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Let's Start with the Three Fundamental Needs
All species of fish have three fundamental needs: suitable water quality, protection from predators and access to food. While these three fundamentals don't change, it is important to remember that how they are satisfied changes based on daily and seasonal conditions.
Suitable Water Quality
All trout require cold, oxygenated water. Why? They have a very primitive gill structure that, compared to other species, is less efficient at absorbing dissolved oxygen. As result, they need to inhabit water with a higher dissolved oxygen content - cold water. This explains why, as the water heats up during the summer months, you will often find trout in the heads of pools or in riffles where the turbulence introduces oxygen into the water. You may also find them holding near springs, which discharge water at a constant temperature, or near the mouths of feeder creeks after a recent rainfall to take advantage of the relatively cooler water.
Protection From Predators
It is a jungle out there, and trout streams are no different. As a general rule, trout will hold where they feel safe from predators. Structure, water or a combination of the two are the primary determinants of safety. For instance, trout feel safer in deeper water or water with a surface disturbance like a riffle, because it is harder for predators to see them or reach them. Structure like rocks or logs provide safe places from which to ambush prey or nearby safe houses to flee to in the case of danger.
Trout anglers generally divide these structure/water combinations into prime lies, feeding lies and sheltering lies. Prime lies are like prime rib. They offer easy access to food and protection from predators. Some examples are the deep water at a pool's head or behind a boulder in moderate current with a moderate depth. The largest trout in any system will occupy these lies, and you should always fish them. Feeding lies are simply prime lies without protection from predators. Trout hold in feeding lies when the temptation to eat outweighs the fear of being eaten. Examples would be trout feeding in the shallow water at the tail of a pool or the slower water on a stream's edge during a prolific hatch. Since you won't always find trout in feeding lies, you should only fish them when you see trout actively feeding in them. Finally, there is the sheltering lie, which is, you guessed it, a prime lie without easy access to food. Trout hold in sheltering lies when they feel threatened, and, as a result, are not actively feeding. Either skip sheltering lies or fish a pattern designed to elicit a reaction strike like a streamer.
Access to Food
That trout need access to food is not particularly insightful. However, if we focus on calories in versus calories out and the effect of abundance on feeding behavior, we might make some headway.
Calories In Vs. Calories Out
If you run on a treadmill all day and only eat one M&M, you will certainly lose weight. In fact, if you stay on the treadmill day after day, you will starve to death. Similarly, if you are a trout, you simply can't survive if you systematically expend more calories pursuing food than its caloric value. This explains why you don't usually find trout holding high in the water column in fast water.
So, where do trout hold that allows them to win the calories in versus calories out battle? A brief overview of hydrodynamics will give us a general idea. (For a thorough discussion of hydrodynamics, you should check out Chapters 8 & 9 in Jason Randall's most recent book, Nymph Masters: Fly-Fishing Secrets from Expert Anglers.) In a nutshell, as water flows downstream, there is friction between the water and whatever it is flowing over (including itself). There is less friction between two water layers flowing over each other than a layer of water flowing over a river bottom. Since friction slows the water at the river bottom, trout will expend less energy holding closer to the river bottom. Similarly, the friction between the river bank and the water flowing against it will generally result in the water near the river bank flowing slower than the water in the middle of the river.
In-water obstructions such as rocks and boulders are important to our brief hydrodynamics overview. When water flows downstream into a submerged rock, it literally bounces off of the rock before continuing downstream. This bounce creates a dead spot in front of the rock allowing a trout to hold in front of the rock with minimal effort. As the water flows downstream, it creates another dead spot behind the rock. So, never pass up an opportunity to present your fly to these dead spots in front of and behind obstructions.
Effect of Abundance
The relative abundance of food can significantly affect a trout's feeding behavior. Unlike the limestone streams of Pennsylvania, Appalachian freestone streams are relatively sterile. As a result, freestone trout must be more opportunistic feeders. If a Big Mac only floats down the river once a week, you better make every effort to eat it. This is one reason you can be very successful fishing these freestones with a relatively limited selection of flies.
On the other hand, limestone streams and tailwaters tend to have a significantly higher concentration of food. This abundance allows trout the luxury of being more selective as well as not having to move great distances for a meal. Think about it, if you are sitting on the sofa with a bag of Doritos, you are going to eat the entire bag of Doritos before getting up to look for another bag. Fishing these waters will generally require a more precise imitation and a more precise presentation.


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[Family House Kathu for Sale] Phuket > Kathu
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Property Overview:
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Steve Jones
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Enthusiastic Optimist Without Concern for the Constraints of Reality
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Showcases realistic human form in dreamlike, primitive backdrops through paintings, drawings and print.
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I am a professional graphic artist located in Fredericton. I can turn your images into wood relief carvings with my pet robots.
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Book Club Extras Packet includes author bio and photo, title information, covers, discussion starters, and full color printable bookmarks.
Hyphema by Chelle Cordero
A Chelle Cordero EMS Thriller
Hyphema: Bleeding in the eye caused by trauma…Matt Garratti, a paramedic from New York, moves his wife and son to North Carolina to work at his dream job as a flight medic. Pakistani born Sudah, his wife, receives frosty stares and insensitive comments from their new neighbors.Before long, Matt wonders if he is pursuing his dream or bringing his family into a nightmare from which they may never wake.
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The Parliamentary Under-Secretary of State for Business, Innovation and Skills (Ian Lucas):
The Government continue to ensure that small and medium-sized businesses have access to the finance that they require. Since January we have secured lending commitment agreements with
banks, introduced the enterprise finance guarantee-which to date has received over £0.5 billion of eligible applications-and, recently, launched the innovation fund as part of the Government's strategy for ensuring the UK's future economic success.
Mr. Swayne: The small firms loan guarantee scheme and the enterprise finance guarantee scheme have produced less than half the target amount of lending. Meanwhile, firms in my constituency with good order books and good prospects are still screaming for credit. What are Ministers going to do about it?
Ian Lucas: What the Government are anxious to do is use public finance to help to guarantee the funds that are available from banks. That is a very positive and innovative approach. The hon. Gentleman must answer this question: where would the money come from under a Tory Government?
Mr. Peter Bone (Wellingborough) (Con): It has nothing to do with the next Tory Government, and everything to do with this Government. They have nationalised the banks-billions of pounds of taxpayers' money have been put in-but small businesses in my constituency are going bust because the banks are not lending to them. What are the Government going to do about it?
Ian Lucas: I have described the active steps that the Government have already taken. I am a constituency Member of Parliament too, and I speak regularly to businesses in my constituency. These issues have been raised, and businesses are well aware that the Government have taken action. However, we will act when individual cases are raised. We will support industry and business, and we know that other parties would not.
Mr. Russell Brown (Dumfries and Galloway) (Lab): I fully recognise that my hon. Friend and other Ministers are doing the best they can, but there are still significant difficulties out there with some of the main banks. Are my hon. Friend and his colleagues making it abundantly clear to Treasury Ministers and officials that small and medium-sized enterprises are, regrettably, still suffering at the hands of the major banks?
Ian Lucas: We all recognise that we are experiencing extremely difficult economic circumstances at present. We are working in the Department to assist small businesses, and of course we liaise closely with the Treasury in discussing the steps that need to be taken to enable us to improve the service that we are giving as much as we possibly can.
Mr. Jonathan Djanogly (Huntingdon) (Con): I suggest that the Government have not been doing all that they can. Is it not the case that the French and Germans had been facilitating credit for their companies months before we got around to it? Is this not too little, too late?
Ian Lucas: I am beguiled by the conversion of the Conservative party to adoration of what is happening across the channel. It seems that the right hon. and learned Member for Rushcliffe (Mr. Clarke) is having rather more influence than I thought.
We are taking action. Great progress has been made in the way in which we are delivering support for business. We will continue to do so-and Conservative
Members have still not told me where they would find the money to pay for these programmes under a programme of cuts.
Greg Mulholland (Leeds, North-West) (LD): Pubs are, of course, small businesses, and evidence from pubs around the country shows that they in particular are not receiving assistance and credit from banks. Will the Minister agree to look into that, and meet a delegation from the save the pub group to discuss this important issue?
Ian Lucas: Mr. Phil Liddell of the Peal O' Bells pub in Holt in my constituency has been very active in trying to draw attention to the difficulties of pubs in the locality. Before I was a Minister, I attended the hon. Gentleman's event on licensing so I am very well aware of the difficulties in the industry. The particular area he raises is not in my remit, but I will speak to my ministerial colleagues concerning this matter and they will get back to him.
T1. [287073] Mr. Desmond Swayne (New Forest, West) (Con): If he will make a statement on his departmental responsibilities.
The Minister for Business, Innovation and Skills (Mr. Pat McFadden): Our Department is focused on creating the conditions for business success, promoting enterprise, innovation and science and making sure people have the skills and opportunities to succeed. To that end, this week we have published the life sciences strategy and, together with our colleagues in the Department of Energy and Climate Change, the low carbon industrial strategy. That is because we take the view that the Government have an active role to play in helping Britain make the most of the changes we will need in how we transport ourselves, how we build and heat our homes, and how we produce our energy for the future.
Mr. Swayne: And another thing: why is it that someone who is languishing on jobseeker's allowance has to wait six months before they can retrain? Why can they not start retraining straight away-and perhaps be retrained in some of the skills for the wonderful strategy the Minister has just described?
Mr. McFadden: The focus for those who are unemployed for a short time is to help get them back into work as soon as possible. That is why it makes sense to give the extra help for retraining for those who have been out of work for that bit longer. I have to say to the hon. Gentleman that if he thinks there should be more expenditure on helping the unemployed, perhaps he should resist his own party's plans to cut public expenditure now in the middle of a recession.
T6. [287080] John Robertson (Glasgow, North-West) (Lab):
The "Digital Britain" report recommends putting a levy of 50p on all copper lines. Is it fair to ask particularly the people of Glasgow and my constituency where 70 per cent. do not take up broadband to pay that 50p levy? I think the Minister
will have to agree that that is totally unfair. Would it not be fairer to get broadband users to pay that extra levy?
Mr. McFadden: The "Digital Britain" strategy published a few weeks ago is a very good example of the active role we take in helping to shape the economic future of the country and making sure that opportunities in it are maximised. The report said that those on low-income tariffs would not have to pay the levy mentioned, so it is not universal regardless of income; instead, it is a measure that would step in where the market would not to make sure the opportunities presented by next generation broadband are not just enjoyed by those two thirds of the population or so that the market would provide for, but are enjoyed throughout the country.
Mr. Kenneth Clarke (Rushcliffe) (Con): Has the Minister of State noticed that Royal Mail is losing business at a rate of about 10 per cent. annually, that it faces a pension deficit that will probably be valued at £10 billion, which it is unlikely to be able to fund, and that it now faces strike action? The Government have suspended all progress on a Bill that we were supporting, and which the Minister said was urgently necessary to secure the future of Royal Mail. Is the Government's policy one of benign neglect, or is he simply doing nothing?
Mr. McFadden: As the Secretary of State announced in the other place a couple of weeks ago, the market conditions have not been conducive to getting the best value for the taxpayer from the partial sale we have proposed. Where I agree with the right hon. and learned Gentleman is that that does not mean that Royal Mail does not face significant problems and challenges. It is important that the company gets on with its plans for modernisation, and that the union, which has said it is up for change, shows that that means something in practice-and I have to say that continued strikes and industrial action within Royal Mail will do nothing in the end to help it on the necessary road to modernisation, which is absolutely essential for the future of the universal service.
T8. [287082] Jessica Morden (Newport, East) (Lab): The consumer White Paper has just been published, so will the Minister take a look at credit reference agencies, such as Equifax and Experian, to see what more can be done with this industry to make the reports that such agencies provide to consumers more accessible and easy to interpret?
The Minister for Further Education, Skills, Apprenticeships and Consumer Affairs (Kevin Brennan): Yes, and I thank my hon. Friend for her welcome for the consumer White Paper. The Government want to ensure that all consumers have access to the right tools to help them understand credit reference files better. Of course, people can request a paper copy of their credit reference-that will cost them two quid, so it is not that expensive. We will work with the industry to look at improving people's access to and understanding of their file, including whether it can be made available online.
T2. [287075] Sandra Gidley (Romsey) (LD): Could the Minister explain why hard-pressed graduates in Southampton and the rest of the country have to pay 4.8 per cent. interest on their student loans, given that we now have a deflationary economy?
The Minister for Higher Education and Intellectual Property (Mr. David Lammy): As I have explained before, the rate on income-contingent loans is based on the retail prices index over the year period. We examined this closely, finding that the loan rate is still one of the cheapest loan products available in the developed world.
Mr. Denis MacShane (Rotherham) (Lab): At the close of business today, I shall present a petition on the steel industry. It has been signed by about 5,000 of my constituents and others, and was assembled in a matter of just eight or nine days. I welcome the announcement made by the Minister for Business, Innovation and Skills that the Prime Minister is meeting Corus this afternoon-Lord Mandelson is, of course, coming to the steel industry in Yorkshire tomorrow. On a very narrow point, before the Prime Minister meets Corus and before Lord Mandelson comes up north tomorrow can the Minister for Business, Innovation and Skills examine credit risk insurance? It has been put to me that that is one of the issues to address. Providing such insurance does not cost the Government a lot of money and it is something that they can do. Taking such an approach would send a powerful signal that our Front-Bench team is on the steel industry's side.
Mr. McFadden: I know that my right hon. Friend has been campaigning hard for the Corus workers in his constituency. As he said, the Secretary of State is to visit Rotherham tomorrow. We appreciate that credit insurance has been an issue, not only in the steel industry, but in other sectors of the economy. That is why we put a credit insurance scheme in place and recently announced that we would backdate the help available under it.
T3. [287076] Mr. Philip Hollobone (Kettering) (Con): Those businesses that survive the recession face a 0.5 per cent. increase in employers' national insurance contributions in 2011, at an additional cost of some £2.7 billion. Given that the subscription payments we make to the EU are set to more than double to £6.5 billion by 2011, would it not make sense to save that money and offset the unnecessary rise in the tax on jobs?
Mr. McFadden: I see that the Conservative party is now free from whatever influence the mainstream centre-right in the European People's party had on it and is giving full rein to the instincts that would see us look away from the European Union. I remind the hon. Gentleman that 3 million British jobs are dependent on trade with the European Union, and I do not think that his proposal would advance the interests of those people or of the UK economy.
Mr. Jim Devine (Livingston) (Lab): When we come back in October, it will be three years since the collapse of the Farepak Christmas savings scheme. The directors who ripped off tens of thousands of decent, hard-working families have never appeared in a civil court or a criminal court. Will the Minister, through his Department, organise a meeting with concerned MPs from both sides of the House and the liquidators?
Kevin Brennan:
Yes, I would be happy to have that meeting. The report on this was completed in May 2008. It is long and detailed, and counsel has been
considering it and its supporting information. If any proceedings are initiated as a result of the report, they obviously have to remain confidential until they reach court.
T4. [287077] Peter Luff (Mid-Worcestershire) (Con): May I commend to Ministers and to the House two excellent reports that the Select Committee on Business and Enterprise published recently on pubs and on post offices? If Ministers were to embrace warmly the constructive proposals in both, they would do a great deal to safeguard the vital services on which many deprived, vulnerable and isolated communities depend.
Mr. McFadden: I am always happy to pay warm tribute to the work of the Business and Enterprise Committee, chaired so ably by the hon. Gentleman. The report on post offices was something that the Government and the Committee worked on together. It is a good and constructive report, and I assure him that it will be considered positively.
Hugh Bayley (City of York) (Lab): I feel especially well disposed to the Department today. Tomorrow I will open a new packing plant at the Nestlé factory in York that will provide an additional 100 jobs initially and 200 in the longer term. It received support from the Government's enterprise finance guarantee scheme for a smaller company, IPS First, which is the co-packer. The new plant will reduce carbon emissions, because the Nestlé factory will no longer have to truck its Kit-Kats, Aeros and Polos to west Yorkshire for packing. I went to see-
Mr. Speaker: Order. May we have a question, in a sentence?
Hugh Bayley: In a sentence, the Secretary of State-I went to see him about this-moved like lightning to get the money through and I would like my thanks to be passed to him.
Mr. McFadden: The Secretary of State is always a speedy mover, and I will pass my hon. Friend's thanks to him. The story shows the advantages that this Labour Government are clearly having for the people of York.
T5. [287078] Mr. Alistair Carmichael (Orkney and Shetland) (LD): May I encourage the Minister to respond to the Business and Enterprise Committee report not just positively, but swiftly? Having recently worked with the local community in Hillswick in the north of Shetland to obtain an outreach post office in the local shop, I can confirm that the suggestions in the report would make an enormous difference not just to the profitability of the post office, but to the shop as well.
Mr. McFadden: Outreach post offices can be very successful, especially for small rural communities, such as the many in the hon. Gentleman's constituency. In some ways, we have already responded to the need: for example, my colleagues at the Department for Transport were able to announce a new contract with post offices for the renewal of driving licences. That comes on top of the decision taken some months ago to renew the Post Office card account. So already the Government are putting more work the way of post offices.
David Taylor (North-West Leicestershire) (Lab/Co-op): The Opposition parties fought tooth and nail in overnight sittings to prevent one of our finest achievements-the national minimum wage. However, far too many of the recipients of that national minimum wage rely on gratuities to top their incomes up to that level. Will my right hon. Friend consider tabling appropriate amendments to the legislation at some stage, and can he publish some research on the numbers of people in that category?
Mr. McFadden: We have already published a consultation on the number of people in that category, and I am pleased to inform my hon. Friend and the House that regulations to prohibit the use of tips, gratuities and service charges to make up the minimum wage were passed some weeks ago. That change was overdue, and I have been committed to it since I came into this job. It is good news for service workers throughout the country.
Mr. David Heath (Somerton and Frome) (LD): My heart was warmed by the glowing account by the hon. Member for City of York (Hugh Bayley) of the building of colleges in his constituency. May I ask a simple question about the college in my constituency? Frome community college is waiting for a response from the Learning and Skills Council about the building project to replace its tertiary blocks that it plans in conjunction with the LSC, which is already more than matched by local authority funding. That project will fail unless the LSC answers by 28 August. Is it asking too much for a positive response from the LSC for that modest building programme?
Kevin Brennan: I will certainly look into the individual case of Frome community college, but an announcement was made on 26 June about the future of the further education capital scheme, which set out, thoroughly and rigorously, the projects that would be going forward in the next spending round. I undertake to look into the hon. Gentleman's case, but we need investment to proceed with these college building projects-I hope Opposition parties will commit to that investment.
T7. [287081] Mr. Peter Bone (Wellingborough) (Con): My question follows the excellent one from my hon. Friend the Member for Kettering (Mr. Hollobone), which the Minister totally failed to answer. In Wellingborough today there are 3,276 people unemployed, compared with 1,712 in 1997. That is an increase of 91 per cent. I do not want that figure to go any higher, so will the Minister answer my hon. Friend's question? Will he freeze our contributions to the EU, and scrap the increase in the job tax?
Mr. McFadden: The Government have every sympathy for people who have lost their jobs as a result of the recession, and we are trying to do everything that we can for them. We know that there are many such people, in the hon. Gentleman's constituency and around the country. Yes, unemployment has gone up, but I remind him that when the right hon. and learned Member for Rushcliffe (Mr. Clarke) was Chancellor unemployment was running at 10 per cent., with 3 million people out of work. The position was a great deal more difficult than the one that we face today.
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KEARNEY - Information Technology Services is updating campus wireless networks Dec. 16 at UNK, UNL and UNO to a common standard. There will be three network options available at each location: eduroam – Secure network for students, faculty and staff. NU-Guest – Network for campus visitors such as guest professors, vendors and event attendees. NU-Connect – Network for IoT devices such as Apple TVs. Existing campus networks will remain active and not be decommissioned … [Read more...] about Changes coming Dec. 16 to UNK, University of Nebraska wireless service
Nominations sought for Technology Excellence Award
The Technology Excellence Award, offered at the University of Nebraska at Kearney the past eight years, is now open for all Information Technology Services across the University of Nebraska system. The University of Nebraska Technology Excellence Award recognizes the exemplary performance of ITS staff members who consistently provide a level of service significantly above and beyond specific job responsibilities. To be eligible, employees must report directly to ITS … [Read more...] about Nominations sought for Technology Excellence Award


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Liability insurance coverage only covers damage to third party properties or persons, this DOES NOT cover damages to the aircraft. You, as the renter, are responsible for all damage(s) incurred to the drone and accompanying equipment.


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Wednesday, Dec. 12, 2018 | midnight
Sun on the Strip
December 12, 2018
The Golden Knights and sports on the Strip, Eataly at Park MGM, The Barbershop at Cosmopolitan and more.
On this episode of the Sun on the Strip, entertainment writer Brock Radke welcomes Las Vegas Sun managing editor Ray Brewer to talk about all this week's Strip entertainment news:
- The Vegas Golden Knights are the hottest ticket on the Strip and are changing the face of Vegas entertainment at T-Mobile Arena.
- Touring Eataly, the massive Italian marketplace and dining destination at Park MGM.
- Clique Hospitality is opening The Barbershop at the Cosmopolitan.
- Construction is under way for the new Smith & Wollensky steakhouse at the Venetian's Grand Canal Shoppes.
- The Flamingo is now offering bunk bed suites and rooms.
- Drake will perform at XS Nightclub for the first time during CES.
- Lady Gaga, Van Morrison and John Fogerty have added new show dates for 2019.


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» Understand the rationale behind broadcasters outsourcing their technology requirements.
» Study and analyze the problems that the company could face while outsourcing.
» Understand the selection procedure that companies adopt to choose the technology service providers.
» Study the role of Chief Technology Officer in an organization in devising and implementing IT outsourcing contracts.
» Critically examine the strategic impact of outsourcing IT requirements in the organization.
Editors Note : This document presents a compelling case forlooking at outsourcing your customer contact process. You might want to compare it withthe views expressed in my article . I have personally had the opportunity to study the cases presentedon site and can vouch for their authenticity. Note that in each case the outsourceactivity was established inside the Clients organisation. Niels Kjellerup editor.
It is introduced by Wal-Mart during the 1990 s and is considered as the latest strategy in the evolution of supply chain collaboration. Where VMI only considers inventory replenishment activities, is CPFR a comprehensive collaboration strategy that provides opportunities to involve both supplier and customer in the demand forecasting and inventory replenishment planning activities. The whole supply chain works together to decrease costs and increase revenues and customer satisfaction (Larsen, Thernøe, & Andresen, 2003). Both the supplier and customer make a sales forecast. Based on a comparison of these two forecast one general forecast will be made. This forecast will be compared to the real sales afterwards to check on differences and find out the causes of these differences. This is done to learn and improve future forecasts (Katz & Hannah, 2000). Based on the sales forecast a planning will be made. Again both the supplier and customer make an individual planning that will be compared and adapted to one general order planning. If the real sales are comparable to the planning, an automatic order will be created as agreed upon in the ordering planning. In case of significant changes in the sales and forecasted planning the automatic order will not be placed and the order planning can be changed for once (Schachtman, 2000). Thus at CPFR the supply chain works together in making one general planning, sales forecasts, and order planning that will be used by everybody. The collaborative planning within CPFR is based on a strategic level. A business plan is made to record the goal and time of the collaboration. The collaborative forecasting is on a tactical level. Partners bundle their knowledge to make one prediction of the sales and orders on short till medium term. Collaborative supplying is on operational level, here the actual deliveries are done with the order plan as starting point (Involvation, 2002) Comparison of VMI and CPFR By aligning the decisions of the different supply chain partners to each other the supply chain can be improved by among other things eliminating double and superfluous processes. An important aspect here is the balance of powers in the chain. Determining the decision making responsibilities of each partner is one of the first steps. The division of these decision making responsibilities depends on the degree of (in)dependency between partners (Involvation, 2002). - Information sharing - this can lead to cost savings and an improvement of the reliability and reactivity of the supply chain. - Redistribution of decision responsibilities - one of the parties becomes responsible for determining the order quantities. This task might include the carrying risk for shortages and surpluses. The other company provides information to execute this task. VMI is part of this category. - Central optimization - one decision-making body is responsible for the supply chain decisions. This mostly happens during vertical integration or a concentrated position of power. Next to the collective responsibilities, decentralized decisions can be made (within preconditioned context). CPFR can be applied as a solution to prevent that one party does not get all the power. When comparing VMI and CPFR based on responsiveness to replenishment some differences can be found. As explained, within CPFR a general order plan is made, which is leading for the order placements. The joint consultations leads to better forecasts, but also to less flexibility. The order plan must be adjusted in case of significant changes with the real sales, which is time consuming and leads to low responsiveness. On forehand a plan can be made for how to react in certain situations to increase the responsiveness to the market. VMI is more flexible. The supplier places the order for the customer. Decisions for changes can be made by one party since no consultation is needed, which leads to faster responses (Involvation, 2002). 17
Also in the (collaborative) planning there are different outcomes. VMI does not work with a joint planning, but only considers the sharing of information. In theory CPFR is a step ahead of VMI, both parties process all information to come up with one joint business plan (De Vos, 2002). However, in practice VMI also can apply a joint planning, but this is not common (Involvation, 2002). When considering forecasting CPFR is performing better, especially in joint forecasts. By making a forecast based on the medium term, improvements in the logistics can be made. Within VMI every party makes their own forecast that will not be shared with others (Involvation, 2002) Application of VMI and CPFR within hospitals Applications of collaboration strategies like VMI and CPFR in the healthcare sector are not one-to-one comparable with other sectors like manufacturing and retail. Healthcare supply chains are much more complex compared to other industries, which is the main reason for difficulties in implementing effective supply chain management practices (Scheller & Smeltzer, 2006) (Shah, 2004). The healthcare sector faces different inventory related problems because the responsibility of replenishment is far more critical in this sector. A stock-out in pharmaceutical products or instruments has far more consequences and is not comparable to a stock-out in for example a retail store. In addition, other general difficulties in the application might be unwillingness among other things due to privacy issues or incapability of sharing information. Also a lack of trust and the conservative culture is an additional constraint factor for the implementation of collaboration (Danese, 2006). This adds extra complexity in the implementation and make the realization of the benefits a demanding and difficult task (Matopoulos & Michailidou, 2013). Outsourcing the supply of materials can have advantages for hospitals, but it is important to have a limited number of suppliers. Outsourcing can lead to costs- and time efficiency for the internal hospital organization. Also the hospital saves storage room since fewer goods needed to be stored within the hospital. A risk of outsourcing (a part of) the logistics is the higher influence of externalities, which can lead to delayed deliveries (Ministerie van Verkeer en Waterstaat and Rijkswaterstaat, 2004). To reduce this risk it is it is important to find a service provider that is closely located to the hospital. Agreements must be made between the hospital and service provider to reduce the risks and maintain the service levels. Claasen et al. (2008) shows that in general better results will be achieved when purchasing managers invest in the relationship with the supplier and have a good IT infrastructure. Most managers expect benefits like major cost reductions when implementing a collaboration strategy like VMI, but these expectations are often wrong. Benefits can be expected from improved service levels, improved supply chain control, and some cost reductions (Claassen, van Weele, & van Raaij, 2008). Matopoulos and Michailidou (2013) show in their case study to hospital vendor collaborative practices that for the hospital specific and measurable cost reductions are achieved next to other improvements such as better inventory control. According to them limited research is available of the implementation of VMI in the healthcare sector, particularly for its adoptions (Matopoulos & Michailidou, 2013). This is confirmed by Bhakoo, Singh and Sohal (2012), they state that the application of VMI systems within the healthcare sector is largely ignored in literature. Oliveira and Nightingale (2007) investigated the relationship of two hospitals in the US with a vendor. This research showed significant improvements in areas such as product availability, visibility of data, and reduction of inventory management labour. Collaborative arrangements within the supply chain partners and their respective perceived benefits can vary significantly due to several conditional factors like product characteristics, spatial complexity, regulations, conformity of goals, and the level of trust between organization and physical attributes (e.g. size of hospital, storage capacity, level of IT 18
(de Bruin, Rosemann, Freeze, & Kulkarni, 2005). For the case of RdGG and it is desired to get a visualization of the current situation and the desired future situation based on the design and to come up with the required actions that must be done for the implementation of the designed process flow. Therefore there is chosen for a prescriptive model. Since no model was found that fit this case, a Supply Chain Collaboration Maturity Model will be introduced to define the changes needed to achieve the desired future state. This model is based on several models found in literature that are combined and adjusted for this specific case of RdGG and. A clear implementation strategy helps planners and decision makers to gain a clear picture of the requirements for implementation and helps them to develop action plans that will raise stakeholder interests (Bryson, 2004). During the analysis and design phases the users were already involved. However, during the implementation phase it is still important to also focus directly on the stakeholders as they still can influence the project (Goggin, Bowman, Lester, & O'Toole, 1990) (Nutt, 2002). This will be done by means of a stakeholder engagement plan. During the analysis and design phase most stakeholders were already introduced and involved in the research. However, when implementing the design it must be clear how each stakeholder must be involved and informed during this phase. Stakeholder analysis is a crucial aspect for problem solving, as some stakeholders can have high power on a project (Bryson, 2004). Analyzing the priority and level of attention of the stakeholders will help to select the proper communication approach for each stakeholder. Different literature based models exists for mapping stakeholders. Among the commonest models of stakeholder mapping are the Power-Dynamism matrix, the Power-Interest Grid and the power, legitimacy and urgency model (Adeyanju, 2013). The power-dynamism model categorizes stakeholders based on the power they exact and the vitality of their attitude. However, the model is mostly used during the development of new strategies. The power, legitimacy and urgency model, also known as the salience model, maps stakeholders behavior into 7 types, depending on the combination of three characteristics. The stakeholders power to influence the organization. Legitimacy of the relationship and actions of the stakeholder in terms of desirability or appropriateness. The urgency of the stakeholders expectations in terms of criticality and time-sensitive (Mitchell, Agle, & Wood, 1997). However, the urgency of the implementation of the project is for all stakeholders the same, as the rehousing to the new building is set on the end of August 2015 and thus does not add a contribution. The power-interest grid determines which stakeholders should be taken into account for a certain (changed) situation (van Ham, 2012). This framework gives a clear visualization of which stakeholders are the key players, context setters, subjects and crowd. This model can be used to point out what type of engagement the organization should have with each of the groups. Therefore the power-interest grid is the chosen model to map the stakeholders. With use of this power-interest grid the engagement style is identified based on the five levels as proposed by IAP2 (IAP2, 2015). Based on the actions that needs to be done a preliminary planning will be proposed. For project implementations different planning tools can be used like the Critical Path Analysis or Gantt Chart. Since this research will propose a preliminary planning including a planning on a high level and will not include specific tasks, making it hard to find the critical path. Besides, when projects become more complex and larger with more activities it becomes more complicated to find the critical path since all aspects of the project and their time frames and interdependences needed to be identified (Choreotools, 2012). Therefore there is chosen for a Gantt Chart. A Gantt Chart makes it possible to make a clear planning for a project, based on identifying actions and indicating the reserved time and responsible person(s). PD is an ongoing process, this leads to that after the implementation plan in Chapter 7 changes can still be made in the design. This is also the case in this research since during the implementation phase 11
The user-friendliness is of high importance since these have lots of consequences for the processes. How these changes will be received by the employees is not thoroughly investigated. As a supply chain collaboration maturity model (SCCMM) is proposed in Chapter 6, one should know that this model has not been been evaluated extensively. As explained the evaluation is done by myself (type 1 evaluation) and by Annetje Guédon and Vivian Hoeijmans that were seen as experts of the process where the SCCMM was applied on (type 2 evaluation). However, during these meetings it was not clearly communicated that their insights would be used as evaluation of the model. When considering the application of the SCCMM and the usage of the outcome I think that the types of evaluations were enough, as the model was used as support and not as a central part of this research. The SCCMM is mainly used to see where the biggest improvements must be made within RdGG and. Together with the implementation requirements set in the design chapter (Chapter 5) tasks were formed to be able to reach these maturity levels during a certain time period. When asking the question if externally storing sterile trays outside the OR-complex and implementing a pull delivery system is a good decision there is no direct answer. However, implementing such a process takes a lot of attention and actions. The total score of high classified risks decreased with almost 20% for the case of RdGG and, but if this is identical for any other hospital cannot be said. In this case a decrease in process time for loan trays can be seen. However, based on data of and RdGG can be concluded that loan trays are only used in 3% of all surgeries. There are thus no huge time saving by introducing a pull based delivery system. Cost savings will mostly occur based on the time shift from the OR department to since employees of are cheaper compared to the OR employees. An estimation of these costs is difficult to make based on the outcomes of this research, because the indicated times are not always per tray or surgery. For example the ortho meeting, which is a 15 minute weekly meeting the surgeries and needed trays for the coming two weeks are discussed. Dividing these 15 minutes per tray is not possible as the number of trays discussed per meeting varies. In the process time of the analysed and divided process flow this step is set on 15 minutes as dividing and assigning these 15 minutes to each tray is thus not possible. Besides, cleaning the trays in the washing machine and sterilization in the autoclave is performed with multiple trays at once. However, the indicated times for the current and designed process are consistent with each other. For the sterilization department clear improvements can be seen as they will be able to distribute the workload by the introduction of tray priority, leading to better and more considered choices of which tray should be first processed. Trays that must be processed to replenish the storage do not have to be processed directly, and can be processed on times when the workload is less high. It is advisable when considering a pull delivery system for the trays to first research the costs and benefits and have a clear plan before really applying. Making clear (service level) agreements on forehand, preferably on paper is an important task. 78
comes with possible failures. Providing the right environment and making clear work agreements can help to minimize these failures. The analysed risks in this research are all related to a specific process step. There are also some residual risks that did not come out nor were investigated during this research as they were out of scope, but should not be neglected. Five of those risks are described below. 1. The focus of this research was on the instrument trays, however also the procedure trays must be demand driven delivered after the rehousing. These procedure trays are manufacturer prepacked packages containing disposable products like sutures, gauzes, covering materials for the patient, syringes and needles. How to include these in the demand driven delivery must still be investigated. A possible solution can be to see these procedure trays as instrument trays and order them just as normal trays via ChipSoft. However, when digitalizing the inventories of these procedure trays the system must keep into account that these procedure trays are for single use and thus do not return to the inventory, but must be ordered at the manufacturer again. 2. A second residual risks is the bottleneck in the number of trays. It was already recommended to start an investigation to bottleneck trays. It can be that these trays are going to need a lot of attention and guidance from the users to prevent delays or even cancellations of surgeries as trays that can stand in for the missing instruments are less accessible. This may lead to inefficiencies in the process. This risk already partly became clear from the HFMEA on de designed process flow, but was not further taken into account. 3. Thirdly, there is no designed emergency procedure for when the IT-system(s) is/are down. There must be thought of an emergency process flow that must be started when support from the IT-systems is not possible. An important aspect is that both RdGG and are clearly up-to-date about when and how to start and perform this procedure. 4. Fourth, it is not clear yet for lower level disturbances in the process how to systematically tackle these, e.g. when a tray is not delivered (or the wrong tray is delivered). When implementing the proposed design these procedures must be investigated. This can be done with help of the identified risks. A step-by-step approach must be designed for these cases. This must be created besides the already recommended clear (service level) agreements between RdGG and. 5. The final residual risk is that over time extra checks might be implemented in the designed process flow as users find it difficult to relinquish responsibilities. These extra checks will cost time and make the process less efficient. Though it sounds contradictory, extra checks can also introduce more risks as tasks are done with less attention since the thought is that work will be checked later on. The slip-in of these extra checks must be closely watched to prevent this to become a standard step. Attention must be given by RdGG and to these residual risks when implementing the designed process flow. During this research a parallel project of RdGG and was ongoing for the preparations of accommodating the sterile trays at by means of pilots and meetings. This made the research more difficult because decisions were made during this research, for example the choice for the IT-systems. The question if a connection between the two systems was going to be implemented or if would to switch to ChipSoft and thus one system would be used was answered after the design was made. Next to this it is not totally clear if the suggested IT solution will be as proposed. 77
8 Conclusions and recommendations 8.1 Conclusions This report proposed a design for the process flow of surgical instrument trays for the future situation of RdGG and, where is going to facilitate the storage of the sterile instrument trays. This means that the delivery process will change from push to pull. The context of this study is taken into the fields of efficiency and safety, which are connected to the process flow of surgical instrument trays. Therefore, the following objective was formulated: To design a process flow for the surgical instrument trays of Reinier de Graaf Gasthuis and with the focus on safety and efficiency and to advice on its implementation, in order to handle the future situation. The chosen method is Participatory Design (PD), which provides a guideline for a structured design process. PD leads to a designed product that meets the users specific needs by actively supporting participation and involvement of a multidisciplinary team into the design and decision-making process (Pilemalm & Timpka, 2008) (Namioka & Rao, 1996). The involved users during this research were from the OR, IT and planning departments of RdGG, and the manager and team leaders of. PD is an ongoing process and thus must continue even after this research is ended. This research focused on orthopaedics, a specialism that uses a large amount of instruments during surgery and frequently use loan instrument trays. The most important changes of the designed process flow compared to the analysed current process flow are that trays will be tracked and traced during the whole process (based on scanning at fixed moments), information is more digitalized in one central system and more systematically entered/retrieved, and an interaction exists between the systems of RdGG and. During various process steps support is given by IT systems, for instance when planning surgeries based on the availability of trays and priority at. Literature states that by applying a pull based delivery system the efficiency and safety should increase. Concluded can be that this is also the case when applying a pull based delivery for the sterile instrument trays. However, no decrease in the overall inventory levels will occur as we are dealing with a closed loop system and most of the inventory will only shift from RdGG to. The number of deliveries stays the same, as these are also used to deliver and retrieve goods to and from the policlinics. An increase in the availability of the trays is expected since can process the trays based on priority, leading to an improvement of the customer service. The most important findings when comparing the current with the designed future process flow are: - The overall process time for normal trays stayed the same at around 450 minutes, whereof the process time of the OR staff decreased with 25% and the process time of increased with 23%. For loan trays the total process time decreased with almost one hour to 660 minutes. There is a decrease of 85 minutes for the OR staff which is equal to 31% and an increase in process time for of 30 minutes, which is equal to a 9% increase. - The total number of risks of the designed process of normal trays increased with 9% (6 risks), and the high classified risks increased with 10% (3 risks). For loan trays the total number of all risks has decreased with 17% (26 risks) whereof 11 (23%) of high classified risks. - The sum of the scores of the high risks is greatly reduced with almost 20% from 510 to 414, indicating that the designed future process is safer. The total number of high scoring risks is decreased with 14% (7 risks). 70


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