Tag Archives: ethics

Academia, Culture, Emergency Medical Services, Health Care, Politics, Public Health, Society

Changing the Paradigm of the Emergency Medical Services

 

Can the Emergency Medical Services Evolve to Meet the Needs of Today?

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The emergency medical services (EMS) provide a means of rapid treatment and transportation to definitive care for those people who suffer immediate life-threatening injuries or illnesses (Department of Transportation, National Highway Traffic Safety Administration, n.d.; Mayer, 1980). There are a number of models across the country and the world that are seeking to redefine EMS in a way that is more meaningful in both of its missions, public safety and public health (Washko, 2012). However, financial constraints and overzealous regulations serve only to pigeon-hole EMS into the decade of its birth and refinement, the 1970s, by restricting incentive and growth and limiting the efficacy of directed research and its application towards the much needed restructuring of EMS.

In this brief literature review, I will examine the roots and context of EMS, its mission and current application, as well as possibilities for research, growth, and development. It is important to recognize that EMS is a grand resource for both public safety and public health, especially in light of the growing body of legislation that officials are using to redefine the current health care system within the United States. As we continue to develop EMS, other nations will look to us as they have in the past to adopt and adapt our system for use throughout the world.

A Brief History of Contemporary EMS

There were many forms of organized out-of-hospital medical aid provided throughout history from the biblical good Samaritan to the triage and extrication from the battlefields of the Roman conquests and the Napoleonic wars through the U.S. Civil War and every major war and conflict in U.S. history; however, it was not until the advent of combined mouth-to-mouth resuscitation and closed chest massage (what we know today as cardiopulmonary resuscitation, or CPR), enhanced 9-1-1 for use by the public in summoning emergency services, and the release of a 1966 white paper prepared by the Committee on Trauma and Committee on Shock of the National Academy of Sciences, National Research Council, that we have the EMS system that we are familiar with today (Department of Transportation, National Highway Traffic Safety Administration, 1996). It was about this time that the Department of Transportation (DOT) was given purview over EMS at the national level with the passage of the National Highway Safety Act of 1966.

During the 1970s, EMS had transitioned from mostly untrained funeral home drivers to providers trained by emergency physicians to treat many of the life-threatening scenarios that prevent people from seeking medical attention at hospitals, such as traumatic injuries, cardiac arrest, and many breathing problems. Since this time, there have been a number of concerted efforts and official recommendations by the DOT to augment and improve the delivery model of EMS throughout the country (Department of Transportation, National Highway Traffic Safety Administration, n.d., 1996, 2008). As early as 1996, the DOT published the vision of the future of EMS:

Emergency medical services (EMS) of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in more appropriate use of acute health care resources. EMS will remain the public’s emergency medical safety net. (Department of Transportation, National Highway Traffic Safety Administration, 1996, p. iii)

Even as today’s emergency rooms, operating suites, and trauma centers throughout the world are overflowing capacity with an increasingly deficient workforce, EMS is expected to answer the call for help as the front-line of a fractured and inefficient health care system (Kellermann, 2006; Mason, Wardrope, & Perrin, 2003; O’Meara et al., 2006; Washko, 2012).

Hampered Efforts

EMS is known throughout the United States as rapid responders in times of medical and traumatic emergencies; however, ever-increasingly, EMS is being used as the front-line alternative to primary care for the non-emergent uninsured and under-insured patient population (Heightman & McCallion, 2011; Washko, 2012). There is a limited number of ambulances, EMTs, and paramedics available at any given moment, which is subject to financial constraints, and non-emergent use of these resources prevents their availability for when a true emergency arises. Secondary to the mission of providing care to the public, EMS is also needed to provide services for fire department and police department operations, such as firefighter rehabilitation at fire scenes and tactical medicine in concert with bomb squads, S.W.A.T. teams, and hazardous materials teams.

EMS resources are costly, and overburdened systems are negatively affected when these resources are misused, especially by those who are unwilling or unable to pay for the services.

Financial Impact

According to the DOT (2008) EMS workforce report, employers reported difficulties in retaining EMTs and paramedics partly due to the inability to raise wages or provide better fringe benefits. The report goes on to show that EMTs and paramedics suffer a wage disparity when compared to other similar public safety ($12.54/hr vs. firefighters: $26.82/hr; police officers: $22.25/hr) and health care workers (licensed vocational nurses and licensed practical nurses: $16.94/hr; respiratory therapists: $21.70/hr; registered nurses: $26.28/hr). In the five years leading up to 2005, the average wage for EMTs and paramedics grew only by $0.29/hr. It is important to note that these numbers do not take cross-trained firefighters and police officers into consideration.

Furthering the concern of wages, as the DOT (2008) report shows, is the lack of growth potential within EMS as most systems lack the ability to provide a meaningful career ladder to the EMTs and paramedics in their employ. These circumstances together create the scenario that EMS is an underpaid dead-end job causing high attrition as most EMTs and paramedics either suffer from burnout, culminated psychological stress from the job, or use the profession as a stepping stone into other health care fields, such as nursing, respiratory therapy, or physician-level medicine.

The DOT (2008) report provides evidence that transport-based reimbursement policies are likely to blame for the unusually low profit margin in EMS (Heightman & McCallion, 2011). The Medicare and Medicaid programs, as well as many private insurers, require documentation that the transport of a patient be medically necessary before they will pay; however, the Medicare and Medicaid reimbursement rates are very low and do not cover the cost of EMS operations. To complicate the matter, EMS providers are mandated by law to provide care to the public regardless of their insurance status or ability to pay (Heightman & McCallion, 2011). EMS is subsidized by either taxes or insurance reimbursement or some combination of the two.

Broad Mission

In addition to providing for the mundane care and transportation of the ill and injured and performing ancillary duties for the police and fire departments as noted above, EMS is tasked with disaster preparedness – preparing for the major incident that is highly unlikely to occur but would be devastating to lives and infrastructure if it does. That is if the EMT or paramedic is employed for an emergency service. Many of the EMTs and paramedics, today, are employed by private ambulance services who transport non-emergent patients to and from skilled nursing facilities and doctors’ offices. The multitude of these EMTs and paramedics are not considered when planning for emergency response schemes.

I consider EMS to be the caulking used to fill many of the fractures and gaps in today’s health care system. If it occurs outside of the hospital, then EMS will take responsibility, yet, they seldom get paid for their actions.

Proposed Solutions

There has been much talk over the past few years regarding the efficacy and efficiency of EMS, and all agree that the current definitive model is inefficient with, at best, questionable efficacy. Washko (2012) describes in detail the number of EMS schemes and their shortfalls. In his article, Washko is correct in stating that transport-based reimbursement policies fail to reward the greater EMS community for their willingness to take on further responsibility within the two scopes of operation: public health and public safety.

Wingrove and Laine (2008) explore the opportunity for training and equipping the most experienced paramedics for a public health centered role delivering community-based care. These community-based paramedics are described as augmenting the traditional emergency responder role with opportunities to direct patients to more appropriate care, such as doctor’s offices and urgent care centers instead of hospital emergency departments when appropriate to their condition. This model was researched recently in Australia with good results, and is now a recommended career path both there and in the United Kingdom (Mason, Wardrope, and Perrin, 2006; O’Meara et al., 2012). In the U.S., EMS professionals feel a responsibility to participate in disease and injury prevention efforts, and research on models that utilize specially-trained paramedics to perform home safety inspections, hazard mitigation, and reduce the risks of injuries to children have proven effective (Hawkins, Brice, & Overby, 2007; Lerner, Fernandez, & Shah, 2009). Hennepin Technical College, in Minnesota, now offers certification in Community Paramedic training when the recommended curriculum is provided by an accredited college, according to Wingrove and Laine.

Other, more immediate (but, arguably, less meaningful) solutions, as Washko (2012) describes, are incorporating operational tactics that better utilize ambulances by attempting to predict call volumes and locations based on historical data, the high-performance model. This, however, creates high-call volume, less resource driven scenarios with ambulances idling on street corners awaiting the next call. As mentioned earlier, attrition is a significant concern in EMS and these tactics are demanding on providers physically and psychologically leading to high incidences of burnout and injury (Department of Transportation, National Highway Traffic Safety Administration, n.d., 2008).

Discussion

The standard operational benchmarks of EMS – response times and mortality and morbidity of cardiac arrest – are antiquated measures and typically distract policymakers when they are considering financial incentives for EMS (Heightman & McCallion, 2011; Washko, 2012). EMS needs to evolve with the changing health care system, and I feel that it is poised, specifically, to help address disparities in health and health care. Using the community-based paramedic model of health care delivery, we can address many public health concerns, provide for public safety, and still maintain the traditional role of emergency responder. The community-based paramedic model will provide an acceptable alternative to the options that lie ahead.

The economics of health care is a reality that must be considered by every EMS operation when approaching growth and change. As long as EMS can fill the gaps in the current health care system, it will be worth the money required to subsidize a robust, well-trained, and well-equipped contingent of emergency medical professionals. In the meantime, though, EMS agencies will have to seek more efficient models that maximize reimbursement while minimizing costs.

References

Committee on Trauma & Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council. (1966). Accidental Death and Disability: The Neglected Disease of Modern Society. Washington, D.C.: Author.

Department of Transportation, National Highway Traffic Safety Administration. (n.d.). A leadership guide to quality improvement for emergency medical services (EMS) systems (Contract DTNH 22-95-C-05107). Retrieved from http://www.nhtsa.gov/people/injury/ems/Leaderguide/index.html

Department of Transportation, National Highway Traffic Safety Administration. (1996). Emergency medical services: agenda for the future (DOT HS 808441 – NTS-42). Retrieved from http://www.nremt.org/nremt/downloads/EMS%20Agenda%20for%20the%20Future.pdf

Department of Transportation, National Highway Traffic Safety Administration. (2008). EMS workforce for the 21st century: a national assessment. Retrieved from http://secure.naemse.org/services/EMSWorkforceReport.pdf

Hawkins, E. R., Brice, J. H., & Overby, B. A. (2007). Welcome to the World: Findings from an emergency medical services pediatric injury prevention program. Pediatric Emergency Care, 23(11), 790-795. doi:10.1097/PEC.0b013e318159ffd9

Heightman, A. J. & McCallion, T. (2011). Management lessons from Pinnacle: Key messages given to EMS leaders at the 2011 conference. Journal of EMS, 36(10), 50-54.

Kellermann, A. L. (2006). Crisis in the emergency department. New England Journal of Medicine, 355(13), 1300-1303. doi:10.1056/NEJMp068194

Lerner, E. B., Fernandez, A. R., & Shah, M. N. (2009). Do emergency medical services professionals think they should participate in disease prevention? Prehospital Emergency Care, 13(1), 64-70. doi:10.1080/10903120802471915

Mason, S., Wardrope, J., & Perrin, J. (2003). Developing a community paramedic practitioner intermediate care support scheme for older people with minor conditions. Emergency Medicine Journal, 20(2), 196-198. doi:10.1136/emj.20.2.196

Mayer, J. D. (1980). Response time and its significance in in medical emergencies. Geographical Review, 70(1), 79-87. Retrieved from http://www.ircp.info/Portals/22/Downloads/Performance/Response%20Time%20and%20Its%20Significance%20in%20Medical%20Emergencies.pdf

National Traffic and Motor Vehicle Safety Act of 1966, Pub. L. No. 89-563, 80 Stat. 718 (1966).

O’Meara, P., Walker, J., Stirling, C., Pedler, D., Tourle, V., Davis, K., … Wray, D. (2006, March). The rural and regional paramedic: moving beyond emergency response (Report to The Council of Ambulance Authorities, Inc.). Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/The%20Rural%20and%20Regional%20Paramedic%20Moving%20Beyond%20Emergency%20Response.pdf

Washko, J. D. (2012). Rethinking delivery models: EMS industry may shift deployment methods. Journal of EMS, 37(7), 32-36.

Wingrove, G. & Laine, D. (2008). Community paramedic: A new expanded EMS model. Domain3, 32-37. Retrieved from http://www.ircp.info/Portals/22/Downloads/Expanded%20Role/NAEMSE%20Community%20Paramedic%20Article.pdf

Academia, Society

Communications: Multicultural Considerations

Episcopalians have recently decided to approve and bless this type of marriage within the church (Dawson, 2012). In light of the recent debate over same-sex marriage, which has implications for societal values, health care, economics, public policy, business, and religion, approaching the subject requires care and specific messaging to ensure factual representation of the lesbian, gay, bisexual, and transgendered (LGBT) community with limited personal bias. A biased or overly-stereotypical argument of debate or discussion point is easily nullified and serves only to discredit the messenger. According to James (2011) and Robison (2002), between 4 and 10% (14.4 – 36-million) of all Americans fall within the LGBT community. Additionally, as religion appears to be the countering force in this argument, the same care must be used for this group, also.

If I were to enter the debate, I would hope to provide a solution to the problem that would be equitable to all parties involved. If not realistic, it would, at least, be a positive addition to the debate; however, I feel that there is an equitable solution. The only was to reach this solution, though, is to maintain a factual position from which to analyze the problem. Hendrix and Hayes (2010) focuses on message construction, and though it is an important aspect of communications, public debate usually requires research more focused to attain understanding of the intricacies of the debate and the environment in which the debate is being held.

There are two aspects of marriage that need to be considered. First, marriage is largely a religious institution; therefore, the religious debate cannot be readily dismissed. The second aspect of marriage that needs consideration is legal definition of marriage and the licensing requirements of each state. Obvious to me, the federal government has no platform on which to stand as they are required to honor the states’ license of marriage. The rapid solution is to provide a state option to allow or disallow same-sex marriage. For this to occur, the states would have to change the marriage license to a license of partnership in household. The partnership in household designation would allow, for tax and legal purposes, the LGBT community as well as others, such as atheists, to enjoy the benefits of traditional marriage without encroaching on the purview of religion. This would leave each religious denomination the choice of presiding over a formal rite of wedding, which would officiate the marriage within the religion. The states and federal government should only honor the partnership in household designations or dissolutions when considering marriage for their purposes. Marriage is the only religious rite where government requires a fee, and they should not.

This solution provides historical precedent as well as satisfying the needs of the communities on each side of this debate, and it does so respectfully and without bias. Other arguments can still be made, such as the worthiness and value of society’s acceptance of same-sex marriage, but these arguments are less important than the official capacity in which each aspect of the argument (government and religion) are able to weigh in. Too many times, we as a society try to use institutions to force behavior when the chosen institution actually has little purview and impact on the behavior, such as the federal government in this case. This tactic only serves to inflame the debate and adds pressure to institutions to act.

References

Dawson, D. (2012, July 9). Episcopalians set to be first big U.S. church to bless gay marriage. Reuters. Retrieved from http://www.reuters.com/article/2012/07/10/us-usa-religion-gaymarriage-idUSBRE86902U20120710

James, S. D. (2011, April 8). Gay Americans make up 4 percent of population. ABC News. Retrieved from http://abcnews.go.com/Health/williams-institute-report-reveals-million-gay-bisexual-transgender/story?id=13320565#.T_1wIOFySOw

Hendrix, J. A. & Hayes, D. C. (2010). Public relations cases (8th ed.). Boston, MA: Wadsworth Cengage Learning.

Robison, J. (Ed.). (2002, October 8). What percentage of the population is gay? Gallup. Retrieved from http://www.gallup.com/poll/6961/what-percentage-population-gay.aspx

Academia, Society

Integrated Marketing Communications Case Study

Integrated marketing communication provides a seamless and comprehensive delivery of information to consumers. Hendrix and Hayes (2010) discusses the prevalence of integrated marketing since the 1990s and its usefulness in complying with the perceptions of consumers. In this way, integrated marketing communication is consumer-centric and relationship driven. An award-winning case study of Pfizer Animal Health, MGH, and TagTeam Global by the Public Relations Society of America (2009) demonstrates the utility of integrated marketing concepts.

Background

Pfizer developed a canine weightloss medication, Slentrol®, in 2007, and relied on the collaborative efforts of MGH and TagTeam Global to launch the marketing efforts in 2008. Slentrol® is the first-in-class drug approved by the Food and Drug Administration to treat canine obesity. The comprehensive effort resulted opening conversations between veterinarians across the country and approximately 200,000 dog owners, increasing dog obesity awareness, and, ultimately, lead to a 42% gain in Slentrol® sales.

Research

Hendrix and Hayes (2010) describe how a SWOT analysis would be extremely useful when preparing for an integrated marketing effort. They stress that leveraging strengths and acknowledging weaknesses honestly allows the firm the ability to maximize market-share while maintaining vigilance against external threats. According to the Public Relations Society of America (2009), the primary research, conducted primarily by Pfizer, helped to define the market. MGH and TagTeam Global furthered this research with anecdotal evidence provided by friends, family, and colleagues and surveys directed to veterinarians, which helped to define the degree of understanding that most people have of the health risks of obese dogs. MGH and TagTeam Global also performed secondary research to help to define the messaging in a way that would resonate with dog owners.

Objectives

The objectives of integrated marketing communications is, by definition, comprehensive. In the case study, the objectives included increasing a focus on canine obesity, educate dog owners to the dangers and risks of canine obesity, motivate dog owners to seek treatment if their dogs were perceived to be obese, and to increase sales of Slentrol® (Public Relations Society of America, 2009). To meet these objectives, a public outreach event, the National Canine Weight Check, was designed to allow dog owners to visit a participating veterinarian during an entire month for a weight assessment free of charge (Public Relations Society of America, 2009).

Programming

The Public Relations Society of America (2009) case study demonstrates a varied use of media and consumer word-of-mouth communication to raise awareness of canine obesity. MGH and TagTeam Global also created a website dedicated to provide education about canine obesity and recruited a number of veterinarians to participate in the outreach. These veterinarians were provided with advice on how to broach the topic as well as the necessary equipment to perform the free weight assessment. Again, they relied heavily on the previous research in order to communicate most effectively with dog owners based on the vernacular present on canine websites and discussion boards. This was a very strategic use of available communication tools.

Evaluation

The National Canine Weight Check is lauded as attracting over 200,000 dog owners to participating veterinarians to discuss the risks and options concerning their overweight dogs, Pfizer enjoyed a 42% increase in sales of Slentrol®, and Pfizer realized a great opportunity for continued marketing to almost 1,500 consumers through social network connections (Public Relations Society of America, 2009). Many other goals and objectives were met, and Pfizer, MGH, and TagTeam Global consider the National Canine Weight Check a large success.

Discussion

Integrated marketing communications is a comprehensive combination of many advertising, marketing, sales, and public relations tactics to provide unification in the messaging and more effectively leverages the strengths of the organization. Integrated marketing relies on two-way communication and serves to establish long-lasting relationships between the organization and consumers. Integrated marketing can be very useful in a myriad of situations, and though it requires great attention to detail and thorough research to accomplish effectively, the rewards can be immense and lasting when done right.

Pfizer, MGH, and TagTeam Global would not, in my opinion, have benefited from such success had they not implemented this comprehensive approach. The research alone allowed the effort to succeed by uncovering more ways to attain credibility with the consumers as well as veterinarians (Public Relations Society of America, 2000). Further, the biggest benefit to integrated marketing that Pfizer now enjoys is the long-term loyalty and commitment found in a significant share of the market. This could not be attained, according to Hendrix and Hayes (2010), with other, more modest, forms of communication and marketing.

References

Hendrix, J. A. & Hayes, D. C. (2010). Public relations cases (8th ed.). Boston, MA: Wadsworth Cengage Learning.

Public Relations Society of America. (2009). National canine weight check (Product #6BW-0916A11). Retrieved from http://www.prsa.org/Awards/SilverAnvil/

Academia, Criminal Justice, Society

Penn State: Analysis of Crisis Communications

On November 5, 2011, Jerry Sandusky, former Pennsylvania State University assistant football coach, was arrested on a number of counts of sexual assault on a minor. The arrest stems from incidents relating to The Second Mile charity, founded by Sandusky, and its association with Pennsylvania State University over the course of 15 years (Garcia, 2011; “Sandusky,” 2011). Two days later, the Pennsylvania State University athletic director, Tim Curley, and senior vice president for finance and business, Gary Schultz, surrendered to police to answer charges for failing to notify authorities for suspicions of sexual abuse of a minor (“Officials,” 2011; “Sandusky,” 2011). In two more days, Joe Paterno, head coach of the Pennsylvania State University football program, resigned over the controversy surrounding the university and its football program (Garcia, 2011; “Sandusky,” 2011). Within days of the arrests (and, before all the facts are known), the university was being severely criticized in the media (Zinser, 2011). This public relations nightmare is an example of how leveraging a crisis communication plan is important in communicating with the public.

Trivitt and Yann (2011) present this case as a reminder that crisis managers cannot fix every problem: “we think it’s important that, as a profession, we don’t overreach and try to uphold our work as the savior for every societal tragedy and crisis. Doing so makes us look opportunistic and foolish considering the gravity of the situation” (para. 13). In the case of Pennsylvania State University, there were a number of glaring failures to report the assaults to the authorities. Still, Sandusky was allowed to have unsupervised interaction with these adolescent boys until an investigation was launched in 2009 after one of the victims notified the authorities (“Sandusky,” 2011). Pennsylvania State University authorities should have reported the accusations to the proper authorities and released a statement to the media as soon as they were made aware, saving the administration from this crisis (Sudhaman & Holmes, 2012). The perception, however, is that there was a cover-up of moral corruption. There were a number of moral requirements that university representatives failed to acknowledge over the past years, and the character and esteem of the school will suffer for it.

Immediately after the revelation of these transgressions, the Pennsylvania State University administration clambered to make the proper attempts towards repairing the school’s suffering reputation, including donating $1.5-million of profits received from the renowned football program to sex crimes advocacy projects, discontinuing the school newspaper’s sex column, and providing a town hall- type venue where concerned students could present their questions and concerns directly to school officials (Sauer, 2011). Ultimately, these steps are proper; however, the only means of reclaiming and recapturing the admirable reputation that Pennsylvania State University once held is time and requires purging those administrators who appear sullied by this controversy. This does not, however, mean that Pennsylvania State University is languishing. According to Reuters (Shade, 2011), applications to attend Pennsylvania State University have increased in the last year, and the current school administration, as well as alumni, are uniting to restore the trust between the school and students.

Further, Singer (2011), a crisis communications and reputation management specialist, outlines the steps necessary for the school to truly enhance its brand. Singer highlights cleaning the slate by terminating any employees explicitly related to or having perpetuated the crisis, creating a team-centric leadership culture by restraining the political power of any one person within the school (especially the lead coach), and living the values that are proffered by the school (e.g. “Success With Honor”). If the crisis is handled appropriately from this point forward, the school’s reputation will be judged not the crisis itself.

Discussion

Coombs (2012), Fearn-Banks, (2011), and Hendrix and Hayes (2010) all agree that crises are unexpected events that are difficult to anticipate; however, the communications focus should not be placed on specific problems that have a low probability of materializing but to have broad and general preparations in place to address unanticipated concerns as they arise.

Hendrix and Hayes (2010) provides an emergency checklist that organizations could adopt to better prepare to respond rapidly to a crisis. Analyzing the Pennsylvania State University response in retrospect by applying the concepts within this checklist will show how poorly prepared the administration was in responding to this crisis. What is glaring in the analysis is that the administration was on the defensive throughout the entire crisis. It seems that they were either unwilling or unable to get in front of the story. Hendrix and Hayes, as well as Coombs (2012) recommends utilizing a central resource as a clearinghouse to disseminate information to and from external publics. This communications center could also serve as an incident knowledge-base for those internal publics requiring more information. Further, preparation, again, is explicitly stated and is a requirement to quickly respond to media inquiries within the hour recommended. Although it is unclear if Pennsylvania State University incorporated a public information center, it was clearly not effective if it was, indeed, instituted.

Another issue that was contentious throughout the crisis and gave the appearance of a cover-up was the lack of full disclosure on the part of the university. It is understandable that the administration might have been caught off guard; however, this is no excuse to appear defensive and largely silent.

The Pennsylvania State University administration later contracted with a public relations firm to restore the reputation of the university. This should have been done much earlier.

References

Coombs, W. T. (2012). Ongoing crisis communication: Planning managing, and responding (3rd ed.). Thousand Oaks, CA: Sage.

Fearn-Banks, K. (2011). Crisis communications: a casebook approach (4th ed). New York, NY: Routledge.

Garcia, T. (2011, November 9). Paterno announces retirement, says Penn State has bigger issues to address. PRNewser. Retrieved from http://www.mediabistro.com/prnewser/paterno-announces-retirement-says-penn-state-has-bigger-issues-to-address_b29902

Hendrix, J. A. & Hayes, D. C. (2010). Public relations cases (8th ed.). Boston, MA: Wadsworth Cengage Learning.

Officials seeking alleged abuse victims. (2011, November 9). ESPN.com. Retrieved from http://espn.go.com/college-football/story/_/id/7203566/penn-state-nittany-lions-sex-abuse-case-officials-arraigned-police-seek-alleged-assault-victim

Sandusky, Penn State case timeline. (2011, November 9). ESPN.com. Retrieved from http://espn.go.com/college-football/story/_/id/7212054/key-dates-penn-state-sex-abuse-case

Sauer, A. (2011, December 1). Penn State bogs down in PR crisis, but a turnaround already showing. brandchannel. Retrieved from http://www.brandchannel.com/home/post/2011/ 12/01/Penn-State-Bogs-Down-In-PR-Crisis-120111.aspx

Shade, M. (2011, December 1). Penn State officials say applications up despite scandal. Reuters. Retrieved from http://www.reuters.com/article/2011/12/01/us-crime-coach-students-idUSTRE7B00GD20111201

Singer, J. (2011, December 7). The Penn State scandal: crisis as opportunity. The Business of College Sports. Retrieved from http://businessofcollegesports.com/2011/12/07/the-penn-state-scandal-crisis-as-opportunity/

Sudhaman, A. & Holmes, P. (2012, January 25). The top 10 crises Of 2011. The Holmes Report. Retrieved from http://www.holmesreport.com/featurestories-info/11377/The-Top-10-Crises-Of-2011.aspx

Trivitt, K. & Yann A. (2011, November 9). Public relations won’t fix Penn State’s crisis. PRSay. Retrieved from http://prsay.prsa.org/index.php/2011/11/09/public-relations-wont-fix-penn-states-crisis/

Zinser, L. (2011, November 9). Memo to Penn State: Ignoring a scandal doesn’t make it go away. The New York Times. Retrieved from http://www.nytimes.com/2011/11/10/sports/penn-state-fails-a-public-relations-test-leading-off.html?_r=1&ref=sports

Academia, Criminal Justice, Society, Technology

Crisis Communications: Imperial Sugar Case Study

At approximately 7:15 pm, on February 7, 2008, a large explosion at the Imperial Sugar refinery rocked the area of Port Wentworth, Georgia, killing 14 people and injuring 36, and although, the incident was found to be the fault of Imperial Sugar, this discussion will focus on the crisis communications and public relations surrounding the event (Bauerlein, 2010; U.S. Chemical Safety and Hazard Investigation Board, 2009). According to a report from the Public Relations Society of America (PRSA; 2009), although John Sheptor was appointed Chief Executive Officer merely nine days earlier and did not enjoy the support of a crisis communications team, he was thrust into the spotlight having to deal with this particular crisis.

According to a local television station, the people of Savannah and Port Wentworth responded admirably at the first hint of trouble (“Sugar refinery explosion,” n.d.). This is more of a testament to the community than to Imperial Sugar; however, it promotes a sense of good-will and community trust that Imperial Sugar was able to leverage. Almost immediately, Sheptor, in conjunction with Imperial Sugar partner Edelman, was holding regular news conferences, disseminating press releases, and correcting the record. The only delay is seemingly the time required to work with first responders and investigators (“4 found dead,” 2008; PRSA, 2009; U.S. Chemical Safety and Hazard Investigation Board, 2009). According to the PRSA (2009), Sheptor and Edelman immediately instituted a program to communicate to “employees, stakeholders, investors, elected officials and the media, and to engage the public in helping the company support the Imperial Sugar employee family” (p. 1).

As the crisis wound down to the recovery phase, it is important to note, as Chapman (2008) chronicles, that all displaced employees were still being paid by Imperial Sugar. All employees that were able were used to help in the clean-up efforts and ultimately maintained their employment status with Imperial Sugar. Within a week of the incident, Sheptor reported that the company was looking to rebuild and, in just over two month’s time, the decision to rebuild was official (Securities and Exchange Commission, 2008).

Sheptor leveraged Edelman’s communication philosophies which allowed communications to be prioritized, correct, honest, and abundant. While also providing much needed information to employees and families of missing employees, especially, this mode of communication also allowed Edelman, and Imperial Sugar, to cultivate media relations that will benefit them in the future.

References

4 found dead in Ga. sugar refinery blast. (2008, February 8). Associated Press. Retrieved from http://www.msnbc.msn.com/id/23059948/ns/us_news-life/t/found-dead-ga-sugar-refinery-blast/

Bauerlein, V. (2010, July 8). Imperial Sugar to pay fines in deadly Georgia explosion case. Wall Street Journal. Retrieved from http://online.wsj.com/article/SB10001424052748703636404575352782366026008.html

Chapman, D. (2008, April 13). Sugar refinery near Savannah determined to rebuild. Atlanta Journal-Constitution. Retrieved from http://www.ajc.com/metro/content/business/stories/2008/04/12/sugar_0413.html

Public Relations Society of America. (2009). Crystallizing a response to a crisis (Product # 6BW-0911A05).

Securities and Exchange Commission. (2008, April 17). Current report: Imperial Sugar Company (Form 8-K). Washington, D.C.: Author.

Sugar refinery explosion (Collection of news reports). (n.d.) WTOC. Retrieved from http://www.wtoc.com/category/125278/sugar-refinery-explosion

U.S. Chemical Safety and Hazard Investigation Board. (2009, September). Investigation report: sugar dust explosion and fire (Report No. 2008-05-I-GA). Retrieved from http://www.csb.gov/assets/document/Imperial_Sugar_Report_Final_updated.pdf

Academia, Politics, Society

Public Relations Terms

Legitimacy and ethical concerns are quite important to the practice of public relations (Hendrix & Hayes, 2010). With some errant developmental forefathers, such as Edward Bernays (1928) and contemporary deviants, such as Saul Alinsky, and self-proclaimed media watch groups, such as the left-wing Center for Media and Democracy’s PRWatch.org, it is increasingly important to understand appropriate use and context for the influences possible with contemporary public relations concepts (Stauber & Rampton, 1999). In this discussion, I will examine and discuss the appropriateness and ethical use of Blackmon’s (2009) three different public relations concepts: press agentry, promotion, and sales and marketing in light of the six provisions of the Public Relations Society of America (PRSA; 2000) Member Code of Ethics: advocacy, honesty, expertise, independence, loyalty, and fairness.

Press Agentry

According to Blackmon (2009), agentry is a tool to increase notoriety for the sake of notoriety and without any other objective or plan. A good example of press agentry is CNN Entertainment’s coverage of Nadya Suleman and her choice of career (Duke, 2012). Suleman is also known publicly as the Octomom. Although the Duke (2012) article expresses her choices as promotion for her new video, the actual article by Duke is borne from press agentry. Considering the PRSA (2000) code of ethics, it appears that Ms. Suleman’s press agent is acting in her best interests and not promoting Ms. Suleman in an unfair way that is not dishonest to the public. The choice of media outlets to cover Ms. Suleman at the behest of her press agent is entertainment journalism and falls outside of the scope of this discussion.

Promotion

Promotion, according to Blackmon (2009), is similar to press agentry, though with some objective or as a means to an end. Frum (2012) fulfills Sony’s promotional wishes by attending an event devoted to promoting electronic entertainment then writing about his findings. Like the Duke (2012) example above, Frum’s coverage is not the subject of the discussion here; however, the promotional event that Frum covers is. I find the pomp of the event likely needed to draw both consumers and journalists. Additionally, the public relations team that advocated for Sony to promote its new games at this heralded event to be in line with the ethics put forth by the PRSA (2000). Sony is putting its products in the public arena for both celebration and scrutiny, equally.

Sales and Marketing

Over the last few years, Sprint (2012) marketed its Simply Everything ™ plan as its premier-tier plan to include unlimited talk, domestic long distance calling, text, data, and roaming. This plan was marketed towards power users who cannot judge their cellular service usage month to month and are willing to pay a premium fee of $99.99 per month for this service. Recently, Sprint decided that network usage was too overwhelming and unilaterally decided to limit consumer phone data usage by implementing limited hotspot plans. A hotspot, in this case, is the ability of a smart phone to act as a wireless router to allow connections from laptops and other network devices to share the phone’s data connection. Initially, there was a single plan costing $29.00 that merely allowed using the phone’s hotspot feature, but they have since decided to even limit the use of the hotspot, specifically, to a set amount of five gigabytes (GB) regardless of the <i>unlimited data</i> included in the Simply Everything ™ plan (Webster, 2011). Sprint has now decided to discontinue the five GB plan and offer a two GB for $19.99/month and a six GB plan for $49.99/month (Tofel, 2012; Welch, 2012). The marketing plan would be within the PRSA’s (2000) code of ethics; however, the recent unilateral decision by Sprint to limit the users’ data usage under the unlimited plan is dishonest, unfair, and is insulting to loyal customers.

Discussion

The PRSA (2000) has chosen not to enforce their code of ethics; however, it does provide a standard to look towards for guidance in judging the ethics of public relations efforts. Public relations efforts that disrespect the consumer are dishonorable and will ultimately be judged by consumer choice. In all three cases above, the efforts are obviously focused at improving the business model of each subject (Ms. Suleman, Sony, and Sprint); however, the public relations effort is focused to an audience and that audience needs to feel some level of respect when receiving the message. Otherwise, the effort will fail.

References

Bernays, E. L. (1928). Propaganda. Retrieved from http://www.historyisaweapon.com/defcon1/bernprop.html

Blackmon, M. (2009). Public relations terms [PowerPoint slides].

Duke, A. (2012, June 5). Octuplets mom Suleman books stripper gigs to save home. CNN Entertainment. Retrieved from http://www.cnn.com/2012/06/04/showbiz/octuplets-mom-stripping/index.html

Frum, L. (2012, June 5). Sony highlights mature games, cross-play at Electronic Entertainment Expo. CNN Tech. Retrieved from http://www.cnn.com/2012/06/05/tech/gaming-gadgets/e3-sony/index.html

Hendrix, J. A. & Hayes, D. C. (2010). Public relations cases (8th ed.). Boston, MA: Wadsworth Cengage Learning.

Public Relations Society of America. (2000). Member code of ethics. Retrieved from http://www.prsa.org/AboutPRSA/Ethics/documents/Code%20of%20Ethics.pdf

Sprint. (2012). Plans: pricing, individual, business. Retrieved from http://www.sprint.com/landings/indirect/sprintplans.pdf

Stauber, J. & Rampton, S. (1999). The father of spin: Edward L. Bernays and the birth of PR [Book review of same title]. PR Watch, 6(2). Retrieved from http://www.prwatch.org/prwissues/1999Q2/bernays.html

Tofel, K. C. (2012. May 22). Sprint bumps per GB price on hotspot plans for phones. GigaOM. Retrieved from http://gigaom.com/mobile/sprint-bumps-per-gb-price-on-hotspot-plans-for-phones/

Webster, S. (2011, September 22). Sprint to cap mobile hotspot plans at 5GB per month in October. CNET. Retrieved from http://www.cnet.com/8301-17918_1-20110106-85/sprint-to-cap-mobile-hotspot-plans-at-5gb-per-month-in-october/

Welch, C. (2012, May 22). Sprint kills 5GB mobile hotspot plan, offers less cost-effective 2GB and 6GB plans to fill void. The Verge. Retrieved from http://www.theverge.com/2012/5/22/3036211/sprint-mobile-hotspot-tethering-plans-updated

Academia, Emergency Management, Society

Crisis as Opportunity

Through the last few weeks, we have explored various means of saving the reputation of an organization in crisis. From reframing arguments to apologizing and promising to making it right, we have many tools at our disposal to turn the conversation in a way that is, at most, beneficial to the organization’s reputation or, at least, less harmful to it. But, what happens when the crisis is so detrimental to the organization’s reputation due solely to flagrant immoral or illegal conduct? Can a crisis communications plan be of any help?

On November 5, 2011, former Penn State assistant football coach Jerry Sandusky was arrested facing 40 counts of criminal activity, including a number of counts of sexual assault on a minor for incidents relating to Penn State’s association with The Second Mile charity, founded by Sandusky, over the course of 15 years (Garcia, 2011; “Sandusky,” 2011). Two days later, Penn State athletic director Tim Curley and senior vice president for finance and business Gary Schultz surrender to police to answer charges for failing to notify authorities for suspicions of sexual abuse of a minor (“Officials,” 2011; “Sandusky,” 2011). In two more days, football legend, Joe Paterno, head coach of the Penn State football program, resigns amidst the controversy surrounding the university and its football program (Garcia, 2011; “Sandusky,” 2011). Within days of the arrests (and, before all the facts are known), the university is being excoriated in the news (Zinser, 2011). This, I believe, constitutes a public relations nightmare.

Trivitt and Yann (2011), of the Public Relations Society of America, present the case of the Penn State crisis as a reminder that public relations and crisis managers cannot fix every problem: “we think it’s important that, as a profession, we don’t overreach and try to uphold our work as the savior for every societal tragedy and crisis. Doing so makes us look opportunistic and foolish considering the gravity of the situation” (para. 13). In the case of Penn State, there were a number of opportunities for the assaults to be reported to the authorities, yet Sandusky was allowed to remain in close unsupervised contact with young boys until, finally, one of the victims contacted the authorities in 2009 and an official investigation was initiated (“Sandusky,” 2011). The best thing that Penn State could have done was to report the accusations to the proper authorities as soon as they were made aware, saving the administration from allegations of a cover-up or their collective morals being called into question (Sudhaman & Holmes, 2012). The perception, now: cover-up and morally corrupt. There were a number of moral obligations that representatives of the university failed to abide over the preceding years, and the reputation of Penn State will suffer for it.

Immediately following the break of the scandal, the Penn State administration scrambled to make appropriate efforts towards repairing the poor reputation of the university, including donating $1.5-million of football profits to sex crimes advocacy programs, suspending the school newspaper’s sex column, and holding a town hall type meeting where students can pose questions and concerns directly to school administrators (Sauer, 2011). Though these steps are good, ultimately, the only means of recovering the reputation that Penn State once held is time and a changing of the guard; however, this does not mean that Penn State is suffering. According to Reuters (Shade, 2011), applications to attend Penn State are up from last year, and the current school administration, as well as alumni, are coming together to strengthen the trust between the school and students. Further, Singer (2011), a crisis communications and reputation management specialist, describes the steps the university can take in the coming years to truly restrengthen its brand. Singer emphasizes <em>cleaning the slate</em> by firing any other employees directly associated with the scandal, <em>creating a team-centric leadership culture</em> by limiting the political power of any one person within the university (especially the head coach), and <em>living the values</em> put forth by the university (e.g. “Success With Honor”). So long as the crisis is handled appropriately since the mass firing of school officials, the school’s reputation will be judged on the response to the crisis and not the crisis alone.

References

Garcia, T. (2011, November 9). Paterno announces retirement, says Penn State has bigger issues to address. PRNewser. Retrieved from http://www.mediabistro.com/prnewser/paterno-announces-retirement-says-penn-state-has-bigger-issues-to-address_b29902

Officials seeking alleged abuse victims. (2011, November 9). ESPN.com. Retrieved from http://espn.go.com/college-football/story/_/id/7203566/penn-state-nittany-lions-sex-abuse-case-officials-arraigned-police-seek-alleged-assault-victim

Sandusky, Penn State case timeline. (2011, November 9). ESPN.com. Retrieved from http://espn.go.com/college-football/story/_/id/7212054/key-dates-penn-state-sex-abuse-case

Sauer, A. (2011, December 1). Penn State bogs down in PR crisis, but a turnaround already showing. brandchannel. Retrieved from http://www.brandchannel.com/home/post/2011/12/01/Penn-State-Bogs-Down-In-PR-Crisis-120111.aspx

Shade, M. (2011, December 1). Penn State officials say applications up despite scandal. Reuters. Retrieved from http://www.reuters.com/article/2011/12/01/us-crime-coach-students-idUSTRE7B00GD20111201

Singer, J. (2011, December 7). The Penn State scandal: crisis as opportunity. The Business of College Sports. Retrieved from http://businessofcollegesports.com/2011/12/07/the-penn-state-scandal-crisis-as-opportunity/

Sudhaman, A. & Holmes, P. (2012, January 25). The top 10 crises Of 2011. The Holmes Report. Retrieved from http://www.holmesreport.com/featurestories-info/11377/The-Top-10-Crises-Of-2011.aspx

Trivitt, K. & Yann A. (2011, November 9). Public relations won’t fix Penn State’s crisis. PRSay. Retrieved from http://prsay.prsa.org/index.php/2011/11/09/public-relations-wont-fix-penn-states-crisis/

Zinser, L. (2011, November 9). Memo to Penn State: Ignoring a scandal doesn’t make it go away. The New York Times. Retrieved from http://www.nytimes.com/2011/11/10/sports/penn-state-fails-a-public-relations-test-leading-off.html?_r=1&ref=sports

Academia, Emergency Management, Society

Public Relations and the Media

Using a fictitious scenario about an international airline company addressing the media after one of its planes had crashed, I will examine the usefulness and limitations of a crisis communications plan. It is also worthwhile to note that although the messaging is important, the manner in which the message is delivered is also important. Battenberg (2002) lays out a compelling case of which tactics to use and which to abandon when dealing with a media frenzy.

Media Questions

As a member of the media, there are some very specific questions that need to be addressed. For instance, was the crash a result of weather, aircraft maintenance, or was this a terrorism event? In addition, recent layoffs of its mechanics coupled with its aging fleet of aircraft might have contributed to the crash and needs to be addressed. Other employees were laid off in addition to some mechanics. It would be important to know if more experienced members of the flight crew were among the lay offs, as this flight was trans-Atlantic and might require some specialized expertise.

Public Relations Response

According to Coombs (2012) and Fearns-Bank (2011), the response to the media needs to be truthful and humble. The cause of the crash will eventually be determined by the federal investigators, and any assumptions now would be premature. This should be clearly stated to the media along with a statement that every effort to assist in the investigation will be made. In regards to the lay offs, it should be made absolutely clear that, along with our dedication to safety, the lowest performing mechanics and pilots were the ones laid off, keeping the most experienced and skilled mechanics who would never sign off on any unworthy aircraft. An example statement might include: “In our corporate culture of safety, we allow any of our employees to trigger a grounding and complete safety check of any of our aircraft for any reason, even with our recent financial difficulties. If we do not fly safe, then we do not fly.” If the company would ground all similar aircraft for an immediate safety check, it would be helpful to reinforce the ideals of the corporate culture of safety.

Analysis

As the public relations officer addressing these media concerns, I would be sure to answer these questions as humbly and honestly as possible. I would try to rely on the messaging provided in the crisis communication plan. However, in light of recent financial difficulties and layoffs, the plan may prove partially inadequate, though it will provide, at least, a framework to ensure the messaging is consistent (Coombs, 2012; Fearns-Bank, 2011). Obviously, information will be limited as the crash just occurred; however, the concerns of the recent layoffs and service expansion still need to be addressed. Any assurance of safety that is less than matter-of-fact might not be convincing enough to the flying public (Stevens, Malone, & Bailey, 2005). Fortunately, I am able to cite the impeccable safety record and award-winning corporate excellence and customer service. Additionally, other sections of the communication plan, such as messaging involving lay offs and other financial issues, might prove useful to help the public and the media further understand the company’s dedication to safety, ensuring that any problems identified will be quickly rectified (Coombs, 2012; Stevens, Malone, & Bailey, 2005).

Though the position of defending the corporate image in light of tragedy is not an enviable one, a strong and ethical corporation deserves to enjoy business continuity even after such a tragedy (Stevens, Malone, & Bailey, 2005). Having an effective communication plan in place and utilizing the plan in an honest, humble, and transparent manner can promote the corporate image even while suffering crises (Coombs, 2012; Stevens, Malone, & Bailey, 2005).

References

Battenberg, E. (2002, December). Managing a media frenzy. Public Relations Tactics, 9(12), 1, 15. Retrieved from http://library.waldenu.edu/

Coombs, W. T. (2012). Ongoing crisis communication: Planning managing, and responding (3rd ed.). Thousand Oaks, CA: Sage.

Fearn-Banks, K. (2011). Crisis communications: a casebook approach (4th ed). New York, NY: Routledge.

Stephens, K. K., Malone, P. C., & Bailey, C. M. (2005). Communicating with stakeholders during a crisis: Evaluating message strategies. Journal of Business Communication, 42(4), 390-419. doi:10.1177/0021943605279057

Academia, Emergency Management, Society

Crisis Counseling: Senior Management

As a crisis management professional, it would be my job to assess the situation, define the crisis, and develop a plan that would address stakeholder concerns allowing the company to move forward with, hopefully, minimal negative and maximal positive impact to the organizational reputation (Coombs, 2012). The Intel Pentium flaw did not impact Intel’s reputation in 1994 as much as preceding inattention to quality that modeled consumers’ perceptions and production and marketing irregularities that computing insiders were quite aware (Mihaiu, 2001). Even as recently as last year, Intel has been plagued with poorly performing processors (Fontevecchia, 2011). I believe that many of the processor issues were merely a result of being cutting-edge in a fast-paced competitive environment, though Intel’s reputation need not suffer from inattention to that fact. The problem: convincing the CEO that a) there is a crisis, b) this crisis needs to be dealt with (costing money), and c) it needs to be dealt with openly and ethically in order to maximize the reputation of the company.

Previously, as a computer programmer and analyst, I was intimately familiar with Intel line of processors, and I can attest to the overall positive reputation Intel has enjoyed since moving into the consumer computing arena; however, as stated above, the company’s reputation was not always seen in a positive light. Using my familiarity with Intel, my primary suggestion to the CEO regarding the Pentium debacle would be to remain honest and open with external publics while making the situation right. The honesty of the situation should be accepted by many consumers so long as Intel garners a net positive reputation. This net positive should be reinforced with the professed willingness of correcting the situation. The message should be: “We are on the cutting-edge of computing and consistently push the envelop in leaps and bounds, and we cannot always get everything right, but we can make it right… and, we will!”

The CEO, however, may decide that the situation is minimal and not unlike others that the company has faced in the past. Dealing with these issues previously may have created an air of complacency that needs to be countered in order to prevent further cumulative effect on the reputation of Intel. Regardless, as Coombs (2012) points out, if implementing a crisis management plan “improve[s] the situation and benefit[s] the organization, its stakeholders, or both” (p. 125), the situation should be approached and handled as crisis. The ethical dictum of “do the right thing” should provide for, at least, the fundamental guiding principles in responding to any issue, which would help to ensure that negativity is deflected and minimized appropriately. A CEO who has no appreciation of the gravity of the circumstances may need to be reminded of this in order to prod him into action.

References

Coombs, W. T. (2012). Ongoing crisis communication: planning, managing, and responding. Thousand Oaks, CA: Sage.

Fontevecchia, A. (2011, January 31). Chip recall hurts Intel’s reputation, tablet fears a bigger problem. Forbes. Retrieved from http://www.forbes.com/sites/afontevecchia/2011/01/31/chip-recall-hurts-intels-reputation-tablet-fears-a-bigger-problem/

Mihaiu, R. (2001, July 3). Intel’s tricks! Retrieved from http://mihaiu.name/2001/intel_tricks/

Academia, Health Care, Politics, Public Health, Society

Paying for Health Care, Today and Tomorrow

Before delving into the substance of this discussion, I must say that my personal beliefs are contradictory to many globalized health care efforts. Penner (2005) discusses some benefits of discussing and comparing health care economics between various nations. However, as we combine efforts to target specific health concerns across the globe, we lose the ability to innovate, promote evidence-based discussion, and promote the sovereignty of each country involved in the global effort. This globalization of health care deteriorates the ability to compare and contrast best practices of various countries. Unfortunately, most of the published works promote an insidious form of social justice and do not address how globalization efforts reduce the sovereignty of nations and people. Huynen, Martens, and Hilderdink (2005) support this deterioration by promoting a foundation for a global governance structure that would lead to better dissemination and control of globalization efforts.

Campbell and Gupta (2009) directly compare some claims that the U.K. National Health System (NHS) has worse health outcomes than the traditional U.S. model. Though Campbell and Gupta provide evidence disparaging many of these claims, they also seem to provide some insight as to the woes the NHS has recently faced and are working to correct. Under a system promoted by Huynen, Martens, and Hilderdink (2005), we would ultimately lose the comparison between nations as to best practices. The U.S. is currently debating the value of nationalizing health care, and similar arguments are arising based on the inability for interstate comparisons of effective and efficient delivery of health care among the various states.

References

Campbell, D. & Gupta, G. (2009, August 11). Is public healthcare in the UK as sick as rightwing America claims? The Guardian. Retrieved from http://www.guardian.co.uk/society/2009/aug/11/nhs-sick-healthcare-reform

Huynen, M. M. T. E., Martens, P., & Hilderink, H. B. M. (2005). The health impacts of globalisation: a conceptual framework. Globalization and Health, 1, 1-14. doi:10.1186/1744-8603-1-14

Penner, S. J. (2004). Introduction to health care economics & financial management: fundamental concepts with practical applications. Philadelphia, PA: Lippincott Williams & Wilkins.