weeds. A one-size-fits-all chemical program is not a safe approach to lawn care in Portland, ME. As the recognized leader in environmentally responsible lawn care services, our approach is safer and more effective than traditional chemical services. Our NaturaLawn of America lawn care programs are customized to the needs of each individual lawn. We work with your complete yard environment to create a naturally healthy lawn that stays that way. You'll receive: Personalized service for your lawn care needs Exclusive, natural and organic-based fertilizers Effective and safer weed and insect controls Let us show you our service is as superior as the safer lawns we create. Sign up for service today or request a lawn care estimate.


text: Friday, February 08, 2013 Research Focuses on Engaging Patients in Health Care The February issue of Health Affairs explores the burgeoning field of activating and engaging patients in their health and health care. Studies show that more informed and empowered patients have better health outcomes, and there is some evidence that they also have lower health care costs. One study featured this month found that patients with the lowest level of "activation"—that is, those most lacking in the skills and confidence to be actively engaged in their health care—had average costs that were 8 %-21% higher compared with patients with the highest level of activation. Another article reports on how offering online health care for patients with simple conditions saved money for a prominent Minnesota health plan. Launched in 2010, "virtuwell" provides 24-hour online access, diagnosis, and treatment (including prescriptions) by nurse practitioners for about 40 simple conditions, such as sinus infections, urinary tract infections, and pink eye. Private and public sector leaders also weigh in with their perspectives on strategies to lower health care costs, improve quality, engage patients, and enhance outcomes research.


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JD Collins
I'm the Brand Manager here at Kickin' Country. Now, you might ask yourself, what does that mean. Well, here's what I do. I wake up, and I make sure this radio station is still Kickin'. I go to work and spend all day keepin' it Kickin'. Then, on my way home I listen and check again before I go to bed, you guessed it, just to make sure it's still Kickin'. Kickin' Country is not just a radio station. Kickin' Country is South Dakota, Southwest Minnesota, Northwest Iowa and Northeast Nebraska. People change. Times change. One thing has remained the same for the past 20 years. This radio station is still Kickin'! My job, my 'what I do,' is to make sure it stays that way.


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Wonderfully elegant with a luxury white faux silk inner shade in a laser cut polished chrome frame with glass diffuser the Alexis with 5 lights throws out a beautiful all round light.
Height adjustable on installation this fitting comes with 1 meter of chain.
Bulbs Required - 5 x 5308
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Cp Lighting & Interiors will normally deliver your order within 4 to 7 working days. Bespoke and Made to order products will be on a longer lead time, For David Hunt Lighting this varies up to 3 weeks, Please contact our showroom sales consultants on (0191) 440 11 11 who can advise you further. All orders placed before 11am on items in stock in either of our Gateshead warehouses will be delivered next working day by courier service. Deliveries to UK non-mainland and Republic of Ireland will be delivered on a two-three courier service. If not in stock in our branches items will be ordered from our suppliers and delivered to you within 4 to 7 working days. If your order is considered urgent we recommend contacting us on (0191) 440 11 11 to confirm stock availability.
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{Giveaway}: My Wedding Favors!
{Chocolate, Copper, Latte, Camel + Ivory}
{Click to Enlarge}
Details We Love
Maple Syrup Favors by 'My Wedding Favors' + Lovely Bride
Official Rules
{Please leave a separate comment for each entry}
Personally, i'd love to win this so i could buy some personalized matches. i know that sounds silly, but we're having sparklers at our wedding and matches would be great to have for our guests :)
i follow my wedding favors on facebook and the perfect palette :)
i'm a follower of the perfect palette :)
I absolutely love the White Baroque Place Card Holders!! So cute!
I follow The Perfect Palette!
I love the "Fleur de Lis" Frosted Glass Tea Light Holders. That's what I'd get. :-)
I'm following My Wedding Favors on Facebook. And I've always been following the Perfect Palette. ;-)
And of course I'm following you!
And you've been tweeted @big_easy_lovin
I love the personalized matches!
Gorgeous palette and giveaway!
I'd love to win those maple syrup favors - would be perfect for my fall wedding !!!!!
xo, lis
I liked you both on FB (firstname.lastname@example.com)
I tweeted :)
I'm now an official follower on GFC
I love the idea of the maple syrup for a Canadian wedding!
xo L.
After looking at the website I would love to spend my GC on the coral bottle toppers
I liked both of you on Facebook
I tweeted too
I love your Shell and Starfish Frosted Glass Coasters
Have been a fan of both of you
following you on here
I tweeted on Twitter
I would let my wife pick what she would like But I love the Beer glasses
facebook DOne
Last I hit follow on your blog
I'm having a fall wedding and I was just saying the other night and cute maple syrup would be! Such a cute idea!
Tweeted: https://twitter.com/#!/DrakeLathrop/status/114342183561211904
Follower of the blog!
Liked PP and WF on Facebook!
My fiancé would love the beer glasses!
following on GFC as Mandy and Justin!
My favorite wedding favors that I would pick include the Love Birds Cork Back Coaster Set and the "Rooted In Love" Miniature Wooden Box with Lid first and foremost. My next favorites would have to be the Sweet Bird House Favor Box and the "Scenic View" Tree-Branch Place Card/Photo Holder...there are so many fabulous favors to choose from!!
I tweeted -- https://twitter.com/#!/aandj8804/status/114346576612306944
I absolutely LOVE the "Meant to Bee" personalized Clover honey....super cute idea. Thanks for pointing me towards the website with the cutest favors ever!
Following MWF on facebook! Done and done.
I liked My Wedding Favors on Facebook
If i won the gift card, I would by the personalized spool of ribbon to attach to my bubbles.
I liked The Perfect Palette on facebook
I followed your blog... @Desirae226
The personalized matches would be great for an outdoor wedding. We love the idea of doing sparklers too.
I tweeted the giveaway... @Desirae226
I follow your blog :)
Because of my outdoor wedding, in June, in the south, I would LOVE to spend the gift card on the fans with bamboo handles! :)
Following MyWeddingFavors and PerfectPalette on Facebook :)
I would spend the giftcard on the personalized candy! It is such a "sweet" idea to give your guests a little after wedding snack, as well as a way to remember how wonderful the day was! Love your blog, thanks for all the tips! firstname.lastname@example.com
Already follow your blog :)
Just tweeted!
We are having an outdoor wedding so I would love to get the Dainty Damask Sunscreen Sticks for our welcome bags!
I follow My Wedding Favors and The Perfect Palette on Facebook!
I am a GFC follower of The Perfect Palette
I tweeted: http://twitter.com/#!/JASIVRAS/status/114375089394425857
i love the love birds coasters - so cute!
i joined GFC!
I love the personalized glass favor jars. They would be the perfect addition to our rustic wedding.
r.clark916@gmail dot com
I have "liked" My Wedding Favors and I have "liked" you guys all along!
r.clark916@gmail dot com
I'm following you here!
r.clark916@gmail dot com
and I tweeted @rrc916!!
r.clark916@gmail dot com
I'd choose Monogram Purse Caddy!
I love the lanterns, heart sparklers, and Margarita mixes!! A lot of fun stuff to choose from!
I spent a lot of time looking at the site and it's hard to choose, but I'd go for either the little lanterns you can put on the tables, or these lovely hand fans (http://www.myweddingfavors.com/contemp-hearts-fan.html).
Such a great idea for a giveaway Chrissy!
I would love the Natural Bamboo Eco-Friendly Coaster Favors!!! Not only is it Eco-Friendly but it shows flair because it emphasizing the asian culture in a subtle way and it will bring my guests luck in the future!
marlana.yee @ gmail dot com
Just tweeted! :)
Just become an official follower of your site!
Just liked the facebooks!
Thank You :)
Those Syrup favors are so cute!!!
I love the heart shaped measuring scoops on My Wedding Favors.
And I am of course your follower!!!
I follow The Perfect Pallate on FB
I would LOVE to buy the "Pop the Top" Flip-Flop Bottle Openers since we are getting married on the beach in Florida!
AND I follow myweddingfavors on FB as well
I would love the "our wedding water"!
southtexaswedding [at] gmail [dot] com
I am an official follower of The Perfect Palette (South Texas Wedding)
southtexaswedding [at] gmail [dot] com
I like My Wedding Favors and The Perfect Palette on Facebook (South Texas Wedding
southtexaswedding [at] gmail [dot] com
I like the slice of love pizza cutter.
Chocolate + latte? This color combo makes me hungry! xo style, she wrote
I like the miniature watering can and the seed paper (the one with the fence). They would be the perfect favors for my spring wedding.
I became an official follower of The Perfect Palette.
I follow The Perfect Palette and My Wedding Favors on facebook.
With this palette I know it is oficially and unmistakably Fall. Very pretty mix of colors here . . .
This is perfect since it definitely feels like fall here in Maryland this morning :) Love those little maple syrup favors- my brother + sister-in-law did those for their New England fall wedding, they were such a hit!
We are wine lover and looking at the Stemless Personalized 9-oz Wine Glasses is perfect to give to our family and friends :)
Love your color choices. And oh! That maple syrup bottle was just perfect. :D
I LOVE the bride and groom brownie pops! I think anything edible favor-wise goes over great, and those are TOO cute!
I'm following My Wedding Favors and The Perfect Palatte on Facebook!
Then birdcage place card holder would be perfect since I will have a birdcage to keep guest's messages!
I love the Luminous Mini-Lanterns!
Already follow The Perfect Palette & My Wedding Favors on facebook
Jen Putnam
Already follow The Perfect Palette on GFC
I'd love to get "Bottoms Up!" Cosmopolitan Cocktail Mix Kit
I'm following My Wedding Favors on Facebook and PP!
I tweeted
'I just entered to win a $25 GC from @MyWeddingFavors via @perfectpalette - Enter here ☛ http://ow.ly/6uPLs for your chance to win xo!"
I'm following The Perfect Palette
I love the maple leaf soaps :) They would be great for our out of town bags for our guests! We have a ton of guests traveling for our wedding, and we really would like to make out of town bags, but putting them together can get pricey. This would be wonderful :)
My fiance and I love the stemless personalized wine glasses. We tried to host our reception at a winery, but it was way too expensive so we're trying to incorporate our love for wine in other ways.
Thanks for the chance to wine this awesome giveaway.
i'm also a fan of Perfect Palette on facebook
I would get the mini lanterns...goes with our whole garden theme!
Lmr3683 at hotmail dot com
I'd spend it on the "meant to bee" honey jars! My honey's dad keeps bees, that would be perfect!
tad.amy.wedding at gmail dot com
The damask lip balm!
I now follow you both on facebook!
tweeted! @carolynster
I love the turning leaves bookmarks...perfect for my fall wedding!
The lucky elephant tea candle holders are super cute. Also the "Meant to Bee" beehive candles.
liked on facebook just now
I would get the autumn leaf bottle openers. Love them for my fall wedding.
following the blog now
just tweeted
Love the "Meant to Bee" honey pots!
i adore the lanterns! i would definitely get those. annieanderson132(at)gmail(dot)com. and i followed on facebook and i joined the site. 3 entries for me :)
I love the Sterlings Heart Bottle Stopper! Wine is something my fiance and I love to enjoy together. I would love to give something as a favor that others can also enjoy!
Plus who doesnt love wine :)
I have also, followed on FB, followed the blog, and tweeted!:)
Thank you,
My Gmail isnt syncing but here is my email!
I love the bamboo coasters and mini lanterns.
Ooh, I love the cracked ice crystals--perfect for centerpieces for my December wedding!
I love the fall Turning Leaves bookmarks, but the Pumpkin patch brownies are adorable!
We are having an autumn wedding (in a month!) with a book theme, so I'm dying for the Turning Leaves bookmarks! Please, please!
I'd get these http://www.myweddingfavors.com/birdcage-lantern-w-matching-cards.html
they are divine.
A love the mocha and caramel colours. Perfect blend with your wedding catering options.
I looove the "Meant to Bee" Honey-Scented Beehive Candles!
geminicalli at yahoo dot com
Beautiful inspiration board and giveaways!
Ahh, I just LOVE those cute little maple leaf syrup bottles! Now those really are competitors for the chocolate wedding favors I was planning on getting. I believe it's too late for the competition, so I will most likely get the chocolates :)
Whether I win or not (& I really would love to win, I'd choose to get the "Black Baroque" Elegant Photo Frames because my fiance and I are dedicating our entire wedding to our Grandparents and their wedding photos would look perfect in those frames.
I also love the "Olive You" dish and spreader as well as the personalized wine glasses. Such amazing favors that I think our guests will actually use! Great job!
Yes i m interesting to win a gift card.
Gift Card printing
Scratch Cards
Printed Gift Cards
I would love to win a gift card so as to buy the Maple Syrup favors.
I've been planning to give these as favors at my wedding all along. My father passed away when I was 17. We used to tap the maple trees on our property and would boil down the sap to make maple syrup. I think giving these favors at my wedding will be a great way to remember him.
I Love, love Love the idea of the maple syrup bottles!!! They are so cute and will go perfectly with my fall theme. I want these so bad for my wedding in October!!!!!! Please!!!!! :) thank you for your time and awesome ideas :)


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Iron On
Shipping Weight: 1.00 lbs.
Product Details: Iron On
- Overview
enduraTEX Heat Press Material "Iron ON"
Press like a PRO, without the heat press, just use your household iron! Yes, that is all that is needed for enduraTEX "Iron On" and it is just that easy. It offers excellent opacity, durability and it is stretchable and has a supple feel.
- Polyurethane, ready-to-cut, custom garment decoration
- Thinner than most films, easier to weed
- 3.7 mil
- Weed small letters and fine designs easily
- Light pressure to start then increase pressure as you iron
- Use teflon sheet or parchment paper
Application Directions Reverse cut, recommend 45 degree blade. This is HOT peel product. Weed excess material. Preheat iron to "Cotton" setting. Apply light pressure then increase as ironing. Apply heat for 1 minute 15 seconds to 1 minute 30 seconds.
Wash Instructions Labeled on garment. Turn garment inside out. Wait 24 hours before washing. Excellent durability, even after repeated washings. Do NOT exceed temperatures of 180 degrees F. CAN be dry cleaned. Do NOT dry in a tumble dryer.
10 simple steps! Learn more about EnduraTex Iron-On heat transfer material application process. Click Here


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LENA — The Panthers couldn't score for three quarters last week against Galena.
Friday night, Lena-Winslow's offense couldn't be stopped.
Aquin surrendered more than 60 points and couldn't stop Ben Moest or Tyler Oakley as the Panthers won, 61-30.
"Our O-line has dominated at times this year," Le-Win coach Ric Arand said. "But we haven't done it for 48 minutes.
"That's what we did tonight and that was good to see."
Oakley ran for 235 yards and scored three touchdowns. Quarterback Ben Moest threw for four touchdowns and ran in another.
Moest put Le-Win (5-3, 4-2 NUIC Northwest) on the board with two passing TDs for a 14-0 score. Aquin (5-3, 5-2 NUIC Upstate) responded with another two for a 14-12 score in the first, but Le-Win was unfazed.
"We needed to rebound," Moest said. "We were trying to put together a complete game."
Oakley torched the Aquin defense on a 70-yard TD, followed by a 12-yard score and the Bulldogs had to play catch up from there.
By halftime, the Bulldogs trailed 42-24 as the team struggled to prevent the big play.
"Five out of the last eight games we've been down because of giving that up," Aquin coach Todd Kramer said. "We just have been digging ourselves in a hole.
"We have to start creating things for ourselves."
Aquin didn't score again until the fourth quarter while the Panthers kept scoring. Moest connected for a 22-yard pass to Oakley for a 54-24 lead.
Le-Win forced two interceptions, the second by Brandan Eilders was returned for Le-Win's last score of the game.
Joey Baskerville: 815-232-0156; firstname.lastname@example.com; @Baskerville_JS


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CHALLIS, Idaho — J.T. Heaps was inspired in church to take a leap of faith, quitting his career as a motorcycle mechanic to learn the ropes of cattle ranching.
The twist on his upstart Holy Cow ranch is that he's building his herd through donations and intends to give the beef away to the less fortunate in his community.
Lofty as his plans are, the 30-year-old believes he's about three years ahead of schedule in establishing his unique charity, compared with where he thought he'd be in 2011, when he first heard a Bozeman, Mont., preacher's inspiring message about doing more to help the poor.
His father, Joe, needed no convincing when J.T. sought his help. Joe, a construction company owner with a ranching background, gave up his business to help make Holy Cow a reality. Throughout the years, Joe has continued his side job of raising bucking bulls for rodeos and futurities.
"For me, I was ready to get back into ranching anyway," Joe said. "It seemed like almost instantly we knew it was going to work. A lot of it is because we know it's what God wants us to do. It settles right in with us."
Wealthy businessman and rancher Christopher James, whose father founded the diversified financial services company Raymond James, gave the Heaps their first big break. Inspired by their vision, James hired them to manage his herd of 800 mother cows at his Shiloh Warm Springs Ranch.
In addition to allowing the Heaps to tend to Holy Cow business on the clock, James has donated the use of Challis ranch land for their charitable herd. He also gave them half of the calves from 250 head of cattle he'd recently acquired. Sales of the calves generated $70,000 in seed money.
The Heaps plan to partner with local churches, who will assist with distribution and identifying needy — and worthy — recipients of Holy Cow beef.
"We'll be making contributions through them to churches and the like. They plan to have a number of cattle ranches down the road, and I may play a big part of that," James said.
J.T. plans to also ask recipients to aid in distribution and to volunteer time for Holy Cow, hoping they'll learn ranching skills that could translate into job opportunities. He believes partnering with churches will also expose recipients to congregational life skills programs and other services.
Holy Cow has four donated cows in Challis and four more regional ranchers have promised to give. J.T. anticipates trading prime beef cuts with jerky producers for greater quantities of hamburger.
Holy Cow is now seeking contributions of cull cattle, mother cows and hay from willing ranchers. They've hired a Tennessee-based company to help them obtain nonprofit status.
"Before the start of calving, this is our time to go talk to ranchers and people around Idaho to try to get cattle donated to bring home and put them on this ranch," J.T. said.


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Other Proposed Uses
- Anti-inflammatory
- Chronic Bronchitis
- Skin Conditions (Topical Use)
Plantain (not to be confused with the relative of the banana known by the same name) is a small weed often found in cultivated fields and at the edge of lawns. Traditionally, the crushed leaves were applied to the skin to treat wounds and bites, a leaf tincture was used for coughs, and the dried leaf was taken internally for the treatment of bronchitis, ulcers, epilepsy, and liver problems.
What is Plantain Used for Today?
Very weak evidence, too weak to rely upon at all, has been used to indicate that topical plantain is helpful for skin conditions, including poison ivy and eczema . 1,2
Similarly weak evidence from two studies performed in Bulgaria hint that oral plantain may be helpful for chronic bronchitis . 3,4
Plantain extracts do appear to have anti-inflammatory effects, at least in the test tube. 5,6 However, unlike most pharmaceutical anti-inflammatory drugs, which work on the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) systems, one study suggests that plantain may work in a different fashion, by decreasing levels of nitric oxide. 5 Whether this indicates any real potential benefit in people remains unknown.
Other possible actions of plantain constituents based on test-tube studies include anti-cancer effects 7 and anti-viral actions. 8,9
Contrary to some reports, one study found that plantain does not have diuretic (kidney-stimulating) effects. 10
A typical dose of plantain for oral use is 1–3 grams three times daily. 11 Syrups and tinctures are used for coughs.
Plantain contains active substances in the iridoid glycoside family, especially aucubin, catalpol, and acteoside. 12-14 The highest levels are found when the plant is collected in mid-fall. 14 Other potentially active ingredients fall in the phenolic category, such as caffeic acid. Some plantain products are standardized to levels of one or more of these ingredients, but it is not clear whether this produces a "better" product.
Safety Issues
Plantain appears to be relatively safe, but comprehensive safety studies have not been performed.
Plantain grown in soil contaminated with heavy metals such as thallium or antimony may develop relatively high concentrations of these potential toxins. 15,16
In 1997, the FDA reported that some "plantain" available for sale on the herb market was contaminated with similar-appearing foxglove (digitalis), an herb with potent and potentially toxic effects on the heart. 17
Safety in pregnant or nursing women, young children, or individuals with liver or kidney disease has not been established.
Revision Information
- Reviewer: EBSCO CAM Review Board
- Review Date: 12/2015 -
- Update Date: 12/15/2015 -


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Certified Hudson Valley
What is Certified Hudson Valley? The "Certified Hudson Valley" designation is given to businesses listed here on our Web site that are members of the Hudson Valley Food & Beverage Alliance.
What is the Hudson Valley Food & Beverage Alliance? The Hudson Valley Food & Beverage Alliance brings organizations within the food and beverage industries together, helping businesses in the seven-county region of Westchester, Putnam, Dutchess, Rockland, Orange, Ulster, and Sullivan forge strong partnerships. Founded by Hudson Valley Economic Development Corp. (HVEDC), the alliance provides access to economic guidance and marketing resources to businesses throughout the region. For more information on the Food & Beverage Alliance, please call HVEDC's CEO Laurence P. Gottlieb at 845-220-2244.


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Built by people experienced in the non-profit world, SWEET takes a fresh approach to pledge and participant
fund raising event software. The approach is simple. Give participants and organizations
an inexpensive, easy to use tool that can be tailored to their specific needs and allow them
to focus on raising funds and creating a great experience. That's it. Easy, effective, affordable.
Some of our competitors charge up to 7% of every donation. We are outraged and so should you be. You should not
pay more because your event is a success! SWEET does not charge a transaction fee and never will.
All donations go directly to your account and are never held. What you pay will not increase with the
more funds you raise.
We understand you have an event to plan and software is only one of things on your to-do list, that is why
we've created the SWEET Process, a simple road-map that guides the process from start
to finish and beyond. SWEET Process takes all the guess work out of setting-up your pledge event online
and allows you to focus on ensuring the success of your event.
We've helped dozens of non-profits raise millions of dollars and add thousands of donors. Since the vast
majority of our business comes from word-of-mouth referrals we strive to make sure we exceed their and their
donors and participants expectations. Read what our customers have to say
and view a sample of our work.
Any non-profit, large or small, that holds participant or pledge events --walk-a-thons, golf-a-thons,
run-a-thons, any-a-thons. See who we've worked with recently.
Since SWEET is hosted on our safe, fast and reliable web servers, you don't need to worry about a thing. To
use SWEET all you and your event donor and participants need is a web browser (IE 6/7/8, Firefox or Safari), a PC
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We take privacy and security very seriously. Your donor and participant data is protected and never shared. All
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and security reviews. All data is back-up and archived nightly.
Phone: 800-330-4109
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The names and logos for SWEET and Blue Sky Collaborative are a registered trademark of Blue Sky Collaborative LLC. All text and design for this site are copyrighted ©2000-2008 by
Blue Sky Collaborative, LLC. All rights reserved.
SWEET online fundraising software is ideal for any non-profit, large or small, that holds participant or pledge events --walk-a-thons, golf-a-thons, run-a-thons, any-a-thons.


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Hear the untold stories of enslaved people and learn about historical and contemporary slavery.
Historical and contemporary slavery.
A beautiful building housing one of the UK's finest collections of fine and decorative art.
Paintings, Wedgwood and Chinese ceramics.
Uncover objects from the Titanic, find out about life at sea and learn about the port of Liverpool.
The Titanic, life at sea and Liverpool's port.
This museum tells the story of Liverpool with diverse exhibits housed in a stunning building.
Liverpool's history and popular culture.
Explore a Victorian merchant's house with its period furniture and beautiful paintings.
Paintings, vintage fashion and furniture.
Beautiful paintings, sculpture and decorative art from the 13th century to the present day.
Paintings, sculpture and decorative art.
Discover treasures from around the world, explore outer space and meet live creatures!
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A needle biopsy uses a needle to removal of a small piece of tissue or fluid for testing. In this case, the tissue is removed from the thyroid gland.
Reasons for Procedure
A thyroid biopsy is usually done when a lump is found in the thyroid. The lump is often called a thyroid nodule. These nodules are fairly common and usually do not need treatment. Only about 5% of nodules are cancerous.
The needle biopsy is usually done to see if a nodule is cancer. The biopsy may also be done if there is no nodule but the thyroid is enlarged.
Possible Complications
Problems from the procedure are rare, but all procedures have some risk. Your doctor will review potential problems, like:
- Bleeding
- Bruising where the needle was inserted
- Pain after the procedure
- Infection
What to Expect
Prior to Procedure
In the days leading up to your procedure, you may have a physical exam and blood tests. Your doctor will talk with you about your medical history, including any allergies you may have. Talk to your doctor about any medications you are taking. You may be need to stop taking some medications up to one week before the procedure
You will need to arrange for a ride home from the care center.
Local anesthesia is used. The area that is affected will be numb.
You may also be given a sedative to help you relax
Description of the Procedure
There are 2 types of biopsies:
- Fine-needle aspiration (FNA)—most common
- Coarse-needle biopsy (CNB)
You will be asked to lie on your back. A pillow will be placed under your shoulders. Your neck will be extended. The site of the biopsy will be cleaned. For an FNA, your doctor will insert a tiny hollow needle into the nodule to collect a sample of tissue. For a CNB, your doctor will make a small cut in the skin. The needle will be inserted through the incision and into the thyroid to collect a sample. The process may need to be repeated several times. After the procedure, pressure will be applied to the biopsy site. A bandage will be applied.
In some cases, your doctor will use ultrasound to help locate the area that needs to be sampled. If ultrasound is used, the doctor will place a transducer on your neck. The transducer will send images to a screen for your doctor to view. These images will be used to locate the nodule and to guide the needle. This helps to make sure your doctor got a sample of the nodule and not the surrounding "normal" tissue.
How Long Will It Take?
About 10-30 minutes
Will It Hurt?
You may feel soreness at the biopsy site for 1-2 days. Talk to your doctor about medications that may help.
Post-procedure Care
When you return home after the procedure, do the following to help ensure a smooth recovery:
- If you had FNA, remove the bandage within a few hours. If you had CNB, remove the bandage in a few days.
- Avoid vigorous physical activity for 24 hours.
- Return to normal activities.
- Take over-the-counter pain medication as needed.
Call Your Doctor
Your doctor will need to check on your progress. It is important to go to any recommended appointments.
- Bleeding
- Signs of infection, including fever and chills
- Trouble breathing or swallowing
- Excessive neck swelling
- Unusual pain or discomfort
If you think you have an emergency, call for emergency medical services away.
Revision Information
- Reviewer: EBSCO Medical Review Board Mohei Abouzied, MD, FACP
- Review Date: 09/2017 -
- Update Date: 09/30/2013 -


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- High-end Work
- Most Reputable Company
- Insurance Claim
- Maintenance Agreements
We will make sure that you fully understand exactly what to anticipate
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