Strategic Management and Organizational Change
The purpose of this assignment is to assess how different types of health care organizational structures impact the process and effectiveness of change.
Write a 1,000-1,250 word paper that addresses the following:
Discuss why it is necessary for a health care organization to develop a strategic management model that addresses both the concept of change necessary for the growth and sustainability of the organization and the processes of changing. Include how the organization is able to go about accomplishing change and how change ultimately impacts the development of an organization.
Differentiate between transaction change and transformational change theories.
Identify three theories of management and provide an example of the areas or departments in which each theory of management might be most effective.
Identify and explain tools and advice that can be utilized to assess leadership effectiveness.
Be sure to justify your explanation with five or more relevant references, including your textbook.
Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment. You are required to submit this assignment to
You are required to submit this assignment to LopesWrite. Refer to the LopesWrite Technical Support articles for assistance.
Sunday, October 16; 3:10 pm to 5:05 pm (Room 206)
2530345
LUNG PARTNERS IMPACT ON REDUCTION IN 30-DAY COPD READMISSION
RATES.
R ussell A. A cevedo, W e n d v Fascia, L in d a Rauc, Jennifer Pedlev; R esp ira to ry C are , C ro u se H o sp ita l,
Syracuse, N Y
Background: L u n g P a r tn e rs P r im a ry R e s p ira to ry
C are is a u n iq u e p rim ary resp ira to ry care m odel for
in-patient C O P D disease m anagem ent. There is a great need to improve
m anagem ent o f C O P D in the hospital setting. In the hospital, care is mostly
delivered by hospital-based physicians aided by extenders. There are delays in
care due to com m unication issues. T he plan at discharge may not be carried out
at hom e. In a hospitalist model, a pa tien ts care team is frequently different on
each readmission. W ith the growing num ber o f patients and the flat or decreas
ing num ber o f physicians, the Respiratory Therapist (RT) is the logical choice
for C O P D disease m anagem ent. If the R T has a prim ary relationship with a
C O P D patient for all hospital admissions and is actively involved in transition
to hom e, the fragm entation o f care can be reduced. Patients enrolled in Lung
Partners will have a Prim ary R T for the initial and all subsequent hospitalizations
and will have Lung Partner RTs as a resource when they are no t in the hospital.
T he Primary R T is positioned as the m ajor physician partner in the m anagem ent
o f C O P D patients. T he Primary R T educates the patient on their disease and
coaches disease m anagem ent skills. T he Prim ary RT screens their patient for
co-m orbidities. These co-m orbidities are poorly addressed in the hospital setting.
Anxiety and Depression are m ajor co-morbidities. Protocols are in place for
patients to receive services based on the Prim ary R T s assessments. T he im pact o f
this program on 30-day readmissions was evaluated. Methods: Since November,
2014 we have enrolled 231 patients, which is about 10% o f our C O P D popu
lation. T hrough our Q uality Im provem ent D epartm ent we measure the 30-day
readmission rates for respiratory diseases on Lung Partner patients, which we can
directly influence. Hospital-w ide CM S 30-day all cause C O P D readmissions was
also evaluated. Results: For Lung Partners patients we saw a significant reduc
tion in 30 day readmissions due to respiratory diseases by 28% (p= 0.0176). W e
also saw a significant reduction in total C O P D CM S readmissions by 24% (p=
0.045). Conclusion: By placing our RTs in a Primary Respiratory Care model
we were able to reduce 30-day readmission rates. T he R T departm ent has moved
from a task oriented to disease m anagem ent focus and utilizes RTs to the full
extent o f their licensure. RTs can be very successful in this role.
Sponsored Research – N one
2531356
BUILDING A STRONG FOUNDATION TO LEAD YOUR TEAM THROUGH
TRANSFORMATIONAL CHANGE.
N atasha T v so n : R esp ira to ry C a re D e p a rtm e n t, C e n tra l D iv is ion , C a ro lin a s H ea lth ca re S ystem . C h a rlo tte ,
N C
Background: H ealth ca re re fo rm has created an im m ed ia te d e m an d for
leaders to transition aw ay from u tiliz ing o u td a te d p erfo rm ance im prove
m e n t strategies to solve com plex , m ulti-facto ria l issues. Leaders are now
expected to be tran fo rm ative by engag ing in soph istica ted p rob lem solving
techn iques to achieve susta inable an d m ean ing fu l change. In o rd e r fo r
R esp ira to ry T h e rap y leaders to b u ild successful p rog ram s th a t are ro o ted
in tran sfo rm in g care a so lid in fras truc tu re m ust be in place to su p p o rt
rap id change in clinical practice an d th o u g h t. C an th e fo u n d a tio n for
tran sfo rm atio n a l change be b u ilt by redesign ing a d e p a r tm e n ts h ierarchy
to allow fo r g rea te r opera tiona l efficiencies an d th e c reation o f viable
strategies to im prove clinical outcom es? Method: A streng ths, weaknesses,
o p p o rtu n ities , and th reats (S W O T ) analysis was c o n d u cted o f th ree , diverse
R esp ira to ry C are d ep artm en ts w ith in a large healthcare system to de te rm in e
i f c reating a divisional leadership o rgan izational s tru c tu re w o u ld e lim inate
silos and create susta inable o pera tiona l efficiencies. A cost analysis follow ed
to de te rm in e th e im pact to th e budget. A th ree phase, tw o year im p lem en
ta tio n strategy was developed to help the team m ates u n d e rs tan d and adjust
to the tran sitio n as well as the new ly created roles w ith in the new leadership
hierarchy. I t was im p lem en ted after receiving approval from the Executive
team . Results: A cross-functional leadership team was c reated by aligning
th ree separate leadership m odels in to a single C en tra l D iv ision o rgan ization
struc tu re . A ro b u st c ross-tra in ing p rog ram and a C en tra l D iv ision P R N Pool
w ere c reated to assist th e div ision in ach iev ing its 3 % Y T D overtim e goal.
O v ertim e goals w ere achieved and susta ined for 2 0 1 4 and 2015 . P rem ier
p oduc tiv ity index percentages stab lized from 118% to 105% by 2015 .
P rem ier labo r expense index percentages stablized from 124% to 112% by
2015 . T h e C en tra l D iv ision F T E b u d g e t allow ed for the use o f 175 F T E s
to flex to vo lum e and su p p o rt facility specific staffing needs. Press G aney
team m ate engagem en t scores im proved from a T ie r 3 score to T ie r 2 d u rin g
th e im p lem en ta tio n period . Conclusion:The C en tra l D iv ision R esp ira to ry
C are D e p a r tm e n t has realized its goal o f ga in ing o pera tiona l efficiencies and
has a s tro n g fo u n d a tio n b u ilt to su p p o rt th e dem an d s o f healthcare reform .
S ponsored Research – N o n e
2531464
IMPLEMENTATION OF A NEWLY DEVELOPED PATIENT AND FAMILY
SATISFACTION SURVEY FOR RESPIRATORY CARE – A PILOT STUDY.
Lisa T v le r, loev lvnn C o v n e , L au ra Salom one: R esp ira to ry C a re . T h e C h ild re n s H o sp ita l o f Philade lph ia .
C h e rry H ill, N J
Background: Patient and family satisfaction surveys are often utilized by
organizations to measure quality and satisfaction w ith nursing and physician
care. These surveys m ost often do no t include questions regarding respiratory
therapists (RT) therefore inform ation on satisfaction w ith R T care is often
unavailable. A quality project targeting patient family satisfaction o f RT care
was initiated and a RT based survey developed. A pilot study was conducted to
assess process m ethods (delivery/return), survey questions, and prelim inary sat
isfaction scores. Methods: A paper based survey was developed using modified
questions from a validated nursing tool. Five questions using a four po in t Likert
scale (never to always) m easuring com m unication practices, consistency o f care,
courtesy and respect, inform ation sharing, and ability to voice concerns were
included as well as one open-ended question. Questionnaires were random ly
given ou t on two units, pediatric intensive care un it (ICU ) and an acute care
unit (ACU), to patients and families who received respiratory care services. A
standardized dialogue was provided for consistency in com m unication. Surveys
were hand delivered and retrieved by staff. Results: 55 surveys (n=55) were com
pleted and returned. T he chart provides the results for questions 1 to 5. 44/55
(80% ) o f the open-ended question were answered w ith positive feedback and/
or areas o f concern. N o patients or families (0% ) reported difficulty in under
standing, needed support, or refused to com plete the survey. Delivery/return
proved to be m ost challenging for staff, com m ents included tim ing o f patien t/
parent approach for initial delivery (ICU ) and ability to return to pick up (ACU)
as their chief problems. Conclusion: Patient and family satisfaction surveys for
respiratory care departm ents can be successfully im plem ented in the IC U and
A CU. T here are challenges to adm inistering a paper based tool in the hospital
setting. W hile the prelim inary overall scores where good, com m unication and
consistency in care are potential area o f im provem ent work. I t is im portan t to
note, these results may be skewed due to RT driven patient selection. Future
w ork will include expansion o f survey use to all patients receiving R T services,
finding m ore efficient means for delivery and return, and to track response rate.
Sponsored Research – N one
2531549
REDUCING NON-CLINICALLY INDICATED BRONCHODILATOR THERAPY
ON NON-ICU FLOORS AT UPHS USING A THERAPIST DRIVEN PROTOCOL.
M arg ie P ierce. M ichae l Frazer, H e n rv S m ith . D av id D om zalsk i. A n d rew Ross: R esp ira to ry C are . H o sp ita l
o f th e U n iversity o f P ennsylvania , P h ilad e lp h ia , PA
Introduction: Respiratory Therapist driven protocols vs. physician-directed RT
orders have dem onstrated cost savings to hospitals and im proved R T resource
utilization in m ultiple studies. T he University o f Pennsylvania H ealth System
R T departm ents piloted a m ulti-hospital bronchodilator protocol in an effort
to reduce variability o f bronchodilator orders, improve quality o f care and
R T resource utilization. Methods: O u r m ulti-hospital team used PI m ethod
ology to assess root causes o f non-clinically indicated bronchodilator orders.
A T D P assessment form was developed to standardize the assessment process.
Phase 1: R T s at H U P, PAH, and PPM C used the assessment form for a 2-week
data collection period to assess appropriateness o f physician ordered respiratory
therapy. D uring the following 8 weeks the R T used the T D P form on a pilot
medical unit and intervened w ith recom m endations for order changes based
on the assessment findings. Phase 2 included Chester C ounty H ospital, and
added a second medical un it to the original pilot units. Phase 3 added surgical
units at H U P and PP M C while C C H and PAH sustained the pilot on m ed
ical units. Results: Pre-intervention data showed an average o f 20% ordered
bronchodilators were not clinically indicated (range 5-33% ). D uring Phase 1,
non-clinically indicated bronchodilators were reduced to 10%. D uring Phase
2, the provider order screen was redesigned to im prove accuracy w hen selecting
frequency o f bronchodilators. Phase 3 included the addition o f 2 surgical units.
H U P reduced non-clinically indicated bronchodilator orders to 5% and PPM C
to less than 8%. U PH S RT departm ents calculated savings o f $82,500 in supply
and m edication costs during the pilot. Providers reported im proved com m uni
cation, improved quality o f care, and that R T recom m endations were clinically
appropriate. Conclusions: T he U PH S project dem onstrated T herapist Driven
Protocols reduce unnecessary therapy and improves quality o f care by ensure
patients receive the appropriate respiratory therapy. By redesigning the provider
order screen, overnight therapy was reduced and frequency o f treatm ents was
m ore appropriately ordered. R T patien t assessments increased and a trend
toward lower median cost per patien t was identified. O rdering providers and
R T s reported positive feedback o f the pilot. U PH S results are inline w ith pre
vious observations from 2 R C T s. U PH S R T departm ents are seeking medical
board approval for hospital-wide R T driven bronchodilator protocol.
Sponsored Research – N one
OF33
Copyright of Respiratory Care is the property of Daedalus Enterprises, Inc. and its content
may not be copied or emailed to multiple sites or posted to a listserv without the copyright
holder’s express written permission. However, users may print, download, or email articles for
individual use. Satisfying Your Customers
Sustaining a Lean
Transformation
Lean, new leadership behaviors necessary for
continuous improvement.
Healthcare organizations are radically
changing the way they work. They have
little choice in the face of declining
reimbursements, increased emphasis on
value-based payments, consolidation of
competitors and the uncertain future of
the national healthcare system. In
response, many have pursued Lean,
which drove initial improvements in
their organizations and has benefitted
patients (improved quality of care at
reduced cost), staff (engaged, meaning-
ful, value-adding work) and the organi-
zation (bottom-line improvements).
But these initial attempts at Lean
have been focused for the most part
on Lean tools, which are not enough;
they must be combined with changed
leadership behaviors and a Lean man-
agement system to achieve lasting
results and continuous improvement.
A Systematic Approach to Change
A Lean healthcare model, one focused
on the principles and behaviors of
operational excellence, begins with
senior leadership defining a vision and
setting strategy and purpose for the
executive team (see the chart on Page
56). The strategies typically are rolled
out via Lean toolssuch as value-
stream mapping and rapid improve-
ment or Kaizen events, which
acquaint staff with Lean principles
and lead to early, innovative results.
Where applied, management and
front-line staff begin to understand
and believe in a new way to work.
But even where organizations have
made substantial improvements with
Lean tools, this initial effort is never
sufficient. There is no shortage of prob-
lems, and early successes often are for-
gotten as newer, bigger problems arise.
Without a systematic way to manage
change and these new ways of work-
ing, it is difficult to sustain improve-
ments long term. Existing systems for
managing the business no longer
align with new Lean practices and
evolving expectations of management
and employees. Old measurement
systems are misaligned with new per-
formance targets. The organization
lacks a consistent, standardized way
to problem solve.
Alignment begins with a leaders strat-
egy and true north metrics (the few,
selected enterprise goals that guide
like the fixed location of the North
Star, an orienting pointall improve-
ment work) that all staff understand
and strive to achieve, and, importantly,
a systematic way to deploy strategy and
metrics. This is the foundation for a
Lean management system, but it is far
more than a deployment strategy. It is a
new way to work and manage the
organization and is necessary to sustain
continuous improvement.
When leaders embrace this holistic
approach, they can quickly innovate
and adapt to any market disrupters.
Breakthrough activities, such as Kaizen
events, and front-line use of tools con-
tinue within a Lean management sys-
tem, but now they are tightly aligned to
true north and strategic objectives. The
management system is an infrastruc-
ture with standard work that supports a
cultural change across departments and
up and down the organization, and
integrates new Lean components that
turn random activities into routines.
There is, of course, a catch: For the
components of a Lean management
system to successfully work together,
the chief executive must adapt his or
her current style of leadership and use
and observe the components of the
new system. Many will find that
degree of change challenging. But as
a Lean transformation proceeds, they
will invariably recognize that their
old ways insulate them from whats
really going on in their organizations.
But the way to get the most powerful
results is to personally lead and imple-
ment the full management system. Just
as changing the organization is possible,
so is changing the leader. The following
leadership principles are transformative
and necessary for optimum perfor-
mance of a Lean management system.
This column is made possible in part
by Change Healthcare.
Kim Barnas
Reprinted with permission. All rights reserved.
Healthcare Executive
JAN/FEB 2018
54
Personal A3 (similar problem-solving
process as plan, do, check, act or
PDCA) and self-assessment sets the
course for a leaders transformation
and the organizationsand gives an
executive a baseline by which to gauge
his or her progress.
Constancy of purpose means an exec-
utive delivers a consistent message that
aligns with true north.
True north metrics are reinforced at
the top of the organization. A leader
ensures the ongoing efficacy and
meaningfulness of metrics.
Transparency through visual man-
agement helps everyone easily see what
is going on and who is doing what by
when. If a leader examines a depart-
ments visual boards, you can be sure
others will too.
Respect for standards (standard
work) involves leaders doing things
on a regular basis to support teams
and steer their own work in the right
direction, such as observe a huddle
on a weekly basis.
Respect for every individual is dem-
onstrated by humbly asking questions,
seeking answers and respecting the
work and ideas of others. Leaders
depend on everyones ideas to inform
the right thing to do at the front line.
Focus on the process to make a dif-
ference. Avoid blaming individuals;
they are most likely good people
trapped in bad processes.
Scientific thinking and Lean tools
are new to most healthcare leaders,
and many of the tools are not intui-
tive. A leader must know how these
concepts change work and traditional
processes and ensure others have
access to and experience with them.
Lead with humility to understand
how things are working. That means
going to the place where work is
done and asking open-ended ques-
tions of staff.
Seek perfection, recognizing that
perfection is not perfectionism. Every
healthcare professional should be
improving daily and seeking
perfection.
Ensure quality at the source is a
mindset to which everyone, especially
the chief executive, should strive.
Never pass along poor quality to a
colleague.
Think systemically so that the
patient experience across the silos of
care always informs the work. We
may never eliminate silos in health-
care, but we can mitigate them by
keeping the patient at the center of
everything we do.
The above are the core principles on
which a Lean transformation is
based. Many executives have adopted
these principles, and, in so doing,
they have grown as leaders and indi-
viduals. But as executives evolve, they
also find that they cannot sustain the
transformation by themselves.
Satisfying Your Customers
Leadership Principles and Behaviors
Source: Institute for Enterprise Excellence
[principles] [leadership] [management] [front line]
IM
PR
O
V
E
A
LI
G
N
EN
A
B
LE
Create value for the patient
Create constancy of purpose
Think systemically
Establish Direction
Develop a vision and strategies to achieve
that vision. Set high but reasonable
targets. Communicate the direction on a
regular basis.
Organizing & Translating
Establish a structure to achieve the plan.
Organize and allocate resources. Monitor
structure to ensure consistency and alignment
to the plan.
Setting & Achieving Goals
Identify meaningful goals that can be
accomplished in area that directly affects the
overall vision and strategy. Report daily on
status and needed support.
Lead with humility
Respect every individual
Learn continuously
Motivate, Mentor, Inspire
Energize people to develop and overcome
barriers to change. Daily be in the work
area to listen to understand. Embrace
failure; celebrate success.
Empower, Involve & Coach
Empower authority within parameters of
an area to improve and solve problems.
Breakdown silos by involving cross-
functional teams to solve value stream
issues. Coach problem solving daily.
Develop & Share
Be a self-developer. Find opportunities to
grow and develop to better support the
organization. Share with others what is
working and what is not.
Focus on process
Embrace scientific thinking
Flow & pull value
Understand & manage variation
Assure quality at the source
Seek perfection
Breakthrough Thinking
Continuously learn by listening, seeing
and translating observations. Support
new models of care delivery developed by
front-line staff.
Monitor & Maintain Predictability
Monitor the outputs of each system to
ensure stability and a standard outcome.
Continuosly challenge the process to
identify areas of improvement.
Adapt & Adjust
Adapt the tools by making incremental
adjustments that all shifts agree with. Treat
tools as a countermeasure, not a solution.
Structurally solve problems area daily.
Reprinted with permission. All rights reserved.
Healthcare Executive
JAN/FEB 2018
56
The board of directors needs to be
involved. Its important the board
understands what the Lean trans-
formation is and is able to lend sup-
port to the CEO when the going
gets tough. The board will require
education, which will help with
succession planning. An internal
candidate should be developed to
help ensure the Lean transforma-
tion is sustainable. Unless Lean
expertise exists internally, leaders
and the board also will need a
teacher or coach to help them get
started and navigate obstacles along
the organizations Lean journey.
Sustainable Results
Developing a principles-based, sys-
tematic approach to healthcare
improvement takes worktwo to
three years to get it fully established
in an organizationbut early
returns provide the momentum to
proceed, and they quickly accumu-
late, resulting in dramatic impacts.
Effects can be seen on:
Patients: There is a consistency
of care throughout the organiza-
tion, with everyone focused on
the value to the patient. Quality
of care and patient satisfaction
improve while costs are lowered.
Healthcare professionals:
Employees develop an ongoing
awareness and understanding of
their work, know how to respond
to problems and feel less bur-
dened by their roles and more
engaged. Management spends
less time engaged in firefighting
and more time coaching, men-
toring, problem solving and
innovating. Leadership under-
stands the organization as never
before, and therefore is better
informed and able to establish
the right vision, set a strategic
plan and move the entire organi-
zation forward.
These are extraordinary times for the
healthcare industry. We need an
extraordinary approacha Lean
management systemto drive and
sustain long-term results and benefits
for all who touch healthcare daily. s
Kim Barnas is president of Catalysis,
Appleton, Wis., and an ACHE
Member ([emailprotected]).
Reprinted with permission. All rights reserved.
Healthcare Executive
JAN/FEB 2018
57
Exceptional capabilities create
exceptional career opportunities
HCA Healthcare is a leader in providing expert, patient-focused care in
communities across America. With more than 170 hospitals, 119 ambulatory
surgery centers, and countless physician practices across all specialties, we
provide exceptional care in more than 27 million patient encounters and 8.5
million emergency department visits annually.
Our scale creates opportunities for professionals in all disciplines to grow
their careers. Through our Leadership Institute, we provide executive
transition support to help leaders thrive in new responsibilities, along with
focused leadership development programs for physicians and C-Suite roles.
And were committed to foster a work experience where all colleagues can
deliver exceptional care, together, to patients, families, communities and
each other.
Copyright of Healthcare Executive is the property of American College of Healthcare
Executives and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder’s express written permission. However, users may print,
download, or email articles for individual use. Need assistance logging in? Contact Technical Support.
Log In
This is a protected document. Please enter your student
or faculty user name and password.
Toll Free: 877.428.8447
M-F, 6am MST or Sat-Sun, 7am-12am MST
Find us on Facebook and Follow us on Twitter!
Doc ID:
https://support.gcu.edu/hc/en-us/articles/202013760-Contact-Technical-Support
https://www.facebook.com/gcutechsupport
joka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka jokajoka joka joka joka joka joka joka joka joka joka
—Healtli
– – — – …….. ,-_
SECOND EDITION
James A. Johnson
Caren C. Rossow
‘–
Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 18880
joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka
joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka
joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka
joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka joka
