Positive Behavioral Supports

Introduction Education 50 years ago was not what it is like today. Schools today are confronted with a vast amount of issues. Within those issues are student achievement, school violence, lack of parental support, and behavioral concerns within the school community and in the classrooms.Advertising We will write a custom thesis sample on Positive Behavioral Supports specifically for you for only $16.05 $11/page Learn More Bowen (n.d.) found that various studies have shown that students who act up in school express a variety of reasons for doing so. Some think that teachers don’t care about them and others don’t want to be in school at all while many don’t consider goal setting and success in school important anymore. Despite these hurdles, students agree that discipline is needed in schools. One high school student stated: â€Å"If there were no discipline, the school would not be distinguished from the street.† Bennett (1999) states that most surveys show that Americans complain that too many schools are disorderly, undisciplined places. How much are students really learning when the main focus in our schools today is student behavior and discipline? Many different programs have been presented to schools in efforts to help alleviate some of the discipline problems found in schools and in the classrooms. PBIS (2009) states that â€Å"a major focus for current policy and systems change efforts in education is the extent to which states are investing in practices and procedures that are supported by rigorous research evidence.† Positive Behavior Support (PBS) is a research-based theory that supports the idea that a student’s behavior can be changed if a full understanding of the child is gained. Through positive interventions students are able to reduce the negative behavior and increase the more desirable one. This literature review will examine the literature related to Positive Behavior Su pport, its foundations and the advantages and disadvantages of implementing PBS.Advertising Looking for thesis on education? Let's see if we can help you! Get your first paper with 15% OFF Learn More Origins of Positive Behavior Support Positive Behavior Support is relatively new to the scene of school reform because it was mainly known as behavior modification for special education students who displayed difficult behaviors. The origins of PBS can be traced back to the theory of Applied Behavior Analysis, an expansion of the operant conditioning theory first developed by B.F. Skinner, the American psychologist. A survey performed by Frey (2006) of four hundred teachers revealed that teachers felt that operant conditioning was effective at managing behavior of both groups and individual students. Positive Behavior Support: A Three Tier Continuum It is important to express that like academic forms of instruction, students also require different levels of behavioral inte rventions and different types of support in order to do well in school. Positive Behavior Support focuses on three key levels within a continuum, according to Nelson, Hurley, Synhorst, Epstein, Stage Buckley (2009) the first tier entails â€Å"universal interventions that are expected to prevent the onset of problem behavior in a majority of children altogether and to sustain improvements in child outcomes by the selected and indicated interventions.† This level is known as universal because it delineates school-wide behavioral expectations for all students along with consistent consequences for unwanted behaviors. Level two also known as tier two is mainly for students who still continue to demonstrate problem behavior after tier one was implemented. Tier two on the continuum focuses more on small group interventions. A study done by McIntosh, Campbell, Carter, Dickey, (2009) examined the effectiveness and differential effects of a tier two daily behavior intervention. Thi s study was conducted over an eight week period and the samples were 36 students. The findings confirmed that the amount of office referrals lessened after small group and targeted interventions were established.Advertising We will write a custom thesis sample on Positive Behavioral Supports specifically for you for only $16.05 $11/page Learn More The final tier consists of a more personalized or individualized intervention. Lewis, Colvin, Sugai (2000) state that â€Å"approximately 5% to 7% of the students will require highly individualized behavior support.† Challenges Faced While Implementing Positive Behavior Supports Weinberger (2009) conducted a study using a mixed methodology that identified the strengths and limitations of the implementation of Positive Behavior Supports. Via surveys, case studies focus groups, and behavioral data of students. The study revealed that although student behavior did not improve, the implementation of PBS wa s successful because it was able to identify specific information needed to provide individual interventions to students. A study carried out by Guthals (2009) expressed that there is no evidence of direct correlation between student achievement and the implementation of PBS. Data pertaining to the study was collected through optional surveys completed by school principals concerned about the immense number of office referrals and discipline problems in the classrooms taking a toll on student learning. While direct correlation between what was intended to be tested, the relationship between student achievement and the implementation of PBS, the surveys conveyed that administrative stress level had decreased after the implementation of PBS. Today’s schools must address the behavioral needs of all students at a number of different levels (Mogan-D’Atrio, et al 1996). First, there must be schoolwide efforts that teach positive communication and social interaction skills, a nd develop positive school routines designed to prevent behavioral issues throughout the school day (Fishbaugh Furshong, 1998; Scott, 2001; Taylor-Greene et al., 1997). Second, in conjunction with schoolwide efforts, classroom norms and routines can be established by educators, in collaboration with their students, to create a sense of caring and community in the classroom.Advertising Looking for thesis on education? Let's see if we can help you! Get your first paper with 15% OFF Learn More Third, behavioral issues must be addressed at the individual student level for students who have more intense, ongoing behavioral challenges. Addressing issues of school safety at the individual student level takes place through the creation of positive behavior support plans (Sailor et al 2007). Advantages of Implementing Positive Behavior Supports In light of increasing frequency and intensity of disruptive behaviors in schools nationwide (Martin, Lloyd, Kauffman and Coyne, 1995), policymakers and school practitioners are increasingly considering the benefits of teaching and supporting pro-social behaviors to decrease disruptive behaviors and increase academic success. Urban schools, in particular, face challenges with limited resources and large numbers of students, many of who are living in poverty or violence-prone environments (Netzel and Eber, 2003). Traditional, and more reactionary, school discipline procedures (e.g., those that rely on punishment and exclusion) are general ly ineffective in either reducing challenging behaviors or increasing desired behavior (Mogan-D’Atrio, Northrup, LaFleur and Spera, 1996). One promising alternative, Positive Behavioral Interventions and Supports (PBIS), is a school-wide approach that promotes social competence through a system of behavioral support wherein expected behaviors are defined, taught, and rewarded. Schools implementing PBIS establish a continuum of proactive, positive discipline procedures for all students across all settings. Universal school-wide strategies are intended to facilitate success for 85-95 percent of the students (Mogan-D’Atrio, et al 1996). The National Conference of the Hamilton Fish Institute On School And Community Violence while targeted small group or individual interventions are designed for the types of students for whom universal strategies have not been successful (5-15 percent (Mogan-D’Atrio, et al 1996). Last, for the one to seven percent of students who hav e chronic and intensive needs across multiple settings, a wrap-around approach is implemented (Eber, Sugai, Smith, and Scott, 2002).Several studies have demonstrated positive effects of PBIS, with some recent research showing success in urban settings. For example, Netzel and Eber (2003) report a 22 percent reduction in suspensions after one year of universal level implementation (e.g., teaching school-wide rules and recognizing and acknowledging appropriate student behavior) in an urban elementary school. Further, Netzel and Eber report a number of encouraging outcomes during the 1st full year of school-wide PBS implementation, including a 20 percent decrease in office discipline referrals, 23 percent decrease in â€Å"time-outs,† and 57 percent decrease in short-term suspensions. Few studies, however, have demonstrated the impact of PBIS in urban settings across a number of different variables and over a number of years. Managing Disruptive Behaviors through Positive Behavi or Supports Misbehavior in K-12 schools hurts every participant. Te misbehaving student is often sequentially moved into more academically impoverished environments; other students are distracted, and teachers are forced to become disciplinarians (Sandomierski, et al 2007). Furthermore, a costly administrative infrastructure; including the very valuable and very limited time of the school principal; is monopolized to deal with discipline problems. A third grader acting up in class does not act up because s/he was born a â€Å"bad kid† (Sailor et al 2007). Most likely, s/he has not yet learned the social skills appropriate to that setting, or there is something in the classroom setting, or a learning disability, or a family issue that interferes with his or her ability to behave properly (Sandomierski, et al 2007). Unfortunately, school discipline systems focus more on punishing kids than on giving them the skills, training, and incentives to behave properly. Behavioral remedi ation, where it exists, typically takes the form of a fifteen-minute weekly visit to a school counselor. Just as if the student was trying to learn math by scheduling a fifteen-minute weekly chat with a math teacher, the system tends to fail the students (Sailor et al 2007). Research points to the benefits of systems that teach and support positive behavior, rather than simply punishing negative behavior. By adopting a positive behavior support (PBS) system, individual schools, districts, and states have dramatically reduced office referrals and suspensions, increased on-task academic time, and made students, teachers, and parents more satisfied with the school. Positive Behavior Support systems have been implemented by a large number of school districts and states, including North Carolina. Vermont is currently implementing PBS. Discipline referrals and suspensions often drop 40-60% over the first two years that the program is implemented (Sandomierski, et al 2007). Principals may save six full workdays worth often-minute visits over the course of a year. In schools with severe behavior problems, teacher satisfaction under PBS may increase by 60%, leading to a more experienced, stable staff. When a third grader misbehaves, it represents not a personal failure, but a failure of the systems around him to equip him for the setting he is in. We can stop this failure by shifting the focus to preventing misbehavior, rather than just punishing it. Providing serious behavioral support to students pays off by reducing distraction and improving academic outcomes, reducing costly referrals to special education, and letting teachers and principals do their job rather than spend all their time on discipline (Sailor et al 2007). Rather than being transferred into special education or punished to the point of dropping out, students with behavior problems are put on a path to social and academic success. Positive behavior support programs in a school may employ a three-tier model. The first tier is a low-intensity, school-wide misbehavior prevention program involving things like certificates of recognition for such pro-social behaviors as picking trash and putting it in the trash can. These programs are targeted to build the skills of the majority of students (80-85%) who have 0-1 office referrals. The second tier of students (10-15% with 2-5 office referrals) typically have significant behavior problems and require intervention, such as group sessions with school psychologists to learn appropriate behaviors, just as they would learn any other skill set in a classroom setting. Te goal of these sessions is to help them emulate their better-behaved classmates, rather than imitating those with more severe behavioral problems. Te third tier (typically 5% with 6+ office referrals) suffers from severe behavioral problems, requiring individualized interventions. Conclusion Results indicate that implementation of universal Positive Behavior Support (e.g., teac hing behavioral expectations, rewarding positive behaviors) in Year 1 and beginning targeted level intervention (targeting small groups of students with two to five behavior referrals for small group interventions) in Year 2 leads to positive changes in one of the two schools examined. Specifically, Addison School demonstrated overall decreases in ODRs, as well as decreases in the most frequent problem behavior and locations over the first 1.5 years of implementation (Sandomierski, et al 2007). These latter two are particularly noteworthy, as they exemplify the successful use of data to target problematic behaviors and contexts. Classroom referrals were specifically targeted in Year 2 through the addition of classroom management training for teachers. Problematic behaviors on the bus were specifically targeted that same year through the addition of bi-monthly bus driver training breakfasts. Teacher ratings on our surveys showed some positive changes across the two years as well, wit h teachers generally rating the existence of negative behaviors lower in Year 2, while pro-social behaviors were rated more highly, although it should be noted that only one of these differences reached statistical significance. Findings further suggest the need for full implementation of the PBS model. These schools are relatively strong in universal level implementation, but are still in the beginning stages of implementation of the targeted level, and have not yet begun intensive-level intervention. These latter two levels are important in decreasing referrals from the most chronic misbehavers, and intervention here would likely have a much greater impact on overall referrals as well as the schools’ â€Å"triangle† profiles and teacher perceptions of both student behavior and effectiveness of the intervention. This finding is consistent with teacher concerns as noted in focus groups and in survey results. Furthermore, given time needed for full implementation of the model, as well as systems-change research indicating that three to five years are necessary to implement full school change (Sandomierskiet al 2007), an evaluation of the effectiveness of such school-wide interventions should additionally allow for a minimum of three years of data. References Eber, L. Sugai, G. Smith, C. and Scott, T. M. (2002). Wraparound And Positive Behavioral Interventions And Supports In The Schools. Journal of Emotional and Behavioral Disorders, 10, 136-173. Frey, S. (2006). Teachers and Operant Conditioning. Retrieved from ERIC database. Guthals, J. The Relationship Between Positive Behavior Supports, Student Achievement, Severe Problem Behavior, And Administrative Stress. Ed.D. dissertation, University of Montana, United States — Montana. Lewis, T., Colvin, G., Sugai, G. (2000). The Effects of Pre-Correction and Active Supervision on the Recess Behavior of Elementary Students. Education Treatment of Children, 23(2), 109. Retrieved from Academic Sea rch Premier database. McIntosh, K., Campbell, A., Carter, D., Dickey, C. (2009). Differential Effects of a Tier Two Behavior Intervention Based on Function of Problem Behavior. Journal of Positive Behavior Interventions, 11(2), 82-93. OmniFile Full Text Mega database. Martin, K. F., Lloyd, J. W., Kauffman, J. M., and Coyne, M. (1995). Teachers’ Perceptions Of Educational Placement Decisions For Pupils With Emotional Or Behavioral Disorders. Behavioral Disorders, 20, 106-117. Mogan-D’Atrio, C., Northrup, J., LaFleur, L., and Spera, S. (1996). Toward Prescriptive Alternatives To Suspensions: A Preliminary Evaluation. Behavioral Disorders, 21, 190-200. Nelson, J., Hurley, K., Synhorst, L., Epstein, M., Stage, S., Buckley, J. (2009). The Child Outcomes of a Behavior Model. Exceptional Children, 76(1), 7-30. Retrieved from Academic Search Premier database. Netzel, D. M. and Eber, L. (2003). Shifting From Reactive To Proactive Discipline In An Urban School District: A Chan ge Of Focus Through PBIS Implementation. Journal of Positive Behavior Interventions, 5, 71-79. PBIS. March 2009. Is School-Wide Positive Behavior Support An Evidence-Based Practice? (2009). Web. Ps@?under, M. (2005). How Effective Is School Discipline in Preparing Students to Become Responsible Citizens? Slovenian Teachers’ and Students’ Views. Teaching and Teacher Education: An International Journal of Research and Studies, 21(3), 273-286. Retrieved from ERIC database. Sailor, W., Stowe, M. J., Turnbull, R., III, Kleinhammer-Tramill, P. J. (2007). A Case For Adding A Social-Behavioral Standard To Standards-Based Education With School-Wide Positive Behavior Support As Its Basis. Remedial and Special Education, 28, 366–376. Sandomierski, T., Kincaid, D., Algozzine, B. (2007). Response To Intervention And Positive Behavior Support: Brothers From Different Mothers Or Sisters With Different Misters? PBIS Newsletter 4(2). This thesis on Positive Behavioral Supports was written and submitted by user Tinley Forbes to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

Shouldice Hospital Case Report Essays

Shouldice Hospital Case Report Essays Shouldice Hospital Case Report Essay Shouldice Hospital Case Report Essay Subject: Problems and Plans Operational Assessment of the Shouldice Hospital Thank you for the opportunity to consult on your Shouldice Hospital operational assessment. I understand that you have implemented a well developed focus strategy (market focus and internal focus) successfully and Shouldice achieves outstanding results by maximizing the difference between perceived quality and value to the patient on one hand and the cost of supplying services on the other. The nurses and doctors treat their patients with care and understanding and treat them more like family members. This has led to the high level of praise for this hospital and its treatment. The rising number of satisfied patients and word of mouth referral has led to demand for the facilities services which outstrip the facility’s current capacity. I understand that you are looking for guidance on specific actions in order to increase the hospital’s capacity while at the same time maintaining control over the quality of the service delivered, and the hospital management. I have identified the problems and offered a list of alternate courses of action. Problem Definition: The problem is that Shouldice is facing a paradox of change. Shouldice is operating at its â€Å"best operating level† for a service company with limited flexibility in its facility, a specialized work force but are failing to meet all the demand for its chosen market niche. Adding additional capacity to meet the unmet market need may upset the existing work force and lower service quality. Failing to meet the market demand may invite competition that could eventually cause Shouldice to lose market share and end up with excess capacity. Problem Justification: It is assumed that they are operating at the â€Å"best operating level† because the way the case describes how efficiently the hospital is ran and how the patients appear to be pleased with their treatment. Capacity is nearly 100% full if they do 30 operations a day and the patients stay 3-4 days. This would fill up 89 beds for a 5 day work week. They also have 15% (14 hostel rooms) additional capacity for peak times. This also works out to be about 70% capacity of their full time potential of 7 days. 70% of maximum capacity is the best operating point. To increase it rate of service utilization will decrease the service quality. For capacity analysis, refer to Appendix-B. To increase their output and maintain their quality they would need to increase the size of the hospital. This involves large capital investments and considerable time. Construction would also cause a disruption to the quality and country club atmosphere of the hospital. Due to shift restrictions the current operating rooms are completely un-utilized for 2 days of the week as well as 15. 5 hours of each weekday. Kitchen and common area are designed to accommodate one hundred patients and it is important that these facilities be kept up to ensure patients still receive the high level of satisfaction with the experience at Shouldice. The staff also has limited flexibility. Surgeons and surgeons’ assistants are specialized fields that have limited desire to be cross trained. It is assumed that the staff is happy with the existing work schedule and do not want a change. Increasing the days worked would cause more aggressive scheduling of the operating rooms and may make it hard to maintain the same kind of working relationships and attitudes. Alternative Courses of Action: Alternative courses of action are based on the assumption that the reason for their desired expansion is to meet an unmet market demand. i) They could add an additional day by operating on Saturday. ii) They could do nothing different and continue to do as they are currently doing. iii) They can add a new floor (i. e. 45 i. e. 50% more hospital beds). iv) They can meet the unmet market demand with external capacity (establish a new facility). v) They can utilize the current facilities during some of its present idle time. Evaluate alternatives and make decisions: i) Adding an additional operating day on Saturday is a valid consideration. It would utilize ideal hospital capacity. It could increase the number of patients served by 9% or 800 patient a year. Would this be a sufficient number of patients served to keep competition from entering the same market is unknown. Adding a Saturday is also assumed to have a negative impact on the work force that drive down the quality that gives Shouldice a competitive advantage. It would increase rate of service utilization beyond 70%. This could be offset by hiring addition staff. But one should consider the time it takes the new staff to come up the efficiency curve. For capacity analysis and financial details refer to Appendix-C. ii) Doing nothing is a valid consideration. Their existing system and reputation sets them apart as a market leader and it is assumed to be a profitable setup. If it is working do not try to fix it. We assume that the existing set up is acceptable to management as far as profit and other operating measures. The assumed risk is if they do not do anything then competition will enter the market place and could eventually take patients away from Shouldice. There is insufficient data presented to truly analyze this risk. iii) Increasing the number of bed by 50% would not be advisable unless they added more doctors and surgery rooms because the existing plant capacity and number of doctors could not fill an addition 45 beds. They would be operating the surgery rooms at over capacity. The construction requires large capital investment, time, and would disrupt the country club atmosphere. For capacity analysis and financial details refer to Appendix-D. iv) Meeting the unmet market demand with external demand is a valid consideration. It could be done in several different ways. They could look to other facilities that are similar and team with their doctors to train them in the Shouldice processes and share in the profits. This would help keep the competition out of the market and could be done as a silent partner until the service quality reaches a level that Shouldice would want to associate their name with the other facility. Another option would be to establish a new facility for Hernia. Another option would be to subcontract or franchise the operation. For merits and demerits refer to Appendix-E. v) Relieve the operating room bottleneck by utilizing the current facilities during some of its present idle time. Addition of weekend or evening surgeries will increase throughput without any capital investment. Expand the facility’s kitchen and social area’s to accommodate the increased patient throughput and continue to provide a high quality patient experience for its customers. Recommendations: I would recommend a combination of doing nothing with the existing staff and plant as to maintain the country club atmosphere and gregarious nursing staff that gives it its competitive advantage and meet the unmet market demand with external sources of capacity to keep the competition from entering the market. I would be happy to elaborate on my recommendations in future correspondence. Sincerely, An MBA Student Appendix-A Cost comparison – Shouldice vs. Other Hospitals: Cost Items| Shouldice| Other Hospitals| Remarks| Costs of typical operations| $954*| $2000-4000| * Without general anaesthetic| Transportation(round-trip fares for travel to/from Toronto)| $200-600| $200-600 **| **No data available. Considered the same as Shouldice. | Time Lost from work in Hospital| 04 days| 05 days| | Time lost from work while recovering| 05 days| 10 days| | Value of time lost (ranging from $50 to 500 per day)| $450-4500| $750-7500| | Total before Allowancefor recurrence| $1604-6054| $2950-12100| | Probability of Recurrence| 0. 80%| 10. 00%| | Expected Cost of Recurrence| $13-48| $295-1210| | Total cost to patient, employee and insurer| $1,617-6,102| $3,245-13,310| | Profitability of Shouldice Hospital Clinic: Hospital: Items| Shouldice Hospital| Remarks| Revenues per year(4 days X $111/day x 6,850 patients/year)| $3,041,400| Charges for hospital stay = $111/day. Operations per year = 6,850 (in 1982)| Cost per year| $2,800,000| | | | | Profit per year (A)| $241,400| | Clinic: Items| Shouldice Clinic| Remarks| Revenues per year(($450 + 60 + 75 X 0. 20) X6,850)| $3,596,250| Surgical fee=$450/operation. Fee for the assistant surgeon=$60. Fee for a general anaesthetic =$75. Operations per year=6,850 (in 1982)| Cost per year| $2,000,000| | | | | Profit per year (B)| $1,596,250| | Total (Hospital + Clinic) Profit per year (A+B)| $1,837,650| | Total Depreciated Assets = $5 million Return on Asset = $1,837,650/$5 million = 0. 36753 i. e. 37% Appendix-B Current Capacity Analysis Current Throughput: * 6,850 Operations/50 weeks = average 137 operations/week with a peak of 165/week in September. Capacity Analysis: * Examination Rooms: (6 rooms x 3 hrs (1-4 PM) x 5 days x 60 min/hr) / (20 min / exam) = 270 patients /week = 54 patients/day. * Admitting Procedure: (2 people x 4 hrs (1-5 PM) x 5 days/week x 60 min/hr) / (10min/patient) = 240 patients/week = 48 patients/day. * Nursing Station: (2 stations x 4 hrs (1-5 PM) x 5 days/week x 60min/hr)/ (10 min/patient) =240 patients /week = = 48 patients/day. * Operating Rooms: (5 rooms x 8. 5 hrs/room/day x 5 days/week)/ (1. 1 hrs/patient) = 187 patients /week = 37 patients/day. Average operation time = (82% x 45 min + 18% x 90 min) + 15 min file time = 68. 1 min/operation. * Surgeons: 12 surgeons x 3. 5 operations/day x 5 days = 210 patients/week = 42 patients/day. * Hospital rooms: 89 rooms = 147 patients per week (assuming 3. 5 days average stay, 3 days recovery and Monday – Wednesday admittance, No procedures on Saturday or Sunday only recovery and admittance) – 29 patients/day. 103 rooms (incld. 14 hostel rooms) = 161 patients (assuming 3. 5 days average stay, 3 days recovery and Monday – Wednesday admittance, No procedures on Saturday or Sunday only recovery and admittance and use of 14 â€Å"hostel† rooms for two nights each week) – 32 patients/day. Current: Check-in day| Beds Required| | Monday| Tuesday| Wednesday| Thursday| Friday| Saturday| Sunday| Monday| 30| 30| 30| 0| 0| 0| 0|. Tuesday| 0| 29| 29| 29| 0| 0| 0| Wednesday| 0| 0| 29| 29| 29| 0| 0| Thursday| 0| 0| 0| 29| 29| 29| 0| Friday| 0| 0| 0| 0| 0| 0| 0| Saturday| 0| 0| 0| 0| 0| 0| 0| Sunday| 30| 30| 0| 0| 0| 0| 30| | | | | | | | | Total Number in Hospital| 60| 89| 88| 87| 58| 29| 30| Total number of patients per week| 147| Appendix-C Adding an additional operating day on Saturday Use current 89 beds + 14 hostel rooms. Consider 3. 5 days average stay. Total number of patients per week = 180. Current throughput = 137 operations/week (refer to Appendix-B). Theoretical throughput = 161 patients/week (refer to Appendix-B). So, new throughput = (137/161)*180 = 153 patients/week. Therefore, additional patients per week = 153 – 137 = 16 Additional patients per year = 16*50 = 800 Additional revenue = 800*(450+75*0. 20) = $372,000 Total cost = $124,250 Therefore, Net increase in profit = $372,000 $124,250 = $247,750 for no additional investment. Demerits of this alternate action: * Require to schedule 23-25 operations on Saturday. * Six surgeons and a supervising surgeon have to work on Saturdays. * Additional other personnel (an anesthetic, nurses). * Violates the implied contract that Shouldice has with its surgeons, strong opposition by the senior doctors. * Operating close to the theoretical capacity of the facility. Merits of this alternate action: * No investment is needed. * Can still maintain quality service. Appendix-D Increasing the number of bed by 50% Current number of beds: 89 Add in a new floor (expand the capacity by 50%) at the cost of $2 million: 45 beds Total beds = 89+45 = 134 Total number of patents per week = 210 Current throughput = 137 operations/week (refer to Appendix-B). Theoretical throughput = 161 patients/week (refer to Appendix-B). So, new throughput = (137/161)*210 = 179 patients/week. Therefore, additional patients per week = 179 – 137 = 42 Additional patients per year = 42*50 = 2100 Additional revenue = 2100*(450+75*0. 20) = $ 976,500 Total cost = $176,500 Profit = $ 976,500 $176,500 = $ 800,000 Therefore, Return on investment (ROI) = $800,000/$2,000,000 = 40% Demerits of this alternate action: * Require to schedule doctors to the full capacity of five days per week * Increase work load on admissions, kitchen, laundry, housekeeping and accounting * Further staggering of meal hours for patients (100 seat dining room) * Disruption during construction. * Expensive Merits of this alternate action: * Easy to control and maintain quality * Retain the culture and environment Addition of 45 beds: Check-in day| Bed Required| | Monday| Tuesday| Wednesday| Thursday| Friday| Saturday| Sunday| Monday| 42| 42| 42| 0| 0| 0| 0| Tuesday| 0| 42| 42| 42| 0| 0| 0| Wednesday| 0| 0| 42| 42| 42| 0| 0| Thursday| 0| 0| 0| 42| 42| 42| 0| Friday| 0| 0| 0| 0| 0| 0| 0| Saturday| 0| 0| 0| 0| 0| 0| 0| Sunday| 42| 42| 0| 0| 0| 0| 42| | | | | | | | | Total Number in Hospital| 84| 126| 126| 126| 84| 42| 42| Total number of patients per week| 210| Appendix-E. Meeting the unmet market demand with external demand – Establish a new facility Merits of establishing a new facility: * New location close to current setup, say a major city (New York) in USA * Improve its competitive position and increase its profits * Operate in a less restrictive environment * New Opportunities for existing personnel * Transfer of knowledge and expertise to the new facility. Demerits of establishing a new facility: * Requires a significant investment and time * Difficult to maintain Quality control * Difficult to create the same culture and atmosphere * Potential competition with the existing facility.