Nanobots Research Paper Example | Topics and Well Written Essays - 1250 words

Nanobots - Research Paper Example This essay examines the nanobot in terms of its purpose, function, development, as well as the moral and ethical concerns related to its implementation in the contemporary and future world environments. Analysis What is this technology? Nanobots are the product of nanotechnology. This is technology that functions within exceptionally small confines – namely within a nanometer (10?9 meters). The field of nanorobotics implements nanotechnology in the creation and engineering of robotic devices ranging in size from 0.1-10 micrometers. These robots are recognized to also be composed of micro or nano processors or components. When one considers that in the mid-20th century the only computers that existed filled a room, the emergence of such nanotechnology measures only a half-century later is a tremendous technological advance. Nanotechnology is created from a bottom up process where the technology is created one atom at a time, allowing developers to achieve the astoundingly small size requirements. Currently nanorobotic technology is in a proto-stage, as primitive molecular machines have been developed. There are also sensors that measure only 1.5 nanometers that are able to identify specific molecules in a chemical conglomerate. Even while nanobots remain largely in the formative development stages, it’s recognized that in the upcoming decade they will increasingly become a part of our daily lives. Purpose of this technology and its effect on people’s lives There are a great variety of potential implementations for nanorobotic technology. Perhaps the most prominent use of this technology has been potential implications of it in combating cancer cells. Indeed, recent trial procedures have been conducted wherein nanobots were able to enter a human and eliminate cancer cells. Describing the function of these nanobots in combating cancer, researcher Mark Davis notes, â€Å"It sneaks in, evades the immune system, delivers the siRNA, and the disas sembled components exit out† (Gizmodo). Essentially, these nanobots are able to enter the human body and deliver RNAi sequences to cancerous cells; these are ribonucleic acid interferences that attack malignant cancer cells. Professor Sylvain Martel, Director of the Nanorobotics Laboratory at Polytechnique Montreal has also foregrounded significant developments of nanobots for the treatment of cancer. While Professor Martel’s treatment of cancer is much in like with researcher Mark Davis’ there are a number of notable innovative differences. It’s noted that, â€Å"Using a magnetic resonance imaging (MRI) system, his team successfully guided microcarriers loaded with a dose of anti-cancer drug through the bloodstream†¦right up to a targeted area in the liver, where the drug was successfully administered† (‘Science Daily’). In these regards, the notable understanding is that this technology is able to improve chemoembolization by tre ating cancerous cells without exposing the unaffected adjacent tissue to the medication’s toxic effects. In addition to specific implications on cancer treatment, nanobots are also believed to have the potential of aiding humans avoid invasive surgery through entering the body and conducting such amendments. Furthermore, the emergent study of nanomedibots is believed to have the potential of developing nanobots that reside in humans to, â€Å"monitor body function; repair damaged tissue at the molecular level; deconstruct pathologic or abnormal material or cells such as cancer or

The Early Years Foundation Stage Children And Young People Essay

The Early Years Foundation Stage Children And Young People Essay Introduction The portfolio is a planning file which contains three detailed assessments of childrens learning. The assessments will be conducted on three different children; each assessment will cover all seven areas of learning. Firstly, the writer will describe the setting, and then the Early Years Foundation Stage (EYFS) 2012, that requires schools to work in partnership with parents. This will be a part of the on-going observation and assessment process. By observation, assessment and planning the system will be effective particularly when these elements come together as a cycle. According to Macleod and Kay (2008) all planning starts with observing children in order to understand and consider their current interests, development and learning. By observing children, teachers understand their needs, what they are interested in and what they can do. Secondly, there will be an analysis of the role of observation and assessment in planning that will highlight the three childrens achievements or their need for further support. This will start with Child A, followed by Child B and lastly Child C who are aged 4-5 years. Observation, assessment and planning will flow into one another. Finally, the writer of this profile will discuss developmental assessment, what it is and how it is used in the setting for each of the children. This all will result in summarising how the planning/observation cycle has enabled progress in the learning of Children A, B and C. The Setting The primary school itself is a four storey Victorian building. The rooms are spacious and very well resourced. They have a dedicated early years centre, music and performing arts suite and a computer suite as well as computers in every classroom. There are three outdoor play areas for the children including a wildlife garden, two quiet gardens and games areas. The school is in Central London, surrounded by world class learning institutions and opportunities, which act daily as extended classrooms. It works in close partnership with parents and carers to encourage them to be involved in their childrens education. As well as valuing their parents and carers, they are always welcome in school. The primary school is a multi-cultural environment but the majority of children are Bengali. The school runs from Nursery to Year Six with the capacity for over 400 children aged between three to twelve years. There are 39 children in reception aged between 4-5 years and this is where the three children are observed. It is formed by having two groups: one called Lady Birds and the other Grasshoppers, the teachers both work in tandem with one another to plan the childrens curriculum. Both of the groups have one main teacher with a teaching assistant. The Lady Birds has 19 children, 10 boys and 9 girls. The Grasshoppers has 11 girls and 9 boys. As this is a primary school all children are expected to attend as childrens attainment and achievement is directly linked to high school attendance (Ref?).   School starts at 9 oclock. Children are expected to attain a minimum of 95% attendance. All classes compete for an attendance award each week and a cup each term. The Equality Act 2010 was introduced to ensure protection from discrimination, harassment and victimisation on the grounds of specific characteristics (referred to as protected characteristics). This means that the setting cannot discriminate against pupils or treat them less favourably because of their gender, race, disability, religion or belief. (The Act also covers discrimination relating to gender reassignment, sexual orientation or pregnancy or maternity which perhaps has less relevance for young children). Early Years Foundation Stage EYFS 2012 is a legal framework that sets the standards for all the providers for early years to certify that children learn and develop as well as maintained in a healthy and secure manor. It encourages teaching and learning and ensures that they are well equipped with a range of knowledge and skills. In addition this will help them build the basis of their learning and aid them to progress through education and life. The school wants the children to develop independence and to co-operate with others and to talk and communicate in a range of situations. The opportunities for learning are provided through a planned and balanced adult-led and child-initiated curriculum. To enable children to develop positive self-esteem and attitude, learning takes place both indoors and outdoors. It is expected that suitable clothing and footwear are worn to school so that children can benefit from the experiences provided in all weathers. All early years providers follow the EYFS (2012) ensuring that every child is encouraged to learn through play. History In September 2008 the EYFS framework becomes statutory for all early years care and education providers in Ofsted registered settings attended by children from birth to five years of age. It created a framework that replaces the three previous early years documents Curriculum Guidance for the Foundation Stage, Birth to Three Matters and National Standards for Under 8s Day-care and Child-minding. However On the 27th March 2012 a revised version of the EYFS framework was established which then followed the execution from the 1 September 2012. This covers a vital part of the Governments wider vision for families in the foundation years. It shows the emphasis of supporting children by removing professionals from bureaucracy. Together with a more flexible, free early education entitlement and new streamlined inspection arrangements, this was the birth of EYFS 2012. In addition the Early Education (2012) is also pleased to launch Development Matters in the Early Years Foundation Stage, new non-statutory guidance produced by Early Education with support from the Department for Education that supports all those working in early childhood education.    The role of observation and assessment in planning for childrens learning Children are observed to assess developmental progress. Observation takes place primarily through childrens normal daily activities, their use of language, social interactions with others and work samples that demonstrate learning. In a sense, observation can have different meanings and imply different degrees of involvement to many practitioners. But in this case, the term observation according to Wadsworth, (1983) is the act of looking at something, without influencing it and recording the scene or action for later analysis (Also see Appendix 3A). The four key ideas of observation involve regular intentional watching of children in a wide variety of circumstances that are representative of their behaviours and skills demonstrated over time. Secondly, a daily observation would be an on-going one involving classroom/home performances and typical activities of the child leading to the collection of a wealth of reliable information. The third key idea of observation relates to demonstrated performance during real activities, not actions that are contrived or unnatural. Finally, as a practitioner the writer would need a solid understating of the meaning and purpose of observation and should have practice recording childrens behaviours and skills every day. According to Bruce (2006), we observe in order to improve our teaching, construct theory, help parents, use an assessment tool, wonder why and solve a problem and communicate with children. The different types of observation include narrative where the observer makes records that keep track of everything that happens in a specified time period. The writer finds this most valuable, but also the most difficult because à ¢Ã¢â€š ¬Ã‚ ¦. Secondly, the observer can use time samples where the method used is to count the number of behaviours occurring at uniform timed intervals. There are also event samples where the observer records a specific behaviour only when it occurs. Finally, there are teacher-designed instruments, like checklists, rating scales and shadow studies. When assessing a plan, evaluation would be key, according to ________ (year), who goes on to say that in education practitioners evaluate for curriculum, materials and equipment, the environment, childrens behaviour and teachers effectiveness. As the writer is a practitioner he can reflect that when he evaluates, it provides information by which to rate performance, define areas of difficulty, and look for possible solutions, as well as goal setting, monitoring growth and progress, and planning. ___________ (year) suggests good evaluations include selecting what will be evaluated, having a clear purpose and stating goals clearly, and so forth. But ___________(year) expresses concern about evaluations making unfair comparison, placing overemphasis on norms and interpretations, and so forth. However, although both theorists might make a justified point, the current writer agrees that evaluation is a broad concept which can be an informal process but is often times confused with more formal testing and measurements. Through evaluation, teachers link specific goals to larger, more encompassing objectives that focus on the relationship between teaching in the classroom and the overriding educational objectives. The writer also understands that observation is a natural process in which all practitioners participate all the time. They look at and listen to children. However the disadvantage and a major problem with observation, according to Wadsworth, (1983) is the fact that an observer is also a learner. Observers, like their subjects, have feelings, aspirations, fears, biases, and prejudices. Any one of these can influence and distort that which is being observed. He goes on to say that, an observer watches a group of children at play. One child turns to another and strikes him on the arm. The observer jots down hostility. The event was one child strikes another. The observer interpreted the act to be one of hostility. Wadsworth (1983) explains that when an observer thus infers motive to observed action, he/she adds something of him/herself to the data. Such data may be distorted and therefore invalid and unreliable. In the early years setting there are seven areas of learning and development which are labelled into two. The first is the three prime areas which are Communication and Language (CL); Physical Development (PD); and Personal, Social and Emotional Development (PSED) Secondly, the four Specific Areas, through which the three Prime Areas are strengthened and applied, are Literacy (L); Mathematics (M); Understanding the World (UW); and Expressive Arts and Design (EAD). Macleod and Kay (2008), mention that all areas of learning and development are important and inter-connected. The Three Prime Areas are particularly crucial for igniting childrens curiosity and enthusiasm for learning, and for building their capacity to learn, form relationships and thrive. The writers school Developmental Assessment follows the EYFS (2012) review. They consider the assessment pyramid. The pyramid demonstrates that there is a large amount of information collected about each child and attempts to define some of these data sets. This pyramid also attempts to demonstrate that there is a link between formative assessment and planning. The pyramid shows that the end result of summative assessment of the data collected is the end product and that the progress of the child remains as the main focus of the process (EYFS 2012). The Statutory framework for the EYFS mentions the responsibility for assessment and day to day practice like the planning cycle. This lies with teachers who observe, assess, plan and do these again and again. Development Matters (2012) is also used as part of observation, assessment and planning. It is used at points during the EYFS (2012) as a guide to making best-fit summative judgements, with parents and colleagues across agencies, about whether a child is showing typical development, may be at risk of delay or is ahead for their age. Appendix 1A shows the Plan in the settings of EYFS Medium Term Planning for Children A, B and C; it displays the seven stages as mentioned before. The main focus and theme is traditional tales. (See Appendix 1A underlined in pink) It also gives objectivess and early learning goals; these are under the seven areas of development and the ones that are highlighted in yellow are the ones Child A, B and C had completed; at the bottom are the Characteristics of Effective Learning like assessment, environment/resources and stories. (See Appendix 1A) Appendix 2A shows the Assessment and Evaluation of the weekly planning for Child A, B and C. and gives the childrens interest, needs and schemas. It also gives the children seven areas as well as the next steps to be taken for Child A, B and C; finally it gives the childrens experiences. (See Appendix 2A) Appendix 3A shows the weekly Environment Plan for Reception giving time to include the activities with the theme set. (See Appendix 3A) Appendix 4A is the characteristics of effective learning process over outcome. This is to give practitioners and teachers ideas and encourage the keeping in mind of these thoughts when interacting with children. (See Appendix 4A) Observation of children A, B, and C Based on the three assessments above the writer observed each child engaged in activity/exp. The framework which the school uses is the Early Years Foundation Stage curriculum (2012). The activities they provide cover the seven areas of learning for Child A, B and C. It will help them to plan how best to support young childrens learning and development and share information and ideas with parents and carers. Assessment and Evaluation Observationsà ¢Ã¢â€š ¬Ã‚ ¦Aresa Prim and Specify à ¢Ã¢â€š ¬Ã‚ ¦Ãƒ ¢Ã¢â€š ¬Ã‚ ¦ Weekly Environment Plan for Reception Observationssà ¢Ã¢â€š ¬Ã‚ ¦ Areas working together Good assessment and planning show that all staff participate together as a team for the good of the children giving the children the best start in life with the parents at the heart of their childs planning and learning. In order to provide an appropriate curriculum, it is required that individuals working with young children learn about the individual childs needs, as well as the needs of the group (Peck et al, 1993). Assessment should be an on-going process, be made both formally and informally, and incorporate a variety of methods. Assessment should include the use of input (Peck et al, 1999) As a practitioner working with young children the writer should acknowledge the importance of consistently updating assessment information and using that information in planning and developing programmes and intervention strategies. The children who were observed are constantly growing, developing new skills, and sometimes developing new concerns and difficulties; it is recognised by the setting that the importance of collecting data on a childs progress is less important than determining how to address their needs. Conclusionà ¢Ã¢â€š ¬Ã‚ ¦ In conclusion, at the school attendee by Child A, B and C curriculum goals would seem to be realistic and attainable for most children and assessing of individual childrens development is appropriate for the curriculum. The literature relating to early learning suggests that assessment and curriculum should be integrated, with teachers continually engaging in observation for the purpose of improving teaching and learning. This seems to be the case at the school in question and the planning/observation cycle has enabled progress in Child A, B and Cs learning. Appendix One Permission slip The father to Child A gives permission concerning Abdul to take pictures, drawing and any other effects to help him to complete his task. I also give him permission to look at my childs profile or anything related that he might need to use. Parent ______________ Abdul Ali The mother to Child B gives permission concerning Abdul to take pictures, drawing and any other effects to help her to complete his task. I also give him permission to look at my childs profile or anything related that he might need to use. Parent ______________ Abdul Ali The father to Child C gives permission concerning Abdul to take pictures, drawing and any other effects to help him to complete his task. I also give him permission to look at my childs profile or anything related that he might need to use. Parent ______________ Abdul Ali - I __________ Mentor for Abdul at the school, give him the permission to take a serious of observation on Child A, B and C to complete his task. Teacher ____________ Abdul Ali Appendix 1A Early Years Foundation Stage Medium Term Planning for Reception Appendix 2A Assessment and Evaluation Appendix 3A Weekly Environment Plan for Reception

Computer Science as a Career :: Computer Programming, Coding

  Ã‚  Ã‚  Ã‚  Ã‚  The field of Computer Science is based primarily on computer programing. Programming is the writing of computer programs using letters and numbers to make "code". The average computer programer will write at least a million lines of code in his or her lifetime. But even more important than writting code, a good programer must be able to solve problems and think logicaly.   Ã‚  Ã‚  Ã‚  Ã‚  The working conditions for a programer very greatly. Most banks require their programers to wear a suit and attend an office during normal work hours. On the other side of the buisness, many game company's and Dot-Com-start-up's allow and incurage a fun work environment. Often including toys, cubicle sleep-in's and cold pizza haphazardly laying accross many a desk. Yet nomatter what the company they all involve the employe to stare at a monitor for endless hours and write the applications of tomorrow on a standard keyboard.   Ã‚  Ã‚  Ã‚  Ã‚  Many programers devote themselves to their craft and thus are compeled to sleep little and acomplish the work in front of them. After leaving the office, (if at all) it is not unusual to spend 8 more hours on the same project at home.   Ã‚  Ã‚  Ã‚  Ã‚  The starting salary for a collage grad or someone of equal ability is about 50-60 a year. High positions requiring people with rare intelect and skill pay up to $300,000.00 per year plus benefits. A rare few achiev millions of dollars on independant/self-employed ventures.   Ã‚  Ã‚  Ã‚  Ã‚  Some things can not be taught and must be present in the prospective programer. For example: the ability to aproach problems methodicaly and solve them with logic. However, Other skills can be tought. Comp. Sci. is becoming widely available in collages and even Highschools. Some technical schools now claim to teach an entire programing language in months.   Ã‚  Ã‚  Ã‚  Ã‚  Opportunities in the field are extremely available to qualified personel. I have heard first-hand accounts of people being yanked out of collage for a programming position at $80,000 a year. With the expanding of the market for technology, comes the need for programers of all backgrounds. Job-security is pretty good as long as you dont kill somebody(wich recently happened at a dot-com-start-up). And the outlook for promotions is good considering the shortage of programers.   Ã‚  Ã‚  Ã‚  Ã‚  There are disadvanges to being a programer. One being that you must risk eye damage with a computer screen every day.

Personal leadership development plan Essay

Introduction This paper defines the leadership and discusses necessary steps to make to achieve a well-developed strategy plan. There are many definitions of leadership and even leadership professionals have diverse views about it. Leadership is not about your position, power or rank, for me, leadership involves the self-awareness, identifying your weakness and strengths. Leadership involves taking opportunity the ï ¬ rst and applying personal self-control methods to win the second, surrounding yourself with the right group to overcome some of your faults; where the ultimate goal is to win the trust of your followers to move them toward a mutual goal. From another standpoint, the spearhead should be able to recognize his team needs, inspire them and add toward the improvement to make many other leaders. Being a leader in a governmental ministry, where the number of permanently employed staff is nine hundred, appropriate leadership strategy and skills is needed; to cover up the daily challenges in the ministry. Therefore, it is very necessary to develop a good and realistic development plan in leadership to handle these challenges. Mission, vision and core values The vision of this development plan of a project is to be the leading leader in developing and creating new leadership and leaders in the team of the ministry. The mission of my development plan is to develop a performance management system to make certain of executing the strategy and clear accountability. The core values of this new leadership strategy or plan is pledging to high moral standards, frankness, and uprightness, and embracing excellence, eminence service and incessant improvement from my followers. Body When developing the development need plan, it very necessary to understand diverse leadership styles and an emotional acumen, strengths and weakness  related to it. Effective leadership eludes many people and organizations (Goleman, 2000). The most successful leaders have stronghold and weakness in the following emotional acumen know-hows; motivation, social skills, self-awareness, understanding, and self-regulation. They are six method of leadership; each one of them applies the key component of the emotional intelligence in not the same combinations. The six basic leadership styles include; coercive, pacesetting, authoritative, coaching, affiliative and democratic. The coercive style is very appropriate in a setback situation, after handling workforces difficulties; it involves do as the boss says, however, it limits organizational flexibility and weaken motivation. In the pacesetting leadership, a leader set high standards of performance which the followers use as impact on positive motivation, but it overwhelm some of the followers. Coaching style focuses on personal development. An authoritative method is the one that uses a â€Å"accompany me† tactic. It organizes well in the industry that is in an implication; however, it is not effective when dealing with more experienced professional than you. A democratic method gives my followers a voice in the decision-making, but it gives birth to endless meeting. The last in the leadership styles is an affiliative method, it valid in coming up with the team accord or growing morale. But the style focus on praise can permit a poor act to go uncorrected. To come out as the top spearhead, I should know more than one method of management. Being this kind of a leader, it is flexible in changing from one style to the other as per dictation of the circumstances. The more method I understood, the better. In particular, being able to switch from one form of style to the other, as the situation dictate, make the best organizational environment in the ministry. Incorporating aspects of each of the three elemental charm proportions, a character-based trailblazer is best seen as an agent of moral change (Wright& Lauer, 2013). Another development need plan is my character, strengths and weakness. Character is defined as the intellectual and ethical attitudes that leave one sensation most intensely and deeply energetic and active. The real me stress the importance of being as exact as possible in outlining the character idea. In that  regard, a character-based leader is someone with the essential self-discipline (ethical discipline) to generously act on his or her own wish (moral autonomy) to motivate, sustain, and change the beliefs and attitudes of both self and followers. Best viewed as giving an all-embracing moral scope, the character-based leader has the standpoint to unceasingly strive to move his or her organization, team or group past narrow, self-interest chases toward the accomplishment of mutual good goals (ethical attachment). While drawing on a number of viewpoints, including servant, mystical, values-based and reliable, character-based leadership is notable by its vital obedience to a core moral context. This ethical focus is drawn clearly when compared with values-based classes to leadership. The weakness in my character is that I don’t provide consideration to facts, and I don’t push people hard. Ambiguity leadership is another area considered in the project development of the need plan. Models for leadership admit uncertainty as a datum of life for employed leaders. While we consider uncertainty grasses upon us, in reality, it exists every day. In fact, one could claim that ambiguity is just â€Å"the way stuffs are† in a post-industrial group. Just like most people, uncertainty makes me panic. It can collapse a plan. Measuring the ability to engage amid uncertainty is no more difficult than measuring any of the other important traits that we look for in self-assessments and multi-rater feedback (Peterson& Mannix, 2003).It can create someone lose Slumber. It can stop you in your ways. Most people try to evade it. Measuring the capability to engage amid doubt is no harder than gauging any of the other vital characters that we consider for in self-assessments and multi-rater response. The personalities of indecision tolerance can also be uncovered through coaching and interviews. Ambiguity architect program can help in accessing the comfort related with discomfort. This program identifies eight kinds of employers founded on their comfort level with vague conditions and their know hoe at dealing the resultant uncertainty. The third type is the Future scanners: These folks are actually fluid philosophers who want to comprehend how a ministry runs  and continually consider how it will play out in future settings. They are not â€Å"seers,† but in its place demonstrate a curiosity for the forthcoming. Number four on the category is the Tenacious challengers: These folks are tire-less in resolving problems. They will, in some circumstances, drive others to do likewise, even though it is not always valued. If they don’t stimulate others, they will be seen as rough or worst-case state or punitive. Fifth on the sorts is Exciters: These persons were mutual in the study. They adore what they do and they need everybody else to like what they do, too. Sixth are the Flexible adjusters: These influential exhibit two inclinations: the capacity to admit they’re incorrect and the ability to trade changes to folks whose conceit is against the adjustment. This is shown to be an exclusively important advantage in corporate. Seventh of the list are the Simplifiers: Using spoken or written approaches, these persons are able to take complex ideas and help everyone in a ministry understand where the organization is heading. Being a simplifier seems to be something that can be well-read. The last but not least are the Focusers: Last but not least, focusers have the ability to pinpoint and spell the critical few actions that require to be done, as well as change to a diverse set of actions at the correct time. The development also recognized sets of manners that tend to limbs performance during ambiguous times and used these to categorize workers. First are the Poor transitioners: These folks have difficulty changing from one kind of duty or conduct to another. Pointers of this feature might include being really capable at some jobs but extremely dared by others. Second under this category are the Wet blankets: They reduce the energy of a group. They may lack zeal for their own work and respond adversely to the commitment of co-workers. Third are the Conflict avoiders: These persons tend to be overly accepting, often the result of being highly opposed to potentially provocative or intense situations. Fourth are the Muddy thinkers: They show misperception that at times is self-inflicted. They process matters in a way that makes the disputes more difficult than need be. The last thing to include in the strategic plan is the assignments development. Using development job assignments productively will have  positive benefits for both the individuals and the organization (Montross, 1992). First let me consider some of the crucial caveats for applying assignment development. Firstly, individuals selected for an evolving assignment should be told the reason why they are getting the assignment. Furthermore, a helpful structure should be put in place. In logic, the greater the expansion stage for the individual and the more counterculture for the group; the more backup should be provided. Conclusion In the development plan and the strategy for the ministry I have clearly elaborated the main things to include in the plan that include; leadership styles (power and fault), character growth, use of duty and ambiguity (causes, effects and how to deal with it in an organization). In the character section, I have described the strength and weakness of myself; being honest, failing to do a follow up etc. References D, G. (Ed.). (2000). Leadership gets result. HARVARD BUSINESS, MAR/APRI Peterson, R. S., & Mannix, E. A. (2003). Leading and managing people in the dynamic organization. Mahwah: Lawrence Erlbaum Associates. Wright, T., & Lauer, T. (2013). What is character and why it really does matter.Organizational Dynamics, 42, 25-34. Montross, D. H., & Shinkman, C. J. (1992). Career development: Theory and practice. Springfield, Ill., U.S.A: C.C. Thomas

Accountable Care Organizations, Bundled Payments, and Health Reform Essay

With the enactment of the Patient Protection and Affordable Care Act (PPACA) in March 2010, health care reform has become the law. The legislation will extend health care coverage to more citizens, stabilize health insurance markets, enhance regulation and consumer protection, and improve the affordability and quality of health care in the United States. Changes in payment system of health care proposed by PPACA have led to the development of Accountable Care Organization (ACO). This paper will address how ACOs and the bundled payments system will impact the future of health care. See more: Strategic Management Process Essay The ACO is a health care organization which provides accountability for quality, cost, and care for medical beneficiaries with single entity providers that are responsible for delivering care. The ACO-model builds on the Medicare Physician Group Practice Demonstration and the Medicare Health Care Quality Demonstration, established by the Medicare Prescription Drugs Improvement and Modernization Act of 2003. Under the Affordable Care Act, the U.S. Department of Health and Human Service (HHS) released new rules that benefit doctors, hospitals, and other health care providers of better care for Medicare patients through ACOs on March 31, 2011(U.S. Department of Health & Human Services, 2001). According to the Centers for Medicare & Medicaid Services’ (CMS) administrator Donald Berwick, MD, â€Å"An ACO will be rewarded for providing better care and investing in the health and lives of patients. ACOs are not just a new way to pay for care but a new model for the organization and delivery of care† (Penton Media., 2011). The new model, which is called the â€Å"Pioneer Accountable Care Organization,† is to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries  (Medicare Parts A and B) and reduce unnecessary costs through establishing a shared savings program, which promotes accountability for Medicare FFS beneficiaries. It requires coordinating care for services provided under Medicare FFS and encourages investments in infrastructure, and it redesigns care processes. Regarding the differences, the Pioneer ACO payment model incorporates a population-based payment in the third year of the ACO’s Participation Agreement. This population-based payment will replace fifty percent of the FFS payments (McDermott & Emery, 2011). The Pioneer ACO model is estimated to save Medicare as much as $430 million over three years by coordinating with private payers to reduce costs for Medicare beneficiaries and improve health outcomes. An ACO may engage in either a Shared Savings Program or in the Pioneer ACO model. In addition, the Pioneer ACO model is separated from the Medicare Shared Savings Program for Medicare beneficiaries by the Advance Payment Initiative (Center for Medicare and Medicaid Innovation Center, 2011). ACOs require the ability to manage cost and quality for patients across the continued extent of care and across different associational settings. They also require the capability to plan budgets and resources needed to allocate payments, and the commensurable size of primary care providers for Medicare patients’ populations assigned to the ACOs (at least 5,000 Medicare or 15,000 commercial patients). According to the Journal of the American Medical Association, doctors Shortell and Casalino recommend a three-tiered system of qualification for ACOs (Shortell, S. and Casalino, L., 2010). The tiers will be based on the degree of financial risk acceptable for ACOs and the degree of financial rewards that can be completed by performance targets. In the first tier, ACOs will receive FFS payment with shared savings for providing quality care at lower than the expenditure targets. In the second tier, ACOs will receive bundled payments and episode of care based payments for managing costs and achieving benchmarks. They will be accountable for care that meets these criteria. In the third tier, ACOs will receive partial and global capitation payments. Under a three tiered structure, ACO providers will submit a three-year plan to the HHS or CMS for achieving qualification status at the varied levels. The U.S Department of Health and Human Services (HHS) announced the â€Å"Bundling Payment for Care Improvement Initiative† to coordinate payments for services delivered across an episode of care, such as a cardiac bypass or a hip replacement, on August 23, 2011 (Vendome Group, LLC, 2011). The definition of bundled payments refers to a single payment for all care related to an entire treatment or condition. Bundled payments, also called episode-base payments or case-rate payments are considered as a mechanism for improving both cost and quality, such as currently exist with Geisinger Proven Care and the Prometheus Payment system (Dark,Cedric., 2011). Bundled Payments do benefit physicians and hospitals if patients complete their medical treatments within a certain time period because it will save the physicians and hospitals additional costs. However, it is a disadvantage for physicians and hospitals if the treatment takes longer than the traditional time because it will cost more money to care for patients. Unfortunately, its emphasis is less about improving care and more about reducing the financing for medical care (Gorman Health Group Blog, 2011). This means hospitals, physicians, and other practitioners will have to take their own approach to improving the delivery of healthcare, which should benefit Medicare patients. The goal of the initiative is to increase efficiency of care, improve quality of care, and lower costs. This initiative consists of four different bundled payment models. The first three bundled payment models are retrospective payment arrangements based on patients’ historical data. However, the fourth model is proposed for the future. Centers for Medicare & Medicaid Services (CMS) make a single bundled payment to the hospital for all services during inpatient stays for hospitals, physicians, and other medical professional specialists. In the first model, the episode of care is the length of time the inpatient stays in the acute care hospital. Medicare pays the hospital a discounted payment based on the payment rates established under the Inpatient Prospective Payment System (IPPS), which starts at zero percent for the first six months and then rises to a minimum of two percent in the third year, based on the IPPS. Physicians are paid under the Medicare Physician  Fee Schedule. Hospitals and physicians are to share in any costs. This model benefits Medicare patients by reducing their costs, but not hospitals and physicians because they must share in any expenditures. The second model, which is also based on IPPS, is different from the first model because it includes inpatient and post-acute care from either 30 or 90 days following discharge. This bundled payment includes physicians’ services, post-acute care, readmissions, and other related services, which can be clinical laboratory services, medical equipment, prosthetics, orthotics, other supplies, and Part B drugs. The minimum discount is three percent for the first 30 to 90 days after discharge and two percent for more than 90 days. The Medicare enrollee is to share the costs if the total payments are less than the target price. However, the provider will be responsible for payment coverage if the total payments exceed the target costs. This model uses an incentive discount for Medicare patients to spend less time in rehabilitation versus the first model which has no early rehabilitation discount. However, this model does not give an advantage to hospitals and physicians because it encourages Medicare patients to leave medical services sooner. The third model begins at discharge from an acute facility if less than 30 days are spent in rehabilitation. These bundled payments are the same as the second model with the exception of a discounted rate, which Medicare enrollees are required to set up instead of CMS, since CMS has not indicated an expected discount for medical service (Becker, Epstein & Green, P.C, 2011). In the fourth model, which is the only perspective model, hospitals will receive a single bundled payment from CMS that covers all medical services by hospital, physicians, and other medical professional specialists. The minimum discount will be three percent of the estimated total costs for the episode care (Proskauer Rose, 2011). The bundled payments are more hospital-centric than ACOs’ program. However, ACOs’ focus will be on how hospitals and physicians will share reimbursements in a post-fee-for-service payment system. Therefore, Medicare beneficiaries will benefit the most but hospitals and physicians will not. Future ACOs include: Integrated Delivery Systems, Multispecialty Group Practice (MSGP), Hospital Medical Staff Organization (HMSO), Physician-Hospital Organizations (PHO), Interdependent Practice Organization (IPO), and the Health Plan Provider Organization or Network (Charles DeShazer, 2011). However, most physicians work in very small practices that would not likely have the resources to develop the capacities to be an ACO. In an ACO-based health care organization, these small practices would either merge into new or already existing specialty group practice, or would engage in an ACO that facilitates clinical integration among small practices. Many physicians may still prefer smaller practices, and under comprehensive healthcare reform may continue to exist. In ACOs completely based on the quality and cost of care, the market may decide whether virtually integrated systems can succeed in competition with systems where physicians are merged into large group practices. Moreover, specialist physicians are creating medium sized or even larger single specialized groups. However, a single specialty group cannot serve as an ACO for full patients care but can be an essential element of an ACO or can be a crucial source of medical care through referrals. In Integrated delivery systems (IDS), medical care is coordinated and reimbursed within the system to make patient care more efficient while improving access to and the quality of the care received. Some examples are: Cleveland Clinic, Henry Ford Health System, Mayo Clinic, Scott & White Clinic, and so on. However, a recent report indicates that challenges may still remain. IDS face lack of compensation from health insurance providers for care coordination services as well as difficulties in finding specialty care, such as mental health care and changes in management and physician cultures in adopting the new organization (United States Government Accountability Office, 2011). The promising advantages of the multispecialty group practice (MSGP) model were recognized in 1932. As stated in the Physician’s Advocate(2008), â€Å"These advantages include having the resources to redesign care processes, take advantage of economies of scale to implement electronic medical records, form health care teams, obtain database feedback on performance gaps, and make the changes needed to improve care† (Physician’s Advocate, 2008). Some evidence indicates that multispecialty group practices do make the most of recommended care management processes like electronic information technology, as well as sharing in quality improvement medical services. Therefore, MSGPs provide better quality care for preventive measures involving screening tests and diabetes management than smaller forms of practices. Moreover, studies also indicate lower Medicare spending on patients related to multispecialty or hospital associated groups than other patients. However, it is unlikely that MSGPs will become the major organization form in the United States health care system since it is so expensive to implement. HMSO, more than 800,000 physicians that currently practice in the United States are members of hospital medical staffs (Carroll, 2011). The hospital medical staff organization can serve as ACOs for either inpatient or outpatient care. Studies indicate that most physicians have primary relationships with a single hospital to form a stronger partnership entity between physicians and their primary hospital (Fisher and et al., 2006). Hospitals have resources to support adopting electronic medical records (EMR), provide performance and accountability data, and assist quality improvement support for physicians. Bundled payments for specific medical conditions or episodes of sickness, such as a coronary artery bypass graft (CABG), hip or knee replacement (Massachusetts Medical Society, 2008) will provide incentives for hospitals and physicians to work together to reduce Medicare costs (Welch, WP and ME Miller, 1994). This model will have future advantages for chronic illness treatment as we ll as episodes of care since physicians and hospitals work together closely to monitor patients’ long term care. However, the HMSOs encounter challenges including leadership of the diverse cultures of hospitals and physicians and legal restrictions to obtain sharing (Primary Care Associates., 2008). An alternative of the MSGP model is the PHO. Hospitals and physicians work together to ensure cost-effective and steady system delivery of medical services and the provisions of the health care services to the patients. There are approximately one thousand PHOs in the United States and most are managed organizations with the goals of achieving and managing the quality  and cost of care (Nixon Peabody LLP., 2010). Under the Affordable Care Act, the contracting PHO model can emerge into an entity that will manage the quality and cost of care. Without meeting the needs of all physicians, this model has the advantage and the incentive of improving performance. With the HMSOs, the hospital will provide resources for EMR, performance reporting, quality improvement, and process management support. However, PHOs must be clinically integrated to avoid anti-trust laws (Casalino, Lawrence P., 2006). A fifth model is the Interdependent Practice Organization (IPO), which is an advancement for those physicians who practice in small organizations or who do not wish to be part of larger organizations for delivering care. The interdependent practice organization is based on an association of physicians in numerous independent practices. IPOs are capable of providing high quality, better care, although most of these organizations are loosely organized (Rittenhouse and et al., 2004). The future IPO model requires strong leadership, administration, and enough patients across individual practices to support financing of technology infrastructure and management systems. IPO models might be attractive to physicians practicing in rural areas. With given sufficient incentives, existing IPOs can became independent organizations by strengthening their management structure and developing a solid shared culture of performance improvement. These requirements are challenges since IPOs are composed of many small practices. The last model, the Health Plan-Provider Organization or Network (HPPO/HPPN) is similar to the IPO. It is based on an association of independent physician practices. The health plan will be the major financial assets to encourage a more cost-effective health care delivery system. Many have capabilities in disease management, electronic information technology implementation, and quality improvement entities that can be used effectively in collaboration with physicians. Some physician practices may participate with health plans rather than local hospitals. Health plans can be part of a smaller physician’s practice and become the unit of accountability of performance. However, the success of this model will depend on an individual physician’s leadership (Shortell and et al., 2008). The Centers for Medicare & Medicaid Services (CMS) released final rules and new opportunities for financial support for doctors, hospitals, and health care providers to work together to improve the care of Medicare patients by adopting ACOs on October 20, 2011. The new rules provide for a new voluntary Medicare Shared Savings Program. Providers will be able to participate in an ACO and share in the savings with Medicare. ACOs will reward providers for reducing the costs and meeting quality measures, such as reducing hospital readmissions or emergency room visits. Providers will begin to share in savings based on how they perform in thirty-three quality measurements in the second and third performance years. Medicare beneficiaries will be a part of the ACO system when they form. Moreover, community health centers and Rural Health Clinics (RHCs) will be allowed to participate in the ACO programs (Galewitz, Phil and Jenny Gold., 2011). To appeal to providers, CMS will provide physician-owned and rural providers early access to the expected saving of up to $170 million dollars, so providers can start ACOs right away. At the same time, the Antitrust Division of the Department of Justice issued the entire final rules that will allow providers to participate in the Medicare Shared Savings Program. In addition, the final rules will no longer require a mandatory antitrust review for collaborations as a condition of entry into Shared Saving Program (Department of Justice, 2011). Electronic health record (EHR) usage is no longer a condition of participation to prompt more RHCs and other programs to join (Center for Medicare and Medicaid Innovation Center, 2011). Moreover, CMS will assist agencies in monitoring the care and quality of performance of ACOs. The program will save up to $940 million dollars over four years (U.S. Department of Health & Human Services, 2001). Patients or Medicare beneficiaries are encouraged to select an ACO as their medical center. ACOs can be used for result-based payments, public report purposes, and claim-based payments which retrospectively allow patients to join who have not adopted ACOs. This advances patients’ choices and encourages ACOs to coordinate their patients’ care to treat patients equally. Because physicians are not required to be part of ACOs, physicians  can still be paid with the Shared Saving Programs used by Medicare, Medicaid, and other commercial health plans. They also can be eligible to achieve quality-based rewards. In addition, physicians and hospitals that are part of ACOs can have both obtainable rewards for improving quality and controlling costs; however, there is more inevitable risk. Furthermore, bundled payments for certain services and procedures, using a combination of capitation, result-based payments, and readmissions, gain sharing between physicians and hospitals tha t can be adopted within ACOs. Physicians also can benefit from the assistance that ACOs can provide with electronic health records and with implementation of established processes to improve quality and efficiency. Health reform will be needed in laws and regulations for the Stark law, anti-kickback statuses, fraud and abuse, anti-trusts, scope of practices, and the corporate practice of medicine. However, the final rules were relaxed and established waivers for the physicians’ self-referral law, the federal anti-kickback status, and certain penalties to encourage the participation in the Medicare Shared Saving Program and the Advance Payment Initiative (FierceHealthcare, 2011). Therefore, more medical providers will be regulated by the programs. In the past, healthcare leadership has relied on organizational structure to deliver higher quality at lower costs, which has not succeeded in improving neither efficiency nor performance. In fact, they have increased the problems that they intended to address. Neither diagnostic related groups (DRG) nor Health Managed Organizations created a shared achievement for all parties. Provider profit motivation lacked the pressure of medical beneficiaries to protect quality while minimizing costs. While each DRG and resource based relative-value unit encouraged providers to focus on provision without interventions, HMOs and other managed providers encouraged providers to minimize intervention, regardless of whether managing could delay the quality or completeness of patient care (Numberof, 2011). Ignoring the minimal role that patient demand plays in driving market completion among providers, the current and past medical health care system has decreased accountability for quality of medical care. ACOs were established to fix the inadequate accountability for wasteful  spending and quality of patient care. The PPACA provisions are consumer based solutions; however, they do not allow patients to have fully informed choices about their coverage and medical care (Numberof, 2011). Employers, who contract with insurers, apply with providers; therefore, accomplishment is limited. However, many physicians are reluctant to assume accountability for patient outcomes, since they admit that outcome is directly under the behavioral control of the patient. Furthermore, it seems that provider contracts could be integrated to a successful ACO in a shared savings program; providers continue to receive funding for each service they perform. Even with the possibility of a bonus from shared-savings, maintaining the FFS system boosts providers into continuing delivering an excess of services. In addition, ACOs, which are a single untested model, are largely hospital based. Eligibility requirements are larger and more involved for ACO organizations. Larger organizations are able to consolidate their markets; however, this consolidation may result in less competition. Therefore, large delivery organizations may become too big to fail but will increase advantages for patients. Without competition, the organizations might have little incentive to reduce the costs or improve quality of medical care. Enduring health reform has to cover the uninsured without exception or conditions. As Victor Fuchs, professor at Stanford University mentions â€Å"It [Enduring health reform] must improve efficiency in medical practice by providing physicians with the information, infrastructure, and incentive they need to deliver cost effective care† (Fuchs, 2010). Information will come from the electronic health records, a process that will be amped up by the HITECH Act, which is part of the American Recovery and Reinvestment Act of 2009 (Leyva, Carlos and Deborah Leyva, 2009). Electronic health records will benefit providers with more accurate real-time data on patients as well as provide analyses on drug responses and provide support to improve the quality of medical care. Health information Exchange (HIE) can enhance information from a wide databases and allow that information to be shared through various technology by providers. This allows related patient information to be shared withi n EMR with the provider who needs that information (Southern New Hampshire Health System, 2011). Furthermore, the  Patients Centered Outcomes Research Institute (PCORI) will offer physicians and patients new information of varied medical technology. Atul Grover, chief advocacy officer for the Association of American Medical Colleges, notes â€Å"It will be an evidence synthesis that really considers different populations and different diseases and tries to get more information to clinicians as they go about doing their daily work† (Marathon Medical Communications, Inc, 2010). The integration of the PCORI will enhance information so that physicians and patients can choose the appropriate test and treatment based on the patients’ condition. Moreover, infrastructure reform will enhance horizontal collocation within providers and monitor patients consistently. Health care reform strengthens greater integration through the redesign of delivery systems such as medical homes and ACOs for physicians. Recent studies suggest that better coordination of care can reduce readmission rates for major chronic sicknesses (Hernandez, AF, 2011). In addition, the PPACA will give incentives for hospitals to support proven practices that essentially reduce their rates (Foster, 2010). Likewise, the PPACA’s pilot program involving bundling payments will bring physicians and hospitals an incentive to allocate care for patients with chronic illnesses. Most essentially, PPACA admits that health reform that brings ACOs as the delivery system is an ongoing process requiring continuous adjustment. The PCORI will develop new medical tests, drugs, and other treatment that will provide continuously updated information for physicians and patients. Over the next decade, similarly, the Innovation Center in the Centers for Medicare and Medicaid will be establishing and evaluating new policies and programs that will enhance the quality of care for Medicare beneficiaries and reduce costs. PPACA not only will expand health care coverage to millions of Americans but also will enact many policies to reduce the amount of costs for health care by bringing ACOs as the delivery system, which will reduce the costs of health care over time. By enacting ACOs as a Primary Care Provider (PCP), PPACA provides the most effective medical care support possible. Moreover, by adopting the bundled payment approach, physicians, hospitals, and other providers will be able to reduce the costs for Medicare beneficiaries.  Therefore, the public should embrace the new health care proposal to reduce their costs and improve the quality of their medical care. References Becker, Epstein & Green, P.C (2011) â€Å"HEALTH REFORM: CMS Innovation Center Announces Four Models in Bundled Payments for Care Improvement Initiative,† Retrieved from http://www.ebglaw.com/showclientalert.aspx?Show=14876 Carroll, Aaron. (2011, June 3). â€Å"Meme-busting: Doctors are all leaving Canada to practice in the U.S.,† Retrieved from http://www.washingtonpost.com/blogs/ezra-klein/post/meme-busting-doctors-are-all-leaving-canada-to-practice-in-the-us/2011/06/03/AGVdAuHH_blog.html Casalino, Lawrence P. (2006) â€Å"The Federal Trade Commission, Clinical Integration, and the Organization of Physician Practice,† Journal of Health Policy, Politics, and Law, Retrieved from http://www.ftc.gov/os/comments/aco/2006jhppl.pdf Center for Medicare and Medicaid Innovation Center (2011) â€Å"Pioneer ACO Application,† Retrieved from http://innovations.cms.gov/areas-of-focus/seamless-and-coordinated-care-models/pioneer-aco-application/index.html Center for Med icare and Medicaid Innovation Center (2011) â€Å"final ACO rule,† Retrieved from http://www.cms.gov/aco/downloads/Appendix-ACO-Table.pdf Department of Justice, the Antitrust Division and the Federal Trade Commission (2011) â€Å"Background Documents,† Retrieved from http://www.justice.gov/atr/public/health_care/276458.pdf DeShazer, Charles. (2011) â€Å"Accountable Care Organization (ACO) Tutorial,† Retrieved from http://www.slideshare.net/cdeshazer/accountable-care-organization-aco-tutorial Dark, Cedric (2011) â€Å"Quality over Quantity: Reforming Payment,† Retrieved from http://www.policyprescriptions.org/?p=2066 FierceHealthcare, (2011) â€Å"CMS, OIG to relax self-referral, anti-kickback laws with ACO waivers,† Retrieved from http://www.fiercehealthcare.com/story/cms-oig-relax-self-referral-anti-kickback-laws-aco-waivers/2011-10-21 Foster, David. (2010) â€Å"Healthcare Reform: Pending Changes to Reimbursement for 30-Day Readmission,† Retrieved from http://thomsonreuters.com/content/healthcare/pdf/pending_changes_reimbursements Fuchs, Victor (2010) â€Å"Health Care Reform,† Retrieved from http://siepr.stanford.edu/system/files/shared/Health_care_document.pdf