Economics: Opportunity Cost
Producer
Food
Shelter
Rochelle
200 OR 50
Larry
150 OR 30
Above we have information for two different producers, Rochelle and Larry, who can each produce food, shelter, or some combination of the two using only 1 unit of labor and 50 units of capital (each). Specifically, with the given inputs, Rochelle can produce 200 units of food OR 50 units of shelter, or some combination of the two and Larry can produce 150 units of food OR 30 units of shelter, or some combination of the two.
Calculate the opportunity cost of producing one more unit of food for Rochelle. Be sure to include the units her opportunity cost is measured in.
Calculate the opportunity cost of producing one more unit of food for Larry. Be sure to include the units his opportunity cost is measured in.
If comparative advantage exists when a producer has the lowest opportunity cost, who has comparative advantage in production of food?
Your response should be one to two paragraphs. DISCUSSION 2
Recent Decisions Weighed Marginal Cost and Marginal Benefit
Students Name
Institutional Affiliation
Weighted marginal cost is the cost incurred to raise one additional dollar for each of these different forms of capital. This implies that one must consider the available alternatives that bring the best out of the current usable opportunity. One has to consider the available opportunity with the most significant weight compared to the other alternatives.
Marginal benefit refers to the maximum amount that one is able or willing to pay for a given service or product. In marginal benefit, the extra price a consumer is willing to pay is likely to be motivated by the additional satisfaction one derives from a given product or service.
One example when I dealt with the weighted marginal cost is when I go to the school canteen to buy snacks. When buying snacks, I have to decide on the units that I can purchase depending on several factors. When I cannot purchase multiple different snacks, I have to buy snacks that will meet my immediate need and forego those that do not meet my immediate needs.
Another example is when I need to increase my study hours when the end-of-semester exams are close. In this instance, the marginal cost I will incur is the leisure time consumed by increased study hours, but the marginal benefit is the thorough revision I will do. 10/27/22, 7:49 PM Economics: Opportunity Cost
about:blank 1/1
Economics: Opportunity Cost
Opportunity cost – Rochelle
Unsatisfactory
1 point – 1%
Needs Improvement
2 points – 75%
Excellent
3 points – 100%
Opportunity cost for Rochelle is incorrectly
calculated or missing and the units of
measurement are correct or incorrect.
Rochelles opportunity cost is correctly
calculated, but the units are incorrect or
missing.
Rochelles opportunity cost is correctly
calculated with the correct units.
Opportunity cost – Larry
Unsatisfactory
1 point – 1%
Needs Improvement
2 points – 75%
Excellent
3 points – 100%
Opportunity cost for Larry is incorrectly
calculated or missing and the units of
measurement are correct or incorrect.
Larrys opportunity cost is correctly
calculated, but the units are incorrect or
missing.
Larrys opportunity cost is correctly
calculated with the correct units.
Comparative advantage
Unsatisfactory
1 point – 1%
Needs Improvement
2 points – 75%
Excellent
3 points – 100%
The individual with the comparative
advantage in production of food is
incorrectly identified or is missing.
The individual with the comparative
advantage in production of food is correctly
identified, but other incorrect individuals are
also identified.
The individual with the comparative
advantage in production of food is correctly
identified.
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HMGT 420 ASSN 1 PART 1
Assignment #1 (15% of the final grade)
Situational Case Study: The Crowded Clinic
LearningObjectives:Upon completion of this case study, you will be able to:
Discuss potential ways to improve scheduling patient visits at a community health center
Discuss the importance of getting to know the traditions, behaviors, and beliefs of the populations that visit the health center
List at least three ways to make health care more accessible and equitable for a diverse population
Instructions:
Read the following Case Study and respond to the 4 discussion questions at the end.
Each response should be 2-3 paragraphs in length. Include a separate page of any references you utilize (APA format).
The Case:
You are one of the health care practitioners in a community health center that provides primary care to a multi-ethnic, multi-lingual urban community. Many, but not all, of the patients live below the poverty line. Physicians and nurses see a large volume of patients with challenging medical and psycho-social issues.
Lately you have realized that the scheduling of patient visits has become something of a nightmare. Because of the high volume of patients, the wait for an appointment for routine care can be anywhere from six to eight months or more. Even acutely ill patients often wait for two to three days to see a health care provider. Out of frustration, many patients are walking in without appointments, often during lunch hour or late in the afternoon when everyone is getting ready to leave.
What makes the problem so challenging is that 20 to 40 percent of patients fail to show up for appointments on a given day. Because of this high no-show rate, every other appointment on physicians schedules is double-booked with the expectation that, out of the 30 to 35 scheduled patients, only 20 to 25 will actually show up. Occasionally, however, most of the patients do show up and when a significant number of acutely ill patients also arrive, the work environment becomes unbearably chaotic for everyone. Providers become harried and more likely to make mistakes, patients wait for long periods of time in crowded waiting rooms, and the atmosphere becomes increasingly hostile as the stress level mounts.
It is clear that the quality and experience of health care for many of these patients is suffering partly because of a simple lack of access to care. And it is also becoming increasingly clear that the better-insured and English-speaking patients may be getting better access: they are more likely to get a timely appointment because they are more demanding of the system, and they are more likely to keep and show up for their appointments because of better communication. You are interested in finding a way to promote more equitable access to health care.
Case Analysis:
The main problem that everyone is experiencing in this clinic is the high rate of no-shows. It would be very easy to simply label the clinics patients non-compliant. But is it so? As health care providers, the burden is on us to find the most effective ways to serve our patient population. One possible approach to the problem at hand is to conduct a survey in an attempt to identify some specific reasons that may be contributing to such a high percentage of no-shows.
When patients are surveyed about their reasons for not coming to appointments, a few common reasons may emerge:
A sick patient waited so long to be seen that she got better and didnt need the visit or got worse and had to go to the emergency room.
A patient did not have a phone, or his phone number changed, so he never received the reminder message the day before the appointment.
A patient showed up for the appointment, but at the wrong date or time. He misunderstood because of a language barrier.
A patient was afraid to take time off work and risk losing her job. It would have been much easier for her to make an evening or weekend appointment.
How should you address this flurry of concerns? You can begin by clearing away the backlog of appointments. One possible solution is a system called Open Access. This system allows patients to schedule appointments, even for routine well care, on the same day usually with their own physicians. This approach has cascading benefits. For instance, if visits are scheduled on the same day, theres no need to make phone call reminders, eliminating the problem of patients not having phones or not receiving the messages. Further, if patients can choose a convenient time to visit (including evening and weekend hours when they are more likely to be off from work), they eliminate the risk of losing their jobs.
There are a number of ways to get this clinic, currently swamped, to a point where it offers Open Access. This work is not easy and the transition period is often quite challenging. Physicians can provide more services during each visit (even if it means that the visits are somewhat longer), reducing the need for the patients to return. The staff can also spend a set period of time — perhaps four to eight weeks working through the backlog of patients and opening up the schedule for same-day appointments. This may lead to a significant patient overload, so there may be a need for overtime work and creative staffing until the backlog is cleared out (i.e., staff lunches may be staggered so that appointments are available at lunchtime). The hope is that patients will receive timely care, that they will be more likely to be seen by their own doctors instead of the most available physician, and that they will be more likely to avoid going to the emergency room for issues that can easily be handled in an outpatient clinic setting.
In addition to making appointment schedules more conducive to patient needs, other ways to serve patients better involve creating an environment more welcoming to the patients and more inclusive of the various cultures, languages, and issues of the various patient populations. There need to be some staff members who can speak the main languages of the patients and who are representative of the diversity of the patients. There should be efforts to educate staff members about the various cultural beliefs of different patient populations. If patients perceive that they can trust the staff and be open with them, they are more likely to comply with the treatment regimens and to make follow-up appointments. Thus, their medical problems are more likely to be successfully diagnosed and managed.
Respond to the following questions in 2-3 paragraphs each. Be sure to cite any references that you utilize appropriately (APA format).
Discussion Questions:
1. As mentioned above, one aspect of patient-centered care is fostering a culturally sensitive and diverse clinic environment that makes patients feel more welcome.
Discuss 3-4 methods in which this may be accomplished?
2. In order to provide good care for a culturally diverse patient population, it is important to gain some understanding of their ways of being (their belief systems, their traditions, their feelings towards western medicine, etc.).
Share your thoughts on a particular patient population that may have unique beliefs about health and illness that would be important to understand?
3. How well do providers know their patients?
Can you think of a patient population (a culture, ethnicity, religious group, sexual orientation) with which you do not have much familiarity? How might this lack of knowledge impact the provision of care?
4. What are some ways in which providers could be better educated in regards to the beliefs and traditions of the patient population? How might this intervention benefit the patients? Perspective: The State of Patient Experience
25-02-2016
HEALTHCARE SUCCESS LEADERSHIP PODCAST: Dr. James Merlino, president and chief medical officer of the strategic consulting division at Press Ganey, talks with Stewart Gandolf, CEO of Healthcare Success, providinga unique and insightful perspective on healthcares evolving landscape, significant leadership issues and the state of patient experience.
Stewart Gandolf: Hello everyone , Stewart Gandolf, welcome to another one of our podcast today Im please again to be speaking with Jim Merlino, who is president and chief medical officer of the Strategic Consulting division of Press Ganey and our readers and subscribers will recognize Jim he used to be with Cleveland Clinic previous or prior to Press Ganey and we’ve had him on this podcast many times and I always enjoy speaking with him we’re just talking offline about how much fun it is to talk and invite him to these things because he’s just has a plethora of insights that I think you’ll find extremely fascinating and helpful. So today as we mentioned a moment ago that Jim was the Chief of patient experience for Cleveland clinic, now in his new role at Press Ganey and it’s been awhile since we’ve talked and so I thought wed like to start off and catch up on how his perspective has changed as he’s taken on a different role for Press Ganey Obviously at Cleveland Clinic Jim had a very broad and important role not just there but along other hospitals being involved with the summit and Association patient experience and so forth. But at Press Ganey obviously will have a new perspective. So, Jim Id like to start off by asking you , broadly speaking share with us now that you’re at a new organization some of the new insights youve had about you know how different Health Care organizations, hospitals, are thinking about patient experience
Jim Merlino: Sure Stewart, First of all Id like to say it’s always a pleasure to have to be having these conversations with you I really enjoy the interaction and appreciate the work that you’re doing to get the message out about the work thats being done across the country and across the world of health care. It’s fascinating to have this perspective now that I’m on the other side and having come from the provider side and obliviously working in private sector to help support health care and Health Care operations and your strategy and a couple interesting learnings for me have been- Number one : is our work with Healthcare Systems really goes beyond just the patient experience. And were much more in now to help organizations with patient operations, improving broader definition of patient experience improving safety and quality. What I thing has been one of the interesting findings for me is that you can pretty much list the top 10 or so issues that hospital C-suites across the country are really paying attention to today but it was a little surprising for me the priority of those listings is very different. So some organizations are you focused on market share , some are focused on safety, some have elevated the patient experience attack, some have elevated integration, so everybody has their own kind of list of what their priorities are. But I think what is the most surprising to me and its probably something that I shouldn’t have had insight into going into this role but it’s really been just been an epiphany for me is how differently organization’s approach problems and it is interesting I use this analogy of treating disease around executing a cure path. A cure path essentially you have a couple ways of doing things well and right and then if you if you do something outside of that right, its outside the standards of care. You think of the analogy of a highway, if youre in the middle lanes youre in the standard of care as you start to move towards the edges you get outside the standard of care. Is the same way to think about how hospitals approach operations around their strategies it is that there’s a handful of ways of doing things for any particular issue and there’s a myriad of different ways that may not be as successful as some ways that other hospitals are doing them. And the variability on how organizations execute to me is just fascinating and I should point out that there’s a lot of right ways to do things and probably less wrong way when it comes to hospital operations but the variability of how organizations, how C-suites think about execution is really really striking to me.
04:26 Stewart Gandolf: So you mentioned the different 10 priorities, you know that we can all think through, market share would certainly be one , for profit hospitals- profit would be one , market share, consolidation , you know building the brand, working on safety, working on patient experience so clearly there’s different ways for approaching things. Are there any strategies that from your perspective you know are the leads? So for example we were talking offline about something that you know we’ve had discussions about, another of our clients have, the insight that you know for example hospital are spending time thinking about branding but really from the patients point of view the patient experience is the brand, right? You can all types of great ads, but my patient experience and my most intimate dealings with the hospital are really the brand from my perspective. I guess as youre thinking though these various priorities, where do you feel for most hospitals, because everybody is different obviously, where do you recommend they start focusing or where do you think would be the place that would be more appropriate than others?
05: 36 Jim Merlino: Well I go back to my roots in where I came from in hospital leadership and operations-which is around the patient experience. I think that when I started in that role at the Cleveland Clinic we had a very narrow experience of what the patient experience was and it was really more around service and satisfaction. But I think as I evolved there and we evolved with strategy there, and now stepping into this role at Press Ganey, the way we see the patient experience is really much broader around this concept of delivering safe, high quality care in an environment where essentially the patients feels cared for, or the service piece, or patient centeredness- however you kind of define that third piece. But the patient experience is really all three components and everything else that we do in healthcare. If you think about the patient promise, so what is it that healthcare organizations deliver to people? or patients more specifically. Its this idea that youre going to provide safe care, that youre going to provide high-quality care you’re going to do it in a patient family-centered environment- that’s what we do. I think that organizations should elevate that to really becoming their top strategic priority. Because if you think about it that’s what we do. and if we can’t get that part of what we do right and don’t do it well then organizations arent going to be successful. Frankly, in today’s environment, as you know with increasing consumerism, more information, greater choice, people going to differentiate against you if you don’t hit the nail on the head with that patient promise.
07:20 Stewart Gandolf: You know thats so critical and I love that you know, that obviously that the broader definition that and you know we talked before about how certainly in the past and even today, you know doctors and administrators and so forth, can dismiss patient experience with that idea and I don’t care if they get better or I don’t care if they like me I just want to get them better but that’s not really getting the broader picture -but on the other hand , the idea of just giving the hotel experience, the outcomes are terrible and the safety is terrible thats not a good idea either. So really I can see demanding all three of those things is critical. Going forward, I’m thinking about there’s a hospital locally here that was just acquired and on some of the quality and safety scores scored really low. It’s funny I’m watching with interest what they’re going to do and again worrying about new billboards and new colors and so forth I think misses the point. One the things we talk about a lot in our seminars and as we write and speak is I think most marketing people from the marketing standpoint start with the promotion, which is to me the last thing to talk about. Basic marketing theory is Product, Place, Price and Promotion. Promotion is the end. The product is the most important thing. In this case with healthcare, the product is keeping people alive, so that’s really the product but it’s more than that. So looking at this again, lets drill down on each of these things a little bit. Lets talk about the safety component the high reliability-tell me more about that.
08:59 Jim Merlino : Well safety is obviously a very important topic in healthcare and if you step back and think about that broader definition, you can create an environment or culture where people are nice, people are working together but if the organization is delivering on harm? patients to caregivers? and there is a lot of safety errors in the organization , then you are not going to fulfill that promise and that patient experience. As it stands today you know we have approximately 440,000 deaths in the United States from serious safety errors. 1 in 25 people coming into the hospital encounter a hospital acquired infection .Senior citizens, people over 65, have a 25% increase risk if they come to the hospital suffering a serious safety event. All told it adds about $2,000 per Hospital discharge in the United States and if you treat safety like a disease and its not but if you did it would be the third leading cause of death in the United States. So we have made tremendous progress in the United States since the institute of medicine study came out To err is human. But we have not me enough progress and it is unconscionable to think that we create such harm in healthcare As a surgeon I always hated the analogy to the airline industry because my first refrain would be that taking care of people it’s not like flying planes but the reality is when you look at organizations that have achieved high performance in higher liability like the airlines, like nuclear power, like the military. The reality is that we can be more like them and we can do a better job of delivering on safer healthcare. We have to standardize more of what we are doing; we have to elevate reduction of harm to a top strategic priority. We have to make safety and other comprisable core values of our organizations. We have to do more to protect people.
11:09 Stewart Gandolf: Its still shocking to me after all these years and hearing the first about the number of airlines planes going down in comparison but still obviously this is still a huge issue. Tell me can you think of any, I can image as a CEO because the CEOs that I know at hospitals , its kind of like when you think about the President of the United States, people blame the president for everything, they can’t really do everything they don’t have the power that you would like to think. and for a CEO of a hospital you know one of the CEOs we work with right now has union problems and all kinds of issues that are not something that’s directly in his control, so it must be daunting if you’re taking over a hospital as ..let me ask you this. Lets say you had a CEO of a hospital that came to you and said hey I just took over this Hospital were an ex-community and it has a terrible reputation and frankly you know privately its deserved, its been a real problem for safety. How and what are some of the case studies that you could share with them or one of the successes that would kind of inspire them that you really can make a huge impact or maybe you can think of a specific hospital or system that really had huge improvements. What would they do first?
12:18 Jim Merlino: That’s a great question and I think that the role of that CEO stepping into a role like that certainly has their challenges thats not a huge gap but I think your point is right they can’t do everything, they cant focus on everything but there are some basic things I think an organization can do . Number one , they can we can put this messaging out that we were going to commit to zero harm, that we have to raise awareness around the issue and that we have to make an organizational commitment. They have to, they should instill safety as an uncompromisable core value. If its not in the value stream it should be. If it is, it needs to be elevated; people need to talk about it. The second thing they need to do is really put a face on safety. What I mean by that is part of the reason I think we don’t pay attention to errors and other opportunities as much as we should is because we create statistics or I should say we have statistics. But people are not statistics. you know if your family member or you experience that harm or serious safety events, you are not just some number on the paper youre a person, you have a family, you have friends youre whole life changes depending upon the magnitude of what happened .So I think we have a responsibility to talk about this, the way it is . Its about people, its not about statistics. When you look at organizations who really raised the bar on safety one of the tactics they use is that put faces on the statistics, the actual patients face on the statistics, so that everything time theyre are seeing the death rate they are looking at a person’s face and knowing that that person died because of a serious safety event. It wasn’t just the wound infection in room two, it was this person and they have a family. The third thing that I think they can do is be transparent and this fits very nicely with, what you already mentioned you know whats going out in your market today and that is there’s more and more information out there and when we have information available we are transparent about it and it drives change. So we should be transparent to our organization about the safety event so people know whats going on we should make it personal and we should commit to the goal of zero harm and when you look at organization that have just driven those three topics you see change in safety rates.
14:47 Stewart Gandolf: Thats inspiring. I can imagine transparency is not always easy. I can just think of somebody coming into a hospital where they havent been transparent that must be quite an uphill battle or is it I don’t know. We talked before about the importance of leadership and really embrace it, transparency. Certainly there are some hospitals that are leading this effort but can this be a real challenge for some of the people you speak with?
15:10 Jim Merlino: I think it’s a tremendous challenge and youre right we have talked about this before. I think we, Healthcare has a lot of progress on topic of transparency. More and more organizations are transparent with their information but we still have a lot of work to do. One the things that were finding and my colleague at Press Ganey , Dr. Tom Lee , talks about this a lot is that, by the way, Its not just being transparent about the opportunities we have, our physicians have, but it’s also being transparent about the accolades and it’s interesting when you look at work that’s been done and published by the University of Utah, Vivian Lee, whos the CEO out there put doctors scores and comments on their website and she got some expected pushback . But a couple things happened. Number one – their scores improved. This idea of getting information out to the physicians got their attention, got them working on it. Number two- the doctors had many many more positive comments than negative comments and they actually like seeing their positive comments out there and third- it has a significant impact on their brand because it’s change the search dynamics on a site like Google, so instead of when type up University of Utah, ask for a specific physician, instead of all the for profit sites coming up the real information, the good information which is what the university put on the site come up first. And since most of the comments are positive, thats what patients see.so there’s a lot of benefits toward driving toward greater transparency. I think we have a long way to go but we’re definitely making progress.
16:51 Stewart Gandolf: You know that it’s funny, Ive spoken to some of the people from University of Utah and its an inspiring case study and Ive seen some hospitals doing it but to me again going back to inspiring, the people are taking leadership , you know that’s the thing , because it’s easy to talk about leadership until you have you a board and a bunch of people looking, or 500 or 1,000 or 10000 employees looking at you like you’re insane. It’s a different kind of thing. So to actually have the courage and the will to put to deal with the inevitable pushback is terrific. Let’s talk about health care reform and you know value based care and some of those developments because of course patient experience is a lot more evolved because of the reimbursement issues and the way things are going but you know what’s happening there and what should we be thinking about?
17:40 Jim Merlino: Well I think that overall, everybody has an opinion on Health Care reform in the ACA and the thing that strikes me the most is it really doesn’t matter what side of the aisle you sit on, what your political meetings are because the ACA is not really a homogeneous modeling of change it’s something that incorporates a lot of pieces of change . Theres good and bad and people argue the merits on all the little pieces for a long time but the bottom line is that healthcare reform has fundamentally brought some good things to healthcare. The thing that I get excited about is this focus finally, on metrics that matter. What I mean by that is if you look at the value based purchasing program for instance, finally what it has done, which has never been done before in the United States to the degree that it has been, is that its taken things that are really important to patients- things like safety, quality and the service experience and it’s linked providers performance to reimbursement. That is driving significant attention and changes in healthcare and its driving change for the better. Now we know that healthcare organizations have always had wanting to do the right thing for patients in fines?? no question, nobody goes into healthcare because they want to hurt people or harm people. Sometimes the priorities on driving improvements didn’t double up to the appropriate places again you see, you saw it when the institute of Medicine issued their report in 1999 problems, all the safety problem. But what this is doing is its really saying is look, this is important stuff and this is important for patients and we’re trying to improve the delivery of what we do and by the way ,we are going to incentivize performance by linking it to how you get paid and that is a good thing for healthcare and it is driving significant change . So, I think that again regardless of where you sit politically or what you think about the law the good pieces that relate to that are probably going to be around and it’s going to be full for a long time and it’s going to continue to drive significant improvements in health care.
20:03 Stewart Gandolf: you know it’s funny I know we probably talked about this in the past and I have talked about this a lot as there’s also Beyond whether its a law or not, there are Market forces in place anyway that were driving somewhere aspects of it and number two it’s kind of, theres aspects of this that are just sort of the right thing to do, so it’s again I agree totally whether you are a Democrat or Republican or whomever that’s not really the issue it’s just that it’s obviously complicated and maybe sometimes convoluted but some of the core underpinnings are I think inevitable. Its just going to happen in respect to this particular law.
20:45 Jim Merlino: Its interesting sir ,because if you think of it were all part of this healthcare ecosystem, not just because we work in healthcare, or workaround Healthcare, or support healthcare but at the end of the day were all in this together because were all going to be patients and our families are all going to be patients so we should all want to work togetherto figure out what is the best way to drive improvements around this idea of the patient promise of safety, high quality and patient experience Its essential for all of us.
21:13 Stewart Gandolf: I totally agree and you know weve talked offline ,while we have trainers and we do staff training and forth, patient experiences isnt the core of what we do were a marketing firm but in terms, on the other hand it is exactly the core of what we do it right- Its the product we have to our clients and that’s why I’m so passionate about this because just like you said were all going to be patients one day and certainly family members are . Right now I happen to be in an epicenter where my personal family is doing pretty good health wise, but people around me, all kinds of friends and family and professional colleagues has families, either personally or family that have a real health problem right now, there are lots of people, something about it so it’s vital to all of us and for me it just as a mission statement for me thats why I love helping get the word on this about this because I think it’s so vital. Tell me about it, we alluded to, sort of , one of the things you mentioned is value based care and our preparation any additional thoughts about value-based care or the concept and what you really think that means today and where we’re going ?
22:16 Jim Merlino: I think that it was about other than the fact I think it’s finally putting a focus on things that really matter for patients and driving significant change is the other thing its starting to ,do, because we need to do it to accommodate it is getting us to focus on our cultures. If you think about the way we used to execute on hospital operations- there would be a new mandate or new law or regulation or something and wed create a process and the dutiful hospital leaders would execute on that process and wed move along. Today when you think about all the things that organizations have to be held accountable for or I should say are being held accountable for, just executing a new process is not enough. What we need to do to be successful is really get to this core issue of how we start to align our cultures so that everyday people coming to work focused on this idea that the patient is at the center and as a result of that I think what youre seeing a lot of health organizations do is investing in developing competencies in their people to deliver better compassionate connected care, to be more empathetic ,to teach the skills to drive towards an organization that delivers high reliability consistently, to develop competencies like emotional intelligence that directly lead to this idea of how we promote better team work. My colleague, Dr. Tom Lee, wrote this book called
Epidemic of Empathy, he talks about how people come together around common desires to do the right thing and one of the things he talks about is this idea of really driving empathy across an organization. I think that value based care because of the need to transform our cultures to create cultures of caregivers that are more empathetic, that are more connected is going to have a dramatic impact not only on the elements that are in the legislation and in the law but ultimately in how we deliver better care across the country.
24:28 Stewart Gandolf :And you know again we talk about engagement or the culture of caring I can imagine it’s daunting sometimes if a hospital doesn’t have that history, so just like we talked about some tips on safety anything specific or that you think you know if you’re the same CEO or different CEO saying everybody I guess is a good clinician or wants to be good clinicians or they don’t seem to, if they care about the patients they don’t show it, where do they begin to change that? It must be like moving aircraft carrier.
24:59 Jim Merlino: I think that’s a great question I think it starts with building blocks I think first we need to measure a lot of organizations don’t measure caregiver engagement so just as we need to listen to the voice of the patient , we need to listen to the voice of the caregiver. Because ultimately you’ll never hear me say that the caregiver, the employee is more important than the person we serve, the patient and her family, but we should be making sur