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Cover Shot! is a regular feature here at the Café. I love discovering new covers, and when I find them, I like to share. More than anything else, I am consumed with the mystery that each new discovery represents. There is an allure to a beautiful cover. Will the story contained under the pages live up to promise of the gorgeous cover art?
Elisha Barber looks interesting. Elisha is a barber-surgeon. Is hacking off limbs like hacking off hair? The first book in E C Ambrose's Dark Apostle series hits store shelves July 2013.
England in the fourteenth century: a land of poverty and opulence, prayer and plague, witchcraft and necromancy. Where the medieval barber-surgeon Elisha seeks redemption as a medic on the front lines of an unjust war, and is drawn into the perilous world of sorcery by a beautiful young witch. In the crucible of combat, utterly at the mercy of his capricious superiors, Elisha must attempt to unravel conspiracies both magical and mundane, as well as come to terms with his own disturbing new abilities. But the only things more dangerous than the questions he's asking are the answers he may reveal..


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MACON, Ga. (March 6, 2010) -- Hoping to earn the program's ninth trip to the NCAA Tournament, the ETSU Buccaneers will take on the Mercer Bears in the championship game of the 2010 General Shale Brick Atlantic Sun Conference Tournament Saturday at 6 p.m. inside the University Center on the campus of Mercer University.
The game will air nationally on ESPN2.
The Bucs (19-14) will face an uphill battle, taking on a Bears team that has defeated them twice already this season. In addition, ETSU will meet Mercer on the Bears' home floor and in front of a hostile crowd.
For more on Saturday's game, click on the game notebook link above or read the game notes below.
Buc bits
With their longest winning streak of the season standing at five victories and serving as momentum, the ETSU men's basketball team will continue its defense of the 2009 Atlantic Sun Conference Tournament championship Saturday night against Mercer on ESPN2 at 6 p.m. ... This is the third trip to the A-Sun finals for the Bucs in four seasons (2007, 2009, 2010) ... But the Bucs are certainly not the same team that won this event a year ago, having lost all four of its five starters from a year ago (three to graduation and one to injury), and giving up over 44 points of the team's 78.1-point average from a year ago ... But there has been even more to overcome, as the Bucs also were forced to deal with the death of rising sophomore forward Seth Coy (Washington, Ind.) to a car accident over the summer and the loss of 1,000-point scoring guard Mike Smith (Vandalia, Mo.) to injury early in the regular season ... Regardless, ETSU now stands at 19-14 overall thanks to a win over Campbell in the quarterfinals and a victory over Kennesaw State in the semifinals, and the Bucs find themselves just one win away from the NCAA Tournament, which would be the programs ninth trip all-time to the Big Dance ... While Smith has been absent and will apply for a medical redshirt season, junior forward Tommy Hubbard (Boston), along with junior guards Justin Tubbs (Trussville, Ala.) and Micah Williams (Manchester) have stepped up their games. In fact, Hubbard has posted double-doubles 13 times this season on way to being named second team All Atlantic Sun Conference ... Currently, Hubbard leads the team in scoring with 14.1 points per game ... Williams and Tubbs are averaging 12.5 and 11.8 points per game, respectively.
The Bucs in the A-Sun Tournament
Entering just their fifth Atlantic Sun Conference Tournament, the Buccaneers are 8-3 all-time, and most recently enjoyed a perfect 3-0 run through the event a year ago en route to a conference title and trip to the NCAAs ... The Bucs' previous trips included a loss in the first round of the event in 2006, advancing to the finals in 2007, and falling in the semifinals in 2008 ... In conference tournaments all-time (including the Southern and Ohio Valley), the Bucs are 38-21, having gone 7-3 in league championship final games.
ETSU in conference finals
The Buccaneers have played in 10 previous tournament finals and hold an impressive 7-3 mark ... The following is a breakdown of those games:
1983 -- vs. Chattanooga, 70-62 (L)
1989 -- vs. Marshall, 96-73 (W)
1990 -- vs. Appalachian State, 96-75 (W)
1991 -- vs. Appalachian State, 101-82 (W)
1992 -- vs. Chattanooga, 74-62 (W)
1993 -- vs. Chattanooga, 86-75 (L)
2003 -- vs. Chattanooga, 97-90 (W)
2004 -- vs. Chattanooga, 78-62 (W)
2007 -- vs. Belmont, 67-94 (L)
2009 -- vs. Jacksonville, 85-68 (W)
Bucs hoping to add one more NCAA trip
Having already made eight trips to the NCAA Tournament in its history, the ETSU men's basketball team would like to add another conference tournament trophy to the case in the Mini-Dome ... The Bucs' current stretch of success under head coach Murry Bartow is arguably the second best stretch of success in ETSU hoops history ... The most successful stretch was from 1989 to 1992, when the Bucs made four straight trips to the NCAAS, were ranked in the Top 10 nationally (1991), and defeated Arizona in the NCAA first round of the tournament in 1992 ... The Bucs only other trip prior to that stretch came in 1968 ... While head coach Ed DeChellis took the Bucs to the tournament in 2003, Bartow has taken the Bucs to the tournament twice (2004 and 2009), while also leading ETSU to the 2007 NIT.
Williams bringing more offense table
Junior guard Micah Williams (Manchester) has worked his way into the starting lineup thanks to more consistent play on the offensive end ... He has scored in double figures in 19 of his last 24 games, and most recently played the best offensive game of his career with personal bests for points (32), field goals (nine), 3-point goals (four) and free throws (10) ... He followed that effort with 20 points against Kennesaw State in the A-Sun Semifinals, meaning he is averaging 26.0 points per game in the tournament ... Currently, Williams is one of three Bucs averaging double figures scoring this year with 12.5 ppg.
Last time in the A-Sun Tournament
MACON, Ga. (March 5, 2010) - Freshman forward J.C. Ward (Marietta, Ga.) sank a critical jump shot, blocked an attempted score and pulled down an important defensive rebound in the final seconds, as the No. 5-seeded ETSU men's basketball team rallied from a 15-point first-half deficit to take a hard-fought 69-64 win over No. 8-seeded Kennesaw State in the semifinals of the 2010 General Shale Brick Atlantic Sun Conference Tournament Friday night at the University Center on the campus of Mercer University. ... The Buccaneers, who are the defending A-Sun Tournament champions, led the game 63-62 with 59 seconds left when Ward sank his 18-foot jumper to make it 65-62, and he later grabbed a missed foul shot by the Owls to help seal the win. Junior guards Justin Tubbs (Trussville, Ala.) and Micah Williams (Manchester) then combined to hit four straight free throws down the stretch, helping send the Bucs to their second straight A-Sun championship game.
ETSU (19-14 overall) will face the winner of Friday night's other semifinal between Mercer and Jacksonville, and Saturday's championship game will air nationally at 6 p.m. on ESPN2. ... Along with Ward's play down the stretch, Williams returned from his career best 32-point effort in Thursday's quarterfinal win to score a team-high 20 points against the Owls. In addition, junior forward Tommy Hubbard (Boston) pitched in 18 points, while freshman Sheldon Cooley (Tampa) had 11. ... ETSU got off to a slow start in the first half, shooting poorly from the field and watching the Owls build a lead of as many as 15 points at 21-6 with 11:35 left in the half. However, the Bucs put together an 11-0 run at that point to get within four at 21-17. ... The two teams traded baskets before ETSU scored the final five points of the half to take the lead at 31-29 when Williams sank a 3-pointer at the buzzer. ... In the second half, the Bucs continued to play well early on as they pushed the lead out to eight points at 45-37 on a layup by Tubbs. However, from there the Owls hit three straight 3-pointers in an 11-0 spurt to race past the Bucs and hold a 52-47 edge with 10 minutes left in the game. ... ETSU managed to rally at that point, regaining the lead at 55-54 and not trailing again even though the Bucs never held an advantage of more than four points down the stretch. In fact, though Ward's bucket made it 65-62, Kennesaw State's Kevin McConnell quickly scored and was fouled, going to the free throw line with a chance to tie the game. The free toss missed however, and Ward was there to pull down the board. From there, both Tubbs and Williams hit free throws to ice the win. ... For KSU, freshman Markeith Cummings had a game high 23 points, while guard Spencer Dixon added 18.
The series against Mercer
Prior to losing twice this season to the Bears, the Buccaneers had enjoyed a nice stretch of perfection against the Bears ... The Bucs were 8-0 all-time against Mercer before falling to the Bears 83-78 back on Jan. 9, and then losing again at the Mini-Dome 82-77 on Feb. 14 ... The Bucs are currently 8-2 all-time against Mercer.
Last time against Mercer
JOHNSON CITY, Tenn. (Feb. 14, 2010) - Going 25-of-25 at the free throw line before eventually finishing the game with a 33-of-40 clip at the charity stripe, the Mercer Bears took advantage of the ETSU men's basketball team's fouling woes on Sunday afternoon, dropping the Buccaneers 82-77 in Atlantic Sun Conference action at the ETSU/MSHA Athletic Center. ... Trailing 72-68 with just under three minutes left in the game, the Bucs missed out on their chance to pull closer by going 1-of-4 at the foul line. From there, Mercer responded by going 8-of-13 at the line to keep the Bucs from rallying. ... It was a game of runs in the first half, as the Bucs went on a 7-0 stretch to make it 17-12 in favor of ETSU with 11:34 left in the half. However, from there ETSU did not score for six minutes of game time and Mercer took that opportunity to go on a 15-0 run and led 27-17 with 6:09 left before the intermission. The Bucs finally responded and outscored the Bears 17-10 the rest of the way to make it 37-34 at the break. ... In the second half, the Bears led by as many as 12 points at 56-44 at the 13:42 mark. The Bucs slowly battled back to make it a two-point game at 65-63 on a 3-pointer by junior guard Justin Tubbs (Trussville, Ala.), but that was as close as ETSU could get the rest of the way ... Along with their 82.5 percent effort from the foul line, the Bears also shot a blistering 63 percent from the floor in the second half. Both teams committed their share of turnovers, with Mercer finishing with 19 and ETSU ending the game with 15. ... The Bucs were led by junior forward Tommy Hubbard (Boston), who posted his 13th double-double of the year with 24 points and 12 rebounds. Meanwhile, teammates Tubbs, Isiah Brown (Miami, Fla.) and Micah Williams (Manchester) finished in double figures with 13, 10 and 10 points, respectively. ... For the Bears - who played without the services of All A-Sun guard James Florence in the second half due to an ankle injury he suffered at the end of the first half - guard E.J. Kusnyer led the way with 21 points. Meanwhile, post Daniel Emerson finished with 17 points and 11 rebounds, while Florence added 12.
Sollazzo honors Coy with number change
When ETSU's rising sophomore forward Seth Coy (Montgomery, Ind.) was tragically killed in a car accident this summer, it left the entire Buccaneer community with a deep sense of loss ... As is often the case, those that are left to mourn have looked for ways to remember the Bucs' 6-foot-11 "Gentle Giant." ... For sophomore guard Adam Sollazzo (Tampa), who was Coy's roommate, the answer was simple ... Changing his jersey number from No. 20 to Coy's No. 43, Sollazzo will play the 2009-10 season to honor his friend and have that memory with him each night. ... In addition, the Bucs were a special "43" batch on their uniforms this season in honor of their fallen friend and teammate.
Century mark not usual for ETSU defense
Giving up 100 points in the loss to Belmont (1/23/10) was not usual for the Buccaneers ... Before that game, the Bucs had not given up 100 or more point in over two years ... The last time it happened was on Dec. 15, 2007, when the Bucs lost to Syracuse 125-75 ... This season, the most points the ETSU defense had allowed was 85, in games at Arkansas and UAB ... For the year, the ETSU defense is giving up an average of just 66.7 points per game.
Hubbard steps up game in 2009-10
Much has been written and reported about junior forward Tommy Hubbard (Boston) and his efforts to improve his offensive game, and those strides have led to some solid numbers ... He currently leads the Bucs with 14.1 points per game and 8.3 rebounds a contest ... while he has posted 13 double doubles on the year, his efforts began to pay off on the offensive end against Chattanooga back on Nov. 17 ... Setting career bests for points (26) and rebounds (13), Hubbard collected his first career double-double against the Mocs ... In addition, he hit his first 3-point shot in three seasons with the Bucs, and didn't stop there -- ultimately finishing with four long-range bombs on the night.
Tubbs getting it done for the Bucs
When junior guard Justin Tubbs (Trussville, Ala.) transfered out of the University of Alabama and came to ETSU, many expected the athletic guard to provide an immediate impact on the offensive end of the floor ... This has been the case ... Against Charleston, Tubbs posted a game high and career high 29 points in the Bucs win over Charleston (11/25) ... He followed that effort up with 21 points against Arkansas, and a game high 22 points in the loss to Tennessee ... Currently, Tubbs has eclipsed double-figure scoring in 20 of ETSU's 34 games.
ETSU the "only" A-Sun team picked among
nation's best "Prestige" programs
JOHNSON CITY, Tenn. (July 22, 2008) - Since the beginning of the modern era for NCAA Division I-A basketball - marked by the expansion of the NCAA Tournament field to 64 teams in 1984-85 - the ETSU men's basketball program ranks in the Top 30 percent of the 300 programs that were eligible for the postseason at that time, this according to a new "Prestige" ranking released by ESPN.com ... The Buccaneers, who have enjoyed six NCAA Tournament trips, one NIT berth, seven 20-win seasons, and a slew of conference regular season and tournament championships since 1984-85, ranked tied for 82nd out of 300 teams, meaning they were in the Top 27 percent of schools making the list. ETSU was ranked ahead of every current Atlantic Sun Conference team, as well as former Southern Conference rivals Appalachian State, Western Carolina, Georgia Southern and UNC Greensboro. The Bucs also were placed ahead of every current member of the Colonial Athletic Association with the exception of Old Dominion ... In addition, the Bucs ranked ahead of SEC schools such as Tennessee, Vanderbilt, South Carolina, and Mississippi State.

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40th Birthday Gifts
Light it up, pour it out or frame it for their 40th
40th Birthday Gifts - if you need a little inspiration...
Turning the ripe old age of 40 is a big milestone birthday for anyone and should be celebrated with big parties, plenty of food and drink, and of course fabulous 40th Birthday Gifts!
So, where better to start than some special celebratory bubbles, customised with their year of birth displayed on the front? Or how about our special 40th Birthday Newspaper Year Book? Certain to bring good ol' memories flooding back from the seventies.
And just to rub it in that they're getting old, we have some fantastic joke gifts such as the Life After 40 - Survival Guide For Him and The Little Book of How To Survive The Big 40. Or if you're feeling a bit nicer, then the Chocoholics Pizza will comfort them in their old age and can be enjoyed straight away!
Whatever you choose, you're bound to give them a 40th Birthday they'll never forget...


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Retrospect Trio
← назадКупить LINN Henry Purcell: Ten Sonatas in Four Parts
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Цена: 890 руб
...celebrating 350 years of Purcell
Album information
The first recording with this new super-group marks the 350th birthday of Henry Purcell. This recording explores the timeless beauty of Purcell's ten sonatas including the magnificent Sonata IX, known as 'The Golden Sonata'.
The SACD layer is both 5.1 channel and 2-channel. The Studio Master files are 88.2kHz / 24-bit.
Download includes - cover art, inlay, booklet
Produced by Philip Hobbs
Baroque Instrumental category finalist
2009 Classic FM Gramophone Awards
Sophie Gent violin (violin 1: Sonatas 1, 3, 4, 5 & 9)
Matthew Truscott violin (violin 1: Sonatas 2, 6, 7, 8 & 10)
Jonathan Manson bass viol
Matthew Halls harpsichord/organ
Recorded 3rd - 6th June 2008 in St Martin's Church, East Woodhay, Berkshire, UK
Recorded and produced by Philip Hobbs
Post-production by Julia Thomas, Finesplice UK
Keyboard technician : Edmund Pickering
Pitch : A = 415 Hz / Temperament : modified 1/5th-comma meantone
Design and cover photography by John Haxby
Henry Purcell: Ten Sonatas in Four Parts
The two sets of sonatas composed by Henry Purcell provide a fascinating insight into the cosmopolitan and often conflicting stylistic tastes of English musicians in the latter part of the seventeenth century. Whilst musical tastes at court still leant very much towards the French models, with a particular penchant for 'theatricall musick' and the 'French air in song', English tastes at large were being challenged by the arrival on the London scene of several notable Italian violin virtuosi. This influx of Italian influences exposed the art of solo violin virtuosity to an astonished and - at times - altogether bemused English audience of connoisseurs and amateurs. On the one hand there were conservatives such as Thomas Mace, whose nostalgic fondness for the traditional string band repertoire led to a feeling of general uneasiness towards the new fashions of soloistic violin playing. Despite his public moanings about the latest assaults on his musical ear and his none-too-affectionate references to 'Scoulding Violins' there were others, such as Roger North, who were altogether more enthusiastic about the arrival of the new Italian style. In marked contrast to Mace, he openly praised the talents of the latest Italian import, Nicolas Matteis, describing him as an "excellent musician" with a "singular" and "surprising" manner - judging the Italian virtuoso to have been second only to the great Arcangelo Corelli. Not surprising then that we discover North to have been one of 'that company which introduc't the Itallian composed entertainments of musick which they call Sonnata's'. Of greater interest though is the fact that Henry Purcell himself participated in such musical gatherings in the company of these English musical Italophiles. His own remarks in the preface to the 1683 set of sonatas affirm a certain desire to promote the novelties of the Italian style.
'Instead of an elaborate harange on the beauty and the charms of Musick (which after all the learned Encomioms that words can contrive, commends it Self best by the performance of a skilful hand, and an angelical voice): I shall Say but a very few things by way of Preface, concerning the following Book, and its Author: for its Author, he has faithfully endeavour'd a just imitation of the most fam'd Italian Masters; principally, to bring the seriousness and gravity of that Sort of Musick into vogue, and the reputation among our Countrymen, whose humour, 'tis time now, should begin to loath the levity, and balladry of our neighbours: The attempt he confesses to be bold, and daring, there being Pens and Artists of more eminent abilities, much better qualify'd for the imployment than his, or himself, which he well hopes these his weak endeavours, will in due time provoke, and enflame to a more accurate undertaking. He is not asham'd to own his unskilfulness in the Italian Language; but that's the unhappiness of his Education, which cannot justly be accounted his fault, however he thinks he may warrantably affirm, that he is not mistaken in the power of the Italian Notes, or elegancy of their Compositions, which he would recommend to the English Artists. There has been neither care, nor industry wanting, as well in contriving, as revising the whole Work; which had been abroad in the world much Sooner, but that he has now thought fit to cause the whole Thorough Bass to be Engraven, which was a thing quite besides his first Resolutions.It remains only that the English Practitioner be enform'd, that he will find a few terms of Art perhaps unusual to him, the Chief of which are these following: Adagio and Grave, which import nothing but a very slow movement: Presto Largo, Poco Largo, or Largo by it Self, a middle movement: Allegro, and Vivace, a very brisk, Swift, or fast movement: Piano, Soft. The Author has no more to add, but his hearty wishes, that his Book may fall into no other hands but theirs who carry Musical Souls about them; for he is willing to flatter himself into a beliefe, that with Such his labours will Seem neither unpleasant, nor unprofitable'.
Setting aside for a moment this written endorsement of the Italian style, what makes Purcell's sonatas so remarkable is the way in which the composer synthesizes the most appealing ingredients of both the French and Italian styles, whilst not neglecting completely his English heritage and the harmonic curiosities of the indigenous consort style - homebred traditions very much in evidence in his earlier set of consort Fantazias. The most obvious English precursors to Purcell's sonatas are the works of Ferrabosco and Coprario ("Cooper" to his friends!). Although generically French 'suites' they are scored alla maniera Italiana for SSB and organ. Drawing heavily upon the traditions of the English fantazia style, John Jenkins and William Young reveal through their compositions a sense of harmonic daring which was to become one of the most appealing and essential ingredients of Purcell's own sonatas. Matthew Locke (Purcell's teacher) must also be mentioned as a significant stylistic influence on the young composer. In fact we hear already in the jagged dotted rhythms of the opening bars of the first sonata on this recording a style which is immediately recognisable and strangely reminiscent of Locke's unique and rhythmically-quirky musical language.
Purcell wrote twenty-two sonatas in total and they have been passed down to us in two published collections. The publication of the first set of twelve Sonnata's of III Parts (1683) was overseen by the composer himself. As we have already seen above, the composer writes in the preface that he has 'faithfully endeavour'd a just imitation of the most fam'd Italian Masters'. Apart from capitalising on the obvious advantages (in marketing terms) of making explicit the Italian connection amongst his own musical circles, Purcell alludes to a significant degree of personal exposure to Italian repertoire that has fascinated scholars engaged in the search for more specific compositional models. Although we cannot say with complete certainty what the specific Italian models might have been - we know that he was aware of Colista's music and that sonatas by the likes of Cazzati, Vitali, Corelli and Bassani were available in London at that time - it is worth pointing out that one of the reasons we find it difficult to locate the 'originals' is because the musical voice of the 'imitator' is always the most immediately recognisable in the so-called 'imitations'!
The second set of Ten Sonatas in Four Parts first came into circulation in 1697 (two years after Purcell's death), with a preface by his widow. There is much to suggest that, despite the posthumous date of publication, these sonatas were already well-known. His widow writes of them as 'having already found many Friends'. It is most likely however - given the experimental nature of the musical style - that this later set contains earlier works than the 1683 publication and was probably compiled from extant instrumental parts.
From Playford's advertisement of the 1697 collection we learn that the bass string part was written for the bass viol rather than the bass violin and that the particular choice of keyboard instrument was apparently left open to the discretion of the performer. The importance of the bass viol's contribution to the general musical discourse is such that we should view these sonatas within the sonata 'a tre' tradition - predominantly a contrapuntal form derived from the early seventeenth-century canzona - as opposed to the more fashionable 'a due' style of Purcell's immediate Italian contemporaries. Why then the numerical discrepancy between the title of the first set and the second set?
It is clear from remarks in the preface to the 1683 set that the composer's earliest intention was to publish three separate-part books on the understanding that the keyboard player would realise a simplified version of the bass line, in line with common practices of the day. With the arrival in London of several important new continental publications, Purcell clearly changed his mind and decided to follow the latest publishing trends by preparing a separate (fourth) part for the keyboard continuo player. It would seem his publisher, Playford, was happier not to be burdened during the late stages of preparation with the arduous task of altering the engraving of the title page to reflect this new vogue, leading to the apparent ambiguity. Despite the discrepancy, both sets of sonatas contained four part books - for two violins, bass viol and organ or harpsichord.
Purcell's sonatas are remarkable for many reasons but not least for the dense and closely-wrought contrapuntal interplay that characterises many of the faster sections. Indeed it is through the richness of the polyphony and the sheer inventiveness of the melodic invention that we find the essence of the composer's musical voice. To this list of defining stylistic characteristics we should also add the composer's obvious and exquisite fascination with bitter-sweet harmonic progressions and the often almost unbearable boldness of his dissonance treatment as important hallmarks of Purcell's compositional style.
Judging by the surviving sales figures, Purcell's sonatas appear to have been only moderately successful in their own day. Only Sonata IX achieved real popularity in the 18th Century - republished in 1704 as 'That Excellent Sonata in F...call'd The Golden Sonata'. As to why it may have been nicknamed in this fashion, scholars have pointed out the possible links with Bertali's Sonata Taussent Gulden or Vitali's La Guidoni (1669) - both in F major and based on the same triadic patterns one finds at the head of Purcell's sonata.
Whatever the reasons for the waning popularity of these sonatas in previous centuries, they continue to delight and enthral both performers and listeners alike today. They stand as wonderful examples of the composer's innate gift for assimilating the styles and trends of the French, Italian and English schools. This ability, coupled with his great flair for writing counterpoint led to the emergence of a truly individual musical language, charged with unusual and exotic dissonances and strikingly abrupt melodic changes of direction. Leaving the composer to have the final word, he once wrote of his art:
'Musick is but in its nonage; a forward child, which gives hope of what is maybe hereafter in England, when the masters of it shall find more encouragement. 'Tis now learning Italian, which is its best master, and a little of the French air to give it somewhat more gayety and fashion. Thus, being further from the sun we are of later growth than our neighbouring countries, and must be content to shake off our barbarity by degrees'. [!]
© Matthew Halls, 2009


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The challenge for industry leaders is to harness the tremendous talent, energy, and commitment of the 10 million people who have been drawn to work in the health care industry because of its strong sense of mission. In order to improve the quality of health care, they must build a health care workforce that is strongly dedicated to caring for patients, knowledgeable and well trained, committed to continuous quality improvement and cooperative work, secure in their employability, confident in the safety of their work, fairly compensated, and competent in caring for the wide diversity of the American people.
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Health care workers must be encouraged to identify and report clinical errors and instances of improper or dangerous care. Health care organizations should ensure that they have appropriate internal processes and support to obtain workers' input and respond to concerns in a timely fashion. Accreditation organizations should provide greater opportunities for health care workers to provide input on quality-of-care issues. Health care workers who report improper, illegal, or dangerous care to management, accreditation organizations, public agencies, or others must be protected against retaliatory action.
Action must be taken to reduce the unacceptably high rate of injury in the health care workplace. The Occupational Safety and Health Administration's special emphasis program in the nursing home industry should be used as a model for additional collaborative approaches to identifying and abating occupational hazards in the health care workplace.
Efforts must be made to address the serious morale problems that exist among health care workers in many sectors of the industry. Health care organizations should acknowledge morale problems by taking steps to address the concerns of physicians, nurses, and other health care workers regarding professional autonomy, rising workloads, nonproductive paperwork, and employment security. Organizations undergoing restructuring should involve their employees in the planning and implementation of such changes. Federal and State governments should make funds available to retrain health care workers at risk of dislocation, conduct research into workforce trends, and disseminate information on model workplace partnerships.
Further research should be conducted into how changes in the roles and responsibilities of health care workers are affecting quality. Federal and State governments as well as private foundations should make funds available to conduct such research. Health care organizations should be open to participating in such research.
Changing work systems in the health care industry also will require changes in how all nursing education programs will operate. The Institute of Medicine's Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes (IOM, 1996) identified a number of areas that nursing programs will need to address, including interdisciplinary education and team approaches to care; management of care, including attention to health care costs, professional accountability, and patient outcomes; and new models of care delivery, including community-based care, managed care, and home care.
Many of these workers are pleased with their new skills and enhanced understanding of the patients and the care process. Greiner (1995) found that in some hospitals undergoing work reorganization, nurse aides and licensed practical nurses/licensed vocational nurses working in broader based patient-focused care jobs are more likely than before to pursue advanced education in nursing and other allied health occupations. At the same time, many of these employees would like to have formal recognition of their enhanced roles, such as certification. Without certification, these workers fear that they will be unable to transfer their new skills to other employers, because each employer defines these generalist jobs differently (Greiner, 1995).
The IOM Committee found that hospitals vary widely in the levels of training they provide to paraprofessionals. The Committee cited a study by Barter and colleagues (1994) that found that 99 percent of the hospitals in California reported fewer than 120 hours of on-the-job training for newly hired ancillary nursing personnel. Only 20 percent of hospitals required a high school diploma. The majority of hospitals (59 percent) provided fewer than 20 hours of classroom instruction, and 88 percent provided 40 hours or fewer of instruction (IOM, 1996). Other than this study, however, there are virtually no data on how much hospitals and other health care providers spend on the training the paraprofessional workforce or whether the amount of training provided has changed over time. It also is unclear whether these workers always receive the kind of supervision they require in the performance of their new tasks.
While there are no national standards for paraprofessionals employed by hospitals, some standards do exist for workers employed by nursing homes and home care agencies. The Omnibus Budget Reconciliation Act (OBRA) of 1987 required certification of nurse aides in Medicare- and Medicaid-approved nursing facilities and instituted competency exams and/or training for home health aides employed in Medicare-certified home health agencies. Requirements include 75 hours of classroom and practical skills training as well as annual in-service continuing education (Pindus and Greiner, 1997). Some industry observers, however, argue that 75 hours (roughly 2 weeks) of training is insufficient to fully cover the material that workers should know and that the inservice trainings are often attended by too many workers to make them useful (Home Care Associates Training Institute, 1997).
Community health workers are another set of paraprofessionals who are playing an increasingly important role in the health care system. These workers play a wide variety of roles, such as assisting pregnant women in underserved areas to access prenatal care, teaching those suffering from chronic disease how to manage their conditions, and educating community residents to prevent communicable diseases. There is growing recognition of the need to develop standardized training and practice guidelines for community health workers. For example, Project HOPE -- which sponsors training programs for community health workers around the world -- is currently working with State officials in New Jersey on a set of practice guidelines for community health workers (Project HOPE, 1998).
These challenges must be met in a time of constrained resources. For many years, medical schools and teaching colleges were able to partly fund educational and research programs from revenue gained from reimbursement for clinical services. Efforts to slow the rate of increase in overall health care expenditures have made this more difficult, and the overall financial condition of teaching hospitals is generally worse than that of nonteaching hospitals (Cohen, 1998; ProPAC, 1997).
While a substantial portion of medical care now is being provided outside of hospitals, most physicians continue to be trained in hospitals. Education in ambulatory settings, while increasingly common, often is hampered by resource and time constraints and difficulties in ensuring adequate supervision. A 1995 review of the literature on training in ambulatory settings found that education in ambulatory settings often is characterized by "variability, unpredictability, immediacy, and lack of continuity" (Irby, 1995). The Council on Graduate Medical Education has recommended that residency programs need "to adequately prepare both their primary care and specialty care graduates for the scope of practice, coordinated relationships, and referral patterns found in managed care organizations" (COGME, 1995). The Pew Health Professions Commission also has recommended that 25 percent of the clinical experience of new medical students should be in community, ambulatory, and managed care settings (Pew Health Professions Commission, 1995). In July 1996, the Pew Charitable Trusts took a step toward these goals by awarding a grant of $8.3 million to Harvard Pilgrim Health Care to oversee a 3-year initiative supporting the development of partnerships between academic medical centers and managed care organizations. The grant will support partnerships in six U.S. cities (AAMC, 1997b).
While preserving its historic orientation toward the individual patient, medical education is also having to concern itself with the health status of defined populations. A joint panel of the American Association of Health Plans and the Association of American Medical Colleges concluded that a population health perspective encompasses the ability to assess the health needs of a specific population; implement and evaluate interventions to improve the health of that population; and provide care for individual patients in the context of the culture, health status, and health needs of the population of which that patient is a member.
Another challenge faced by medical educators is to incorporate into the medical curriculum the lessons of nonmedical disciplines for quality improvement. Leape (1994) notes that while the biomedical sciences are invaluable for understanding how to diagnose and treat illnesses in individual patients, many disciplines other than the biomedical sciences -- such as cognitive psychology, systems theory, and the statistical sciences -- provide insights into ways to improve quality and reduce the frequency of error in complex modern medicine. Nonmedical industries such as aviation, nuclear power, and weapons production and design have gained a vast body of practical knowledge about how to prevent error. While this kind of training is important for all types of health care workers, it is particularly important for physicians, as physician leadership is considered critical to the success of these kind of efforts.
This knowledge is just starting to be applied in the health care industry, and educators of health professionals can play a major role in its diffusion. This may require a major change in the culture of the medical profession, which has often held physicians to an unrealistically high standard of performance. As Blumenthal (1994) notes:
All Health Professionals Must Be Able To Use Information To Improve Quality
As health care organizations attempt to implement strategies for improving the quality of their care, they are finding that one of the key challenges is training employees in the recording and use of information. This is especially true if the institution is employing the kind of quality improvement techniques -- process flow analysis, control charts, cause and effect diagrams -- that have been pioneered in other industries (Berwick, 1989). Increased facility with information will also be required as accreditation organizations, group purchasers, and governments require health care organizations to disclose a larger amount of information about the structure, process, and outcomes of care.
The Pew Health Professions Commission has highlighted the importance of health professionals being able to selectively access and use information. In its 1995 report, Critical Challenges: Revitalizing Health Professions for the Twenty-First Century, the Commission stated:
Workforce Education Must Address Issues of Diversity and Cultural Competence
Increasingly, effective communication between physicians and patients demands some degree of "cultural competence." Cultural competence refers to "demonstrated awareness and integration of three population-specific issues: health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy" (Lavizzo-Mourey and Mackenzie, 1996).
The need to improve cultural competence among health care workers is particularly important in light of the changing demographics of the United States. By the year 2000, nearly one-quarter of the U.S. population will be members of racial or ethnic minorities, and this number will grow to almost 50 percent by the middle of the next century. As of 1995, however, members of these groups made up only 12 percent of the total U.S. medical school enrollment, 17.5 percent of enrollment in baccalaureate nursing programs, and 12.3 percent of enrollment in master's degree nursing programs (AAMC, 1997a; AACN, 1997). This has an impact on care for the underserved, because minority professionals are more likely to practice in underserved areas. Minority physicians, for example, are twice as likely as nonminorities to practice in Health Professional Shortage Areas and choose primary care careers at a one-third higher rate than nonminorities (NAPH, 1994).
Health professional schools and professional associations have been taking action to improve diversity and cultural competence in the health care workforce. The American Nurses Association, for example, operates an Ethnic/Racial Minority Fellows program that seeks to increase the representation of racial and ethnic minorities among health service researchers as well as to improve the quality of health services provided to these populations. The Association of American Medical Colleges' (AAMC) Project 3000 by 2000, established in 1991, seeks to increase the number of underrepresented minority students entering the Nation's medical schools to 3,000 by the year 2000. In 1995, the AAMC received a Robert Wood Johnson Foundation grant to establish the Health Professions Partnership Initiative, which extends the 3000 by 2000 model to other health professional schools.
Because of chronic shortages of health care providers in inner-city and rural areas, individuals living in those areas face additional obstacles to obtaining quality health care. Federal and State programs, such as the National Health Service Corps, the Area Health Education Centers, and the Rural Health Interdisciplinary Training Program, provide incentives for physicians, nurses, and other primary care providers to practice in underserved rural and urban areas. Many underserved communities also are developing their own strategies to recruit and retain nonphysician primary care providers, such as nurse practitioners, physician assistants, and certified nurse-midwives (Rural Information Center Health Service, 1995).
Public teaching hospitals in underserved urban areas face a particular challenge in adapting to workforce change. There is a growing public consensus that there is an oversupply of medical specialists in the United States, and a number of organizations and policymakers have recommended curtailing the number of specialist residency spots in hospital graduate medical education programs. The newly merged Medicare Payment Advisory Committee will be examining Medicare funding of graduate medical education. However, the existence of teaching programs is one of the major ways in which urban public hospitals attract specialist physicians, and the loss or curtailment of these programs could have a negative impact on access to care for urban residents (NAPH, 1994). This dilemma suggests that some measure of workforce planning may be needed to ensure that changes in the composition of the physician workforce do not adversely affect underserved areas.
There are signs of a growing morale problem among health professionals. Surveys of nurses, the majority of whom work in hospitals, have identified rising levels of dissatisfaction and work-related stress (Davidson et al., 1997; SEIU, 1992; Shindul-Rothschild et al., 1996). The results of a 1997 survey of nurses and therapists that found that two-thirds rated morale at their facilities as fair or poor (Peter D. Hart Research Associates, Inc., 1997).
While surveys of physicians reveal that most are broadly satisfied with their work, many are frustrated with key aspects of their practice, especially their perceived loss of professional autonomy, the loss of control over clinical decisionmaking, and the growing burden of paperwork (Collins et al., 1997, Lewis et al., 1991, Skolnik et al., 1993). A 1993 survey by Baker and Cantor found relatively low rates of dissatisfaction among younger physicians, suggesting that younger physicians may face less of a "culture shock" in practicing in a managed care environment.
One of the largest and most representative of these studies was conducted recently by the Center for the Study of Health System Change. The survey of 9,264 physicians found that the majority of doctors either agree strongly (45 percent) or agree somewhat (31 percent) with the statement "It is possible to provide high-quality care to all my patients." Almost one in four (24 percent) physicians, however, do not agree that it is possible to provide high-quality care to all of their patients, with specialists (27 percent) more likely to express this view than primary care physicians (18 percent) (Reed and St. Peter, 1997).
Another sign of job dissatisfaction is the high degree of turnover that exists in some sectors of the industry, particularly long-term care. The Institute of Medicine has documented extremely high levels of annual turnover in nursing facilities, with rates ranging from 55 percent to 65 percent for registered nurses and close to 100 percent for nursing assistants, who provide the bulk of personal care to residents (Mass et al., 1996). Turnover rates in home care agencies are between 40 percent and 60 percent (Home Care Associates Training Institute, 1997). High turnover rates are a serious problem because they can interrupt continuity of care and act as a disincentive for employers to invest in additional training.
It is unclear whether the problems faced by the existing health care workforce are deterring new entrants into the health professions. According to the Association of American Medical Colleges, applications for medical school rose to record levels each year from 1993 through 1996, and then dropped sharply by over 8 percent in 1997 (AAMC, 1996; 1997a). Enrollment in bachelor's degree nursing programs has fallen over the past 2 years, and enrollment in master's degree programs fell in 1996 for the first time since 1988. On the other hand, enrollment of nurses with associate degrees or hospital diplomas in BSN programs continues to rise, as does enrollment in doctoral programs in nursing (AACN, 1997).
The rate of occupational injuries and illnesses in the health care industry has been rising for some time. Between 1985 and 1995, the injury and illness incidence rate for workers in hospitals rose by 25 percent, while the rate for workers in nursing and personal care facilities rose by 37 percent. During the same period, the rate for workers in private industry as a whole increased by only 3 percent (BLS, 1997; IOM, 1996).
Back injuries -- usually incurred while lifting or moving a patient -- are the most common type of injury faced by health care workers. Certain subsectors of the industry present their own unique risks. For home care workers, work-related automobile accidents are a major cause of injuries. Hospital workers also face the risk of infection from needlesticks and communicable diseases.
The Occupational Health and Safety Administration (OSHA) is working with health care administrators and labor union leaders to reduce the rate of work-related injuries and illnesses in the health care field. In 1996, OSHA unveiled a seven-State initiative to address the rising number of injuries in the nursing home industry. The program involves educational outreach to employers and workers. OSHA offers free 1-day comprehensive safety and health seminars to help participants identify safety and health hazards, including back injuries from lifting residents, slips and falls, workplace violence, and risks from blood-borne pathogens, tuberculosis, and other infectious diseases. A number of nursing facilities participating in the program have already reported savings of hundreds of thousands of dollars, primarily as a result of reducing back injuries, which has cut their workers' compensation insurance premiums (SEIU, 1997b).
While employment in all sectors of the health care industry is expected to grow substantially over the next decade (Franklin, 1995), the outlook for a large number of hospitals is unclear because of the substantial number of excess beds that exist in many markets. A 1997 survey of hospital human resource managers by Deloitte and Touche found that 21 percent intended to eliminate positions in 1997, as compared to 28 percent in 1996 and 36 percent in 1995 (Moore, 1997).
Data from the Bureau of Labor Statistics suggest that hospital restructuring already has had a significant labor market impact, with 163,000 hospital workers losing their jobs between January 1993 and December 1995. While 74 percent of these workers were reemployed by February 1996, their median weekly earnings were 12 percent lower. Seventeen percent of the laid-off hospital workers remained unemployed and 10 percent had dropped out of the labor force (BLS, 1996). While it may be possible for displaced hospital workers to move into jobs in expanding sectors of the industry, those jobs often require different skills than hospital workers currently possess (IOM, 1996).
Wages and benefits in the expanding sectors also are lower than those that prevail in the hospital sector. This is especially true for paraprofessionals. Of the 2 million health care paraprofessionals in the United States, 600,000 are earning wages below the poverty line (Home Care Associates Training Institute, 1997). Home care workers often find themselves excluded from Federal minimum wage or overtime protections because their employers classify them as "independent contractors" or providers of "companionship services" to the elderly. Home care workers generally receive few benefits, and many are without health insurance (Capitman et al., 1994).
In 1995, the U.S. Department of Labor developed a demonstration program to test early intervention strategies for nonmanagerial workers at risk of dislocation in the health care industry. In June 1995, the Department awarded more than $5 million for 12 grants to conduct training programs for at-risk workers. In June 1996, 7 of the original 12 grantees were awarded a total of more $1.5 million in option year extensions to June 1997. The health care demonstrations ended in June 1997, and a final report on the demonstration program is due in 1998.
State governments also have taken action to address the impact of industry restructuring on health care workers. The New York Health Care Reform Act of 1996 made available $50 million to $100 million a year over the next several years to retrain hospital workers at risk of dislocation. An additional $250 million a year is being made available as part of the State's Medicaid demonstration waiver program to "support worker retraining, expand primary care capacity and increase provider readiness for managed care" (New York State Department of Health, 1997).
Nurses also have expressed concern about limitations on their ability to be patient advocates. There are a number of cases where the National Labor Relations Board or State regulators have issued complaints or otherwise sanctioned employers for disciplining nurses or other health care workers who have spoken out publicly about quality problems at their facilities (Marbin, 1995; NLRB, 1996). There are no comprehensive studies of this problem, however, so it is not possible to estimate how widespread it is.
Unions and professional organizations representing nurses and other health care workers have supported bills in a number of States to protect health care whistleblowers. During the 1997 session, a number of State legislatures have debated legislation, including California, New York, North Carolina, and Oregon, with legislation passing in Minnesota, Rhode Island, and New Jersey. Some bills cover only nurses, while others cover health care workers in all classifications. There also is significant variation in enforcement measures, with some bills giving affected workers a private right of action while other bills would enforce through a civil monetary penalty (StateNet, 1997).
In the health care context, the Institute of Medicine's Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes observed that many of "the harmful and demoralizing effects of these changes on the nursing staff can be mitigated, if not forestalled altogether, with more recognition on the part of the hospital industry that involvement of personnel from the outset in redesign efforts is critical" (IOM, 1996).
Employers in many sectors of the health care industry, including HMOs, hospitals, and nursing homes, are taking up this challenge. Examples of such efforts include the following:
St. Vincent's Hospital. St. Vincent, a Catholic medical center located in suburban Indianapolis, was one of the original institutions to implement patient-focused care (PFC) under the name St. Vincent Care 2001. In response to some initial resistance by staff to the implementation of PFC, management made changes to its plan to allow for more employee involvement and began to encourage grassroots-initiated shared decision making. The second PFC unit then was redesigned by a group of affected staff and physicians, and subsequent units have been designed and continually enhanced by employees. PFC has yielded improvements in patient satisfaction, and quality in PFC units has been equal to or better than non-PFC units (Greiner, 1995).
GranCare. While much of the activity in work redesign has been found in hospitals, some nursing homes also are experimenting with ways to improve quality and reduce costs. GranCare, a national nursing home chain, signed an agreement in early 1996 with the Service Employees International to establish Quality Patient Care Committees. These committees have helped address a number of issues at GranCare facilities. At one Michigan GranCare facility, for example, several residents were found to be infected with vancomycin-resistant enterococci (VRE), a drug-resistant strain of bacteria. There were communication problems among the staff regarding infection control procedures, which could have led to more residents or workers becoming infected. The Committee was able to provide information about VRE to managers and ensure that workers on all shifts were informed about the problem (SEIU, 1997a).
Los Angeles County. In September 1995, Los Angeles County was granted a Medicaid waiver that allowed the county to begin a significant restructuring of the public health system. During the 5 years the waiver is in effect, the restructuring effort will reduce hospital beds by one-third and increase outpatient volume by 50 percent. The terms of the waiver, as well as its subsequent implementation, have been negotiated with the unions representing county employees, which has contributed to acceptance of the systemwide reengineering among the workforce.
The reorganization of work often involves breaking down departmental barriers and professional alliances; challenging commonly accepted assumptions about the need for centralized clinical support functions (e.g., lab, radiology); and reexamining and reconfiguring job requirements and skills (Shortell et al., 1995). Various terminology for work redesign is found in the literature, including patient-centered care; PFC; work redesign; operational restructuring; or simply restructuring.
While the reengineering of the hospital sector has been going on for a number of years, surprisingly little is known about whether it has been successful in improving quality or controlling costs. The Institute of Medicine has noted that while "much anecdotal information is available about these changes, objective data are not available to determine how widespread these changes are and whether or not this redesign accomplishes its dual goals of increasing patient-centered care and cost reductions" (IOM, 1996).
Most hospitals and health plans that attempt to evaluate the quality impact of their changes measure patient satisfaction and some short-term outcomes (e.g., nosocomial infections, readmission, medication errors) pre- and post-intervention. Greiner (1995) compared the impact of work system changes at seven hospitals and HMOs and found that, for most organizations, the results were inconclusive, with some measures showing improvement and others a decline. Organizations that had implemented a PFC model tended to have statistically significant increases in patient satisfaction, with patients being particularly pleased with staff responsiveness and communication.
To date, attempts to estimate cost savings associated with the introduction of new work systems have been inconclusive. More rigorous methodological approaches using longer timeframes for analysis of impact will be needed (Greiner, 1995).
Since a key element of many of these new work systems is changes in staffing patterns, new research in this area could build on existing research into the relationship between staffing patterns and quality. While a number of witnesses before the Commission presented testimony about the negative impact of nurse staffing reductions on the quality of care (Clark, 1997; Foley, 1997; Ziegler, 1997), there is limited empirical evidence to either support or refute such a link. In its recent study on this subject, the Institute of Medicine (1996) concluded that there was a "serious paucity of recent research on the definitive effects of structural measures, such as specific staffing ratios, on the quality of patient care." A number of new research initiatives in this area are under way, including a national nursing research program on staffing and quality sponsored by the Agency for Health Care Policy and Research in conjunction with the National Institute for Nursing Research and the Division of Nursing of the Health Resources and Services Administration (Pindus and Greiner, 1997).
The need for further research, however, should not be interpreted as a call to halt the pace of work reorganization in the health care sector. Significant changes in work organization in all health care organizations are necessary in order to improve the process of care, eliminate waste, and improve quality. Chapter 12 outlines a number of organizational changes that leading health care organizations are making in order to better carry out their mission.
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Capitman, John A., Ruby Abrahams, and Edith G. Walsh, Working Conditions and Retention of Home Care Workers: A Survey of Providers and Regulators (Boston: Institute for Health Policy, Heller Graduate School, Brandeis University, 1994).
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Richard Crawford
- Associate Director of Development for Law and Business, Law School Foundation
Richard D. Crawford is associate director of development for law and business at the Law School Foundation. He also teaches Finance of Small Enterprise at the Law School.
Crawford's experience includes management positions with major financial service firms, including Citigroup and Dean Witter, and the founding of an Internet-based online venture fair service. Crawford was an Echols Scholar and earned all of his degrees at the University of Virginia: a B.A. in economics from the College of Arts and Sciences, an M.B.A. from the Darden School of Business and a law degree. He is a visiting executive at the Darden School of Business
Between 1988 and the present, Crawford authored 14 technical articles and over 40 copyrighted and numbered Darden Graduate Business School Case Studies and Technical Notes. He is a noted author and co-author of several books on finance, lending and management. Crawford continues to teach in programs for Darden and author case studies.
Crawford is managing director of the Virginia Active Angel Network and chairman of the board of its management company, Virginia Investment Capital Group Inc. VAAN is a statewide group of accredited investors who invest in start-up and early stage companies. Crawford manages the overall administration for VAAN, travels throughout the state to find deals for possible screening, and facilitates the analysis of deals, including developing deal terms, portfolio strategies and financing options. Crawford enjoys and promotes VAAN's relationships with UVA and is a frequent moderator and panelist on "University Angels" programs.
- J.D.University of Virginia School of Law
- M.B.A.Darden School of Business
- B.A.University of Virginia
Current Courses
Faculty in the News
A. E. Dick Howard, U.S. Anti-Abortion Activists Once 'Chipped Away' at Roe vs. Wade — Now They've Picked Up a Sledgehammer (CBC News)


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If a friend or colleague asks you to recommend an office suite, our first thought is often Microsoft Office. However, we forget that this suite can costs many hundreds of pounds, which makes it cost prohibitive for an individual or small business. Besides, everyone just assumes that they automatically require 'Office compatibility', but even Microsoft do not help themselves here. The Office 2007 suite produces documents, by default, that wasn't compatible with older versions of Office, still widely used across many corporations. The Mac Office couldn't open Office 2007 documents until recently, either.
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1940's Original Vintage WW2 era Antique Torpedo Boat Poster Print
CONDITION: A, beautiful! archivally linen mounted.
Artist: Signed "O.F. Schmidt"
Printed by: Copyright 1944 Electric Boat Company, New York.
This is a beautiful and original poster print, from the 1940's WWII era, printed by the famous Electric Boat Company of New York. These images were used as part of the large advertising campaign from many popular magazines of the day. It has vibrant color and is in wonderful condition, linen mounted. Note: This is not a reprint, but an original.
The General Dynamics Electric Boat Company (GDEB) has been a builder of submarines and boats for the USN United States Navy for over 110 years, since 1899. The shipyard is located in Groton, Connecticut, Quonset Point, Rhode Island and New London, CT. These original WWII WW2 World war two era Elco poster prints are a set of beautiful images produced for the military war effort.
This image is printed in lush deep greens and depicts The "Green Dragon's" Lair showing the Green Dragon, an Elco PT Motor Torpedo Boat in the jungle, men working, monkey overhead. Please see others we have in this series here, all found together. Mint, beautiful and ready for framing.
Keywords: subs, sub, childrens room, children's room, WW2, World War two, Military, propaganda, war effort, American, United States, USA, U.S.A., japan, Japanese, US Navy
Size: 21 x 16.50 inches
You'll deal directly with gallery owner Debra in your purchase: USPS Priority Shipping is FREE in US, Reduced rate for International USPS Priority shipping. We have a 100% approval policy. We want you to be happy with your poster purchase. A signed COA (Certificate of Authenticity) is included with each poster purchase. Debra has been selling original vintage antique posters on the web since 1995. We do not sell reproductions, only authentic antique posters.


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The Lennon (@lennon.bear.yc)
The Lennon (@lennon.bear.yc)
from 24.00
Handmade in Calgary, Alberta
This frayed edge bandana is made with cotton, plaid material that looks perfect on all dogs. Pick your fav color and review sizing below to hit the dog park in style. Each one comes with a hand-sewen, leather label signifying the Doodle Dogs trademark logo.
Available in the sizing below with snaps to attach around neck, or can be ordered in tie-on style.
Need a custom size? Want a tie on instead? send us an email.
XS - 11" Neck
S - 15" Neck
M - 18" Neck
L - 24" Neck
Wash on delicate, lay flat to dry and warm iron to press.
Add To Cart


text:
R 950.5 D611d 2003 c.l
Oklahoma Department of Rehabilitation Services
HOpening Doors To Opportun itY'
The Disability Determination
Program in Oklahoma
Table of Contents
Tab A Regulations Pages 3-7
Tab B Process .. .. .. .. ... .... .. ... .... .. .. .... .. .. Pages 8-10
Tab C Oklahoma Specifics Pages 11-13
Tab D. . .... Performance ... .. ... ... ... ... .. .... .. . Pages 14-18
Tab E Budget Pages 19-21
TAB A Regulations
Basic Responsibilities
The Social Security Administration (SSA) administers the Social Security and
Supplemental Security Income (SSI) disability programs. SSA employs the
services of state Disability Determination Services (DDS) to make disability and
blindness determinations on behalf of the Commissioner for individuals living in
the states.
The Regulations governing the relationship between SSA and the DDS are found
in two separate places in Title 20, Code of Federal Regulations, Chapter III.
Part 404, Subpart Q (Sections 404.1601 through 404.1694)
Part 416, Subpart J (Sections 416.1001 through 415.1094)
The language in these sections is identical. One section pertains to title II of the
Social Security Act, and the other to title XVI of the Act. (Note: title II relates to
Social Security benefits and title XVI to SSI benefits.) The duplication is required
because, although the programs fall under separate titles, they have many
similarities including the fact that they are administered by the same agency, SSA.
The following are excerpts from these regulations. We have reorganized the
material for clarity. For convenience, we are only citing regulation references
from Part 404. Comments that are not direct quotes from the Regulations are
shown in brackets.
Responsibility of the State
• The State is responsible for making accurate and prompt disability
CFR 404.1620(b)
• The State will
1. Provide management needed to insure that the State agency carries out the
disability determination function so that disability determinations are made
accurately and promptly;
2. Provide an organizational structure, adequate facilities, qualified personnel,
medical consultant services, and a quality assurance function;
3. Furnish reports and records relating to the administration of the disability
4. Submit budgets;
5. Cooperate with audits;
6. Insure that all applicants for and recipients of disability benefits are treated
equally and courteously;
7. Be responsible for property used for disability program purposes;
8. Take part in the research and demonstration projects;
9. Coordinate with other agencies;
lO.Safeguard the records created by the State in performing the disability
determination function;
11.Comply with other provisions of the Federal law and regulations that apply
to the State in performing the disability determination function;
l2.Comply with other written guidelines;
l3.Maintain liaison with the medical profession and organizations that may
facilitate performing the disability determination function; and
l4.Assist us in other ways that we determine may promote the objectives of
effective and uniform administration.
CFR 404.1603 (c)
Selected Additional Requirements
• The State will make personnel available to attend meetings or workshops as
may be sponsored or approved by us for furthering the purposes of the disability
CFR 404.1621(c)
• Subject to appropriate Federal funding, the State will, to the best of its ability,
facilitate the processing of disability claims by avoiding personnel freezes,
restrictions against overtime work, or curtailment of facilities or activities.
CFR 404.1621(d)
• The State will permit us access to the premises where the disability
determination function is performed and also where it is managed for the
purposes of inspecting and obtaining information about the work and activities
required by our regulations and assuring compliance with pertinent Federal
statutes and regulations.
CFR 404.1623(c)
• The State may not incur or make expenditures for items of cost not approved by
us or in excess of the amount we make available to the State.
CFR 404.1626(d)
• Any monies paid to the State which are used for purposes not within the scope
of these regulations will be paid back to the Treasury of the United States.
Responsibility of SSA
• We will work with the State to provide and maintain an effective system for
processing claims of those who apply for and who are receiving benefits under
the disability program. We will provide program standards, leadership, and
oversight. We do not intend to become involved in the State's ongoing
management of the program except as is necessary and in accordance with these
regulations. The State will comply with our regulations and other written
CFR 404.1603(a)
• [SSA] will:
1. Periodically review the regulations and other written guidelines to determine
whether they insure effective and uniform administration of the disability
program. To the extent feasible, we will consult with and take into
consideration the experience of the States in issuing regulations and
guidelines necessary to insure effective and uniform administration of the
disability program;
2. Provide training materials or in some instances conduct or specify training;
3. Provide funds to the State agency for the necessary cost of performing the
disability determination function;
4. Monitor and evaluate the performance of the State agency under the
established standards;
5. Maintain liaison with the medical profession nationally and with national
organizations and agencies whose interests or activities may affect the
disability program.
CFR 404.1603(b)
T B B.....faces.
Social Security regulations define disability as the inability to do any substantial
gainful activity (SGA) by reason of any medical determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than 12 months.
The following chart represents the evaluation process used to determine if an
individual's circumstances/condition meets the definition of disability.
Step 1 Is the person A person who is gainfully employed does not qualify for
engagmg m disability benefits. DDS examiners do not make SGA
SGA? decisions, but must be aware of the criteria used to assess
SGA and alert to reports of work activity.
Step 2 Is there a severe, Disability must result from a medical condition that can be
medically proven to exist. DDS examiners must know basics of
determinable anatomy and physiology as well as the tests that are normally
impairment? used to prove a diagnosis.
Step 3 Does the The listing of medical impairments is part of SSA regulations
impairment meet and provides examples of impairments that are considered to
or equal a be disabling. It also outlines our standards for documenting
Listing? and assessing medical conditions. Medical consultants are
available to help an examiner apply the listing criteria
consistently. Examiners are expected to be able to use the
listings independently in most cases.
Residual Thought not a step by itself, the RFC enables the examiner to
Functional move to step 4 and 5. RFC assessment is complex and must
Capacity (RFC) be unique to the case being decided. The examiner decides
Assessment what activities the person can do and how that conclusion
relates to the medical evidence, the allegations, and the
medical opinions in file. The RFC must contain sufficient
detail to allow comparison to the Dictionary of Occupational
Titles (DOT) and SSA instructional materials.
Step 4 Can the person The examiner must compare the RFC to the specific duties of
perform past work the person has done before. The examiner uses DOT
work? reference material as a baseline to understand how jobs are
generally performed in the national economy.
Step 5 Can the person This final step requires integration of DOT references and the
do other work? SSA vocational grid guidelines to assess whether sufficient
numbers of jobs are available to represent a meaningful
outlook for work and whether past work, age and education
inhibit or enhance the ability to adjust to other work.
The Determination
• The allowance and denial decisions processed by DDS disability examiners
(DE) represent the determinations of the Commissioner of Social Security.
• The DE decides not only whether the facts support a finding of disability, but
also must determine when the medical impairment first became disabling. The
DE must consider work efforts before and after a medical onset and whether
prior determinations or non-medical eligibility requirements present a legal
barrier to effectuating an allowance.
• The DE must explain conclusions in a notice that is sent to the claimant and
legal representative.
• Determinations are sampled for review within the DDS and in a Federal quality
review component. All judgments that were made in reaching a decision are
subject to considerable scrutiny. The DDS is held accountable for the accuracy
of its examiners' work-that is, how well those judgments stand up to review.
• Decisions to award disability benefits are subject to special reviews to assure
that benefit dollars go only to people who truly meet the disability standards.
• All decisions are subject to appeal and must be legally supportable.
~----- ....•0
Benefit Payments
• The Social Security program provides monthly benefits to workers and their
families when earnings stop because the worker becomes disabled. The amount
of the worker's disability benefit is based on the worker's level of earnings in
employment or self-employment covered by the Social Security program. The
benefit amount for the auxiliary or survivor beneficiary is based on a percentage
of the worker's benefit. This is the Title II program.
• In Oklahoma, disabled workers receive average monthly Social Security
payments of $773.
• Supplemental Security Income (SSI) is a federal cash assistance program that
provides monthly payments to low-income aged, blind, and disabled persons.
The program is based on nationally uniform eligibility standards and payment
levels. This is the Title XVI program.
• As of January 2002, the maximum monthly benefit for SSI is $545 for an
individual and $817 for a couple.
• In Oklahoma, disabled individuals receive average monthly Supplemental
Security Income payments of $378.
• These disability programs make a huge difference to the citizens of the State of
• The Social Security Administration currently pays $79.1 million per month in
disability benefits to 146,439 Title II and Title XVI beneficiaries and
dependents in Oklahoma.
• This is $950 million dollars to the State of Oklahoma annually.
Disability Examiner Responsibilities
The main responsibility of the disability examiner (DE) is to make the
determination of the claimant's eligibility for disability benefits for both the
Title II and Title XVI programs.
The DE has a unique position in that there are both medical and non-medical
criteria that must be evaluated to determine eligibility.
The rules of eligibility are complex and difficult to administer and the DE is
directly accountable for a significant impact on the economy of Oklahoma.
Examples of work performed by the DE include the following:
• Examines applications and case records of claimants for completeness of
factual information to document eligibility.
• Interviews claimants, employers, agency officials, etc., to obtain information to
assess non-medical evidence for the determination of claims.
• Reviews medical evidence from claimants, physicians, and hospitals to ensure
conformance with established SSA regulations.
• Consults with DDS medical consultants and also with members of the medical
community at large to review medical evidence to determine eligibility.
• Approves or disapproves claims in accordance with guidelines established by
• Records findings, recommendations, and services provided during the claims
• Completes required case forms and necessary correspondence for cases.
Case Production
• Total case clearances for Oklahoma have been increasing over the past several
• The Oklahoma DDS received 57,335 cases, 17.9% more initial cases than
received in FY 2001. They disposed of 55,306 cases in FY 2002,6.3% more
cases than they disposed of in FY 2001. The DDD exceeded the agency's
expectation by 3%.
Total Clearances
Oklahoma DDS
Producti vity Per Work Year (PPWY) is a standard measure of DDS productivity.
It is computed by dividing DDS dispositions by the number of workyears used. A
workyear is a measurement of personnel effort and is the equivalent of one person
working for one year.
PPWY Comparison
Oklahoma 299 298 304
Nation 264 262 262
• Out of the 52 DDSs, Oklahoma ranked 8th nationally in PPWY in FY 2002,
and 9th in FY 2001.
Oklahoma DDS PPWY
310~----------------------------------~ 304.5
3>aa..: 280 -1-----1
290 +--------------------1>--
270 -+-==-=---1
Processing Time
• Average processing time on disability decisions in Oklahoma has decreased 11
days from 96 days in FY 2001 to 85 days in FY 2002. In FY 2002, they
successfully reduced Social Security (SSA) and Supplemental Security Income
(SSI) processing times to an average of 82.9 and 88.6 days, respectively. These
times are down from 93.7 days for SSA and 98.9 days for SSI during the prior
year, and they are better than both the average Regional and national times for
Arkansas Louisiana New Oklahorra Texas
Nation Dallas
Average Processing Time
140.0 i i
120.0 -1--------1
100.0 -1----,
c~ 80.0
Accuracy of Adjudication
• Accuracy is based on an ongoing statistical sample of cases that are reviewed
by SSA in a quality assurance component in Dallas.
• Comparing cumulative accuracy for each fiscal year, Oklahoma's accuracy has
remained good at 97.5% in FY 2000 and 95.3% in FY 2001. In FY 2002,
Oklahoma's overall accuracy was 94.9% compared to 94.2% nationally.
Initial Accuracy Cum. Sept. 02
99.0% -,---------------------,
98.0% +---------------------j
97.0% -1--_'"
96.0% +--fJ"
95.0% +-----.".
94.0% -.----.....
93.0% -j---II!;.
92.0% -I---lE·.c··
• Nation
Total Budget
• We spent $15.9 million for Oklahoma DDS expenditures in FY 2002.
• Over half of those costs are for personnel.
• We will spend about $1 million on Indirect Costs in FY 2002. Indirect costs are
payments to the Oklahoma Department of Rehabilitation Services (the DDS
parent agency) for the costs of overseeing DDS operations.
Oklahoma DDS Budget
Other Costs
Medical 53%
Continuing Disability Review (CDR) Workload Processing
Individuals who receive SSA and/or SSI disability benefits must have their cases
re-evaluated periodically to determine if they are still disabled within the meaning
of the law. This re-evaluation is called a Continuing Disability Review (CDR).
• The Oklahoma DDS was budgeted to process 11,740 CDRs in FY 2002. Actual
FY 2002 production was 11,794 or 100.5% of the budgeted goal.
COR Production
Oklahoma Region
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text:
90% effective at capturing large allergens like:
Attracts and captures microscopic allergens like:
* This filter should be changed at least every 3 months. Certain conditions in your home will significantly add particles to the air - this will cause the filter to capture more particles, shortening it's life to less than 3 months. These conditions would include: dirty ductwork, pets, construction work, sanding projects, tobacco smoke, burning candles, fireplaces and wood-burning stoves.
Actual Dimensions
Nominal Dimensions


text:
Every day 'fore supper time
She'd go down by the truck patch
And pick her a mess o' poke sallet
And carry it home in a tote sack . . .
Those lines are from one of my favorite Tony Joe White songs, "Poke Sallet Annie," but it might as well be called "Poke Sallet Granny" for my maternal grandmother, who loved poke sallet ("salad") more than anybody I have ever known.
What, you might ask, is poke sallet? If you're asking, you must not be from these parts. Tony Joe explains it pretty well, actually:
If some of y'all never been down South too much,
I'm gonna tell you a little bit about this, so that you'll understand what I'm talking about
Down there we have a plant that grows out in the woods and the fields,
Looks somethin' like a turnip green.
Everybody calls it poke sallet.
Poke . . . kuh . . . sallet . . . ungh.
Mee-Ma lived with us for awhile when I was in my early teens. She really would take a grocery sack — a poke — and walk the country roads near our house and pick the smallest, tenderest shoots of this weed. She'd bring a ton of it back to the house, wash it thoroughly, then boil it several times until the house stank like some kind of hot sulfur springs. Then she would scramble it in eggs cooked in bacon grease until the eggs were brownish-green and the house really stank. She'd eat the entire mess with a big hunk of cornbread crumbled up in a tall glass of buttermilk.
Poke doesn't grow only in the woods and the fields. Last weekend I was piddling around on the back 40 and watching the chickens forage. They were feasting on the long-legged purple ladies of poke I have let grow freely at the rear of my lot, partly because I think they are rather stately and partly because birds other than the chickens love them for the berries they form in the late summer.
They reminded me that I've been meaning to give Mee-Ma's recipe, which I haven't tasted since I was about thirteen, a try. So I gathered up a mess in a basket (I didn't have a poke handy).
Mee-Ma didn't eat the youngest, smallest leaves just because they were the tastiest. Poke sallet is actually pretty poisonous, the roots and berries especially (though not for birds), and the larger leaves can make you very sick. She boiled them three times because that's how she cooked the toxins out.
In fact, if you read around, the prevailing wisdom is that only a damn fool would eat poke sallet, even if you cook it over and over again. My favorite dire warning comes from Wikipedia:
The eating of limited quantities of poke, perhaps of the shoots, may cause retching or vomiting after two hours or more. These signs may be followed by dyspnea, perspiration, spasms, severe purging, prostration, tremors, watery diarrhea and vomiting (sometimes bloody) and, sometimes, convulsions. In severe poisonings, symptoms are weakness, excessive yawning, slowed breathing, fast heartbeat, dizziness, and possibly seizures, coma and death.
Well, there's no fool like a southern fool waxing nostalgic for her dead granny's weird cooking. Mee-Ma had to have eaten enough poke sallet in her life to kill her several times over, and while she may have suffered from prostration a time or two (mostly due to orneriness, I'd say), she lived a long life and died because she was old and wore out.
So I went with it. Between my obsessive weeding and the chickens' nibbling, there really wasn't much in the way of young poke to be gathered. So my mess was pretty small, which might have been a blessing. I gathered what I could, brought it in and gave it a good washing, carefully took out all the stems, and put it through its first cooking in salted boiling water.
I drained it, rinsed it, boiled it again in more salted water.
Drained it, rinsed it, boiled it again, this time with a hunk of smoked pepper bacon. Now the house was smelling pretty good.
After the third boiling, I noted that the greens were beginning to resemble a traditional palava dish of okra leaves that I had eaten in Liberia a couple of years ago, which had been delicious, so how bad could this be?
Mee-Ma would have answered that there was nothing that bacon grease couldn't make taste good. So I melted a good tablespoon of it in a skillet and let the slimy poke slide in along with some spring onions. After it sizzled a bit I threw in a couple of eggs and a good dose of salt and pepper. I cooked them down til the eggs were dry.
It looked familiar. Mee-Ma would have eaten it, I think, but she would have fussed at me for not having any cornbread and buttermilk for her.
I washed mine down with a big glass of iced tea. It weren't too half bad — the poke gave the eggs a darkened flavor that was definitely enhanced by bacon grease. Caleb liked it, too. And in spite of some excessive yawning and a wee bit of perspiration, we both lived to tell the tale — so far.
Here's what Tony Joe White has to say about it.