Bellwether 2017 vol 9

The Bellwether ď‚› An awards annual dedicated to housing the best and brightest student ideas at Bellevue University

Volume 9 2017

Editor: Amy Nejezchleb Editorial Team: Pat Artz, Kent Burkholder, Karla Carter, Anthony Clarke, Robert Hankin, Brian Kear, Colin Kehm, Tony Jasnowski, Kristin Lynch, Clif Mason, Kaylene Powell, and Dan Silvia Cover artwork: Designated States of America by Brian Kear Laser-cut wood design, Bellevue, NE The Bellwether recognizes and awards academic, innovative, and creative written and visual works. We encourage submissions from across the disciplines. Our mission is to feature outstanding academic projects with a diversity of voices, styles, and subjects meaningful to the BU community.

The Bellwether is further evidence that critical thinking and creative expressions are valued and alive at Bellevue University.

The Bellwether is published in July of each year, coinciding with commencement. Submissions are accepted year-round from BU students and from nominating faculty. Please submit works to writing@bellevue.edu, and direct any questions to Amy Nejezchleb by calling 402-557-7505 or emailing anejezchleb@bellevue.edu.

The content of this publication does not necessarily reflect the views of the editorial team or anyone associated with Bellevue University.

Š2017 Rights revert to the author or artist after publication in The Bellwether.

TABLE OF CONTENTS

 5 Best Overall Bradlee Robbert Brian O’Malley Blaine Blasdell 6 Best Undergraduate Creative Expression Janelle Massey Michelle Shanks 15 Best Undergraduate Formal Composition Katrina Kilgas Taylor Fluellen Colin Rubino 54 Best Technology Project Sahra Henningsen Mahalaxmi Kottapalli Michael LaGreca 118 Best Innovative Business or Community Idea Brian O’Malley Amanda Kunes Deborah Reese 153 Best Graduate Creative Expression Blaine Blasdell Jessica Mohr 164 Best Graduate Formal Composition Bradlee Robbert Amiram Zeiger Alex Kellerstrass

EDITOR’S NOTES

 Welcome to the new and improved Bellwether, Bruin fans! Our purpose has changed from a creative and visual arts publication to an awards annual.

This will help us celebrate amazing student ideas and work.

Another part of the annual awards publication will be cover art that features a community artist. This year’s community artist is Brian Kear. Enjoy the ninth volume!

Brian Kear is the Program Director for the Master of Fine Arts in Creativity and User Experience Designer for Bellevue University’s College of Arts and Sciences. He serves on the Board of Directors and holds the Co-State Director position for Nebraska Academic Decathlon.

As a recipient of the Tom and Annie Pratt Entrepreneurial Award, Brian founded Brainasium Design, a creative design studio specializing in web, print, and product design. He has worked with a gamut of clients (U.S. General Services Administration, The National Industry for the Blind & The City of Alexandria in Virginia, to name a few) and focuses on the intersection of user experience and function to create data-driven design solutions.

In his free time, Brian loves seeking adventure through cycling, snowboarding, and traveling. He is also an active member of the Omaha design community and is passionate about sharing the power design has to change lives.

BEST OVERALL

First Prize Bradlee Robbert SpaceOAR Hydrogel Feasibility

Second Prize Brian O’Malley

A Case for Leadership Development: Analyzing Leadership Impact in the Omaha Restaurant and Foodservice Industry

Third Prize Blaine Blasdell The Bioless

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BEST UNDERGRADUATE CREATIVE EXPRESSION

First Prize Janelle Massey Self-Talk Matters

Second Prize Michelle Shanks

Personal Accountability: The Attainment of a Dream

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JANELLE MASSEY

Self-Talk Matters Being a teen is tough. On top of figuring out who you are and how to navigate this world, you also have to deal with the stresses of parents, grades, peer pressure, bullying, learning to drive, hormones, sex (the list could go on and on)－that’s a lot for one person to handle. But, believe it or not, the toughest obstacle you’ll ever have to face in growing up is you－more specifically, your internal dialogue, also known as selftalk. Your self-talk precedes and determines everything you think, feel, say, and do; therefore, it can either lead you down a constructive path, or it can lead you down a destructive path. For this reason, it’s so important to avoid self-talk that’s negative and self-defeating. Three of the most common types of negative internal dialogues are criticism, complaints, and condemnation; but, with a little practice and awareness, you can turn criticizing into affirming, complaining into attaining, and condemning into accepting.

Turning criticism into affirmation. Instead of criticizing your flaws, focus on affirming your flaws. When you criticize the characteristics that make you unique, you’re setting yourself up to think, feel, say, and do things that reflect the idea of not being “good enough.”

“Senior Picture Day,” by Michele Serros, shows the negative impact criticism can have. In this story, the seventeen-year-old speaker squeezes the sides of her nose to make it smaller and narrower. She had been teased about her nose in seventh grade and has since tried to make it look “less Indian.” She tells herself that, because of her Indian heritage, her nose is unfeminine and that it makes her look like she doesn’t belong. The story ends with her squeezing her nose as she makes her way to school to have her graduation pictures taken.

This story shows just how powerful internal dialogue can be. The speaker’s criticism has clearly damaged her self-esteem－so much so, that she feels compelled to alter her appearance. Unfortunately, she doesn’t consider the possible long-term consequences of that decision. As she gets older, and isn’t as driven by the approval of her peers, she may begin to take pride in her heritage, which may cause her to regret the decision to alter her nose. But, even if you haven’t been driven to the point of altering your appearance, it’s important to know that criticism, alone, can 7

do long-term damage. If you constantly have an I’m-not-good-enough sense of self, you’ll go into many situations with a preconceived feeling of defeat.

So, exactly how do you turn criticism into affirmation? It’s not something that’ll happen overnight－you’re essentially reprogramming your brain that, for years, has been accustomed to negative self-talk.

Therefore, don’t beat yourself up if you find the process challenging－it’s best to just take it a step at a time. That being said, the first step is to become aware of your internal dialogue－practice being mindful of what you say to yourself. If you don’t know how to do this, one way is to set an alarm to go off a couple times a day; when it goes off, reflect and try to spot any self-criticism since the last alarm; as you continue to do this, it’ll eventually become habit. The next step is to really start focusing on replacing criticisms with affirmations. Anytime you catch a criticism, try to come up with twice as many affirmations, no matter how silly they may seem. For example, in response to her self-criticism, the speaker from “Senior Picture Day” could’ve said, “My nose is perfect just the way it is, especially since it displays my heritage,” and, “Because of my nose, my graduation pictures are going to be beautiful.” Practicing positive self-talk will probably feel foreign and uncomfortable at first. But, over time, you will internalize your affirmations. With practice and consistency, you’re self-image will improve, and one day you may even wake up feeling confident. With a new attitude like that, you’ll be ready to face anything－ including your negative self-talk.

Turning complaints into attainment. Instead of complaining about what you don’t have, focus on attaining what you don’t have. When you complain, you’re setting yourself up to think, feel, say, and do things that will actually hold you back from getting what you want. Look at complaining like a roadblock－once you remove that roadblock, you’ll have access to a straighter, easier road towards getting what you want.

“Two Kinds,” by Amy Tan, is an example of this very roadblock. The speaker in this story is an Asian-American woman who reflects on her relationship with her Asian-immigrant mother. The speaker explains how their cultural differences caused conflict in her childhood. Her mother was very focused on making her a child prodigy, and imposed a strict schedule in pursuit of that dream. The speaker, on the other hand, just wanted to find her own way in life, and resented the disapproval she felt from her mother. As a child, the speaker complained about her mother and wished they had a better relationship. Now that she’s an adult, she’s learned to set aside her complaining and has focused on making peace with her mother. She finally acknowledges that the cultural differences will always exist 8

between them, and she’s okay with that now. She also realizes that despite disagreeing with her mother’s methods her mother only wanted the best for her. Unfortunately for the speaker, however, she doesn’t manage to make peace with her mother until after her mother passes away.

The conclusion of this story really drives home the point that complaining can hold you back from attaining what you truly want－ possibly forever, as the speaker learned. In her childhood, the speaker complained about circumstances that were beyond her control－the chances of her mother changing were pretty slim. Even so, the speaker could’ve accepted her mother as she was, just as she wished to be accepted by her mother. Obviously, that wouldn’t have fixed all their problems, but eliminating the complaining and having acceptance would’ve gone a long way towards fostering the mother-daughter relationship she had desired.

To avoid similar disappointments in your own life, learning how to turn complaints into attainment is important. As with criticism, the first step is to become aware of your internal dialogue. When you catch yourself complaining, focus on replacing that complaint with what you can actually do to attain whatever it is you want. For example, instead of complaining, a better alternative for the speaker in “Two Kinds” would’ve been to write her mother a letter. In the heat of an argument, it can be hard to effectively express emotions. Therefore, explaining all of her thoughts and feelings in a letter might’ve helped her mother to understand her better. Similarly, something you can do to understand yourself better is to write your internal dialogue down on paper－seeing all of your thoughts laid out in front of you can give you a much better perspective on how to make appropriate changes. Also, oftentimes in writing, you’ll make discoveries that you otherwise wouldn’t, which can be especially helpful when working to improve your self-talk. Once you get the hang of removing your own roadblocks, you’ll see that the road towards attaining what you want is much smoother than you initially thought.

Turning condemnation into acceptance. Instead of condemning your mistakes, focus on accepting your mistakes. When you condemn your mistakes, you’re setting yourself up to think, feel, say, and do things that prevent you from maturing into the person you want to be. Essentially, condemnation is like denying water to a seed－the seed’s not going to grow into the beautiful flower it’s meant to be until it has water－ just as you cannot grow into the person you want to be until you accept your mistakes.

“Greasy Lake,” by T. Coraghessan Boyle, is a great example of how accepting your mistakes can help you determine who you are－or, who you are not, as the speaker in this story learns. In trying to find 9

himself, the nineteen-year-old takes a shot at the bad boy lifestyle. He experiments with drinking, partying, and other things of that nature. One night, he and his friends drive to Greasy Lake, a place where all the bad boys and girls are known to hang out. The friends loiter in the parking lot, sip on beers, and enjoy their newfound lifestyle. However, their fun is interrupted when they play a prank on a real bad boy, mistaking him for one of their friends. They quickly realize there’s no reasoning with the guy－in a nutshell, it doesn’t end well for them. They all get beat up; the car gets trashed; and they have to run and hide to escape the guy. On top of that, while hiding in the lake, the speaker even comes across a dead body. The next morning, when it’s finally safe for them to emerge, the friends make their way to the parking lot. As they begin driving away in the wrecked car, they’re stopped by a woman, who offers them some drugs and a “good time.” Without hesitation, the speaker responds, “no.”

The speaker’s ambivalent response to the woman is significant－ not only is he saying “no” to the drugs and a “good time,” but he’s also saying “no” to the whole bad boy lifestyle itself. All it took was a little glimpse of reality for him to realize that he’d made a big mistake. It probably wouldn’t be hard for him to condemn himself, especially since there were a lot of things that went wrong, but that would only hinder him even more. A better response, although more difficult, would be for him to accept and learn from his mistake, as it’s the only way he’ll grow into a more mature person.

In order to turn condemnation into acceptance, there’s a few important things you should concentrate on. First, really work to shut off, or at least ignore, your negative self-talk－it will only cloud your perception of the situation. Next, fully explore your mistake－what exactly did you do wrong? What could you have done differently? What did you learn about yourself? Is there a lesson that can be taken away from the experience? How might you handle a similar situation in the future? All of those answers will help you determine the type of person you want to be, but more importantly, it’ll keep you from making the same mistake twice. Finally, when you catch yourself condemning your mistakes, remind yourself that mistakes are a necessary part of life－ mistakes have to be made in order for you to grow into the person you want to be.

As you can see, your internal dialogue is the core of your existence. It plays an important role in determining how you choose to navigate your life. Negative self-talk, such as criticism, complaints, and condemnation, will promote undesirable outcomes; while positive selftalk, such as affirmation, attainment, and acceptance, will promote 10

desirable outcomes. Reprogramming your brain is a process, so it’ll definitely take practice and awareness to positively change your self-talk.

But once you transform your internal dialogue for the better, you’ll realize it’s the best gift you could’ve ever given yourself.

JANELLE MASSEY is an undergraduate student at Bellevue University.

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MICHELLE SHANKS

Personal Accountability: The Attainment of a Dream Have you ever considered that you might personally be contributing to the perpetuation of racism? Subtle behaviors, such as ignoring someone, purposefully avoiding proximity to someone, not making eye contact, making a comment about someone’s appearance, or even telling a joke, can each contribute to the perpetuation of subtle forms of racism. We have all been guilty of such behavior, even if the act was not intentional. These deceptively small slights, over time, cause more damage than do the occasional blatant acts of hatred. Because these subtle acts are usually unintentional, we can work to change these behaviors if we truly are “people of goodwill” by taking three actions toward proactively managing our personal actions or reactions.

The first action we must embrace is to choose a positive reaction toward a real or imagined slight. In his “Letter from Birmingham Jail,” Martin Luther King, Jr. said, “If I sought to answer all the criticisms that cross my desk…I would have no time for constructive work” (King 1301, 1302). He is telling us he will not spend his time or energy on the defensive.

He spent his life trying to facilitate understanding between people and their differences. Someone once told me that “offense cannot be given. It can only be taken.” If each of us chooses not to take offence but rather chooses responses which build a bridge toward understanding and mutual regard, think about the collective success one could have in eradicating racism.

The second action we must implement is to refuse a passive role when we hear or see an unjust racial act or comment. We can no longer stand by and watch or listen. For example, if we hear someone refer to a Brazil nut as a “nigger toe,” we must take action, yet such action must ensure we maintain the dignity of all participants. In this same, “Letter from Birmingham Jail,” King also said, “We will have to repent…for the appalling silence of the good people” (King 1307). Good people, let us join our voices together to eradicate the “appalling silence” we have been guilty of allowing for far too long!

The third action is to help each other as we work, building our skills while implementing the first and second actions. If each of us, with positive regard, works toward raising each other’s awareness of how one’s 12

words and actions are perceived, one creates fellowship and brotherhood.

How differently the Native American man, introduced to us in “The Lone Ranger and Tonto Fistfight in Heaven,” might be had he and his girlfriend actually worked on building each other up instead of tearing each other down. He tells us, “But those arguments are just as damaging as a fist” (Alexie 1262). He also tells us of his regard for Mohammed Ali because Ali “…knew the power of his words…” (Alexie 1262). When we actively and effectively communicate our meaning and intent with the shared goal of creating relationships, we could attain King’s vision of reaching “…the majestic heights of understanding and brotherhood” (King 1304).

Some of you might be thinking, “Well, we can’t control how others respond.” I would ask you to think about the many instances where people’s perceptions and behaviors are influenced by others. We are influenced by what we see and what we hear. Social media can build someone up or tear someone down, regardless of “facts”. We must question whether the idea that we can’t control how others respond is really a true perception. For example, in “The Lone Ranger and Tonto Fistfight in Heaven,” the young Native American man initially chooses to create fear and tension in the 7-11 store clerk when the clerk asked, “Can I help you?”

(Alexie 1261). How did he do this? By his deliberate actions of allowing a long pause before his response, the tone of his response, and even his actions as he scanned the aisles as if he were casing the store. Eventually, our Native American character used humor to dissipate that fear and build a bridge of understanding between them. He successfully controlled the response of the store clerk, both negatively and positively. Our words and actions mean more to others and can have more far-reaching impact than we credit or understand at the time. So, you see, we really can influence how others respond to our words and actions. Let’s be a positive influence, shall we?

You might also be asking how we can go about helping when we are strangers to each other. You personally might feel hesitant in approaching someone because of your own misgivings and insecurities.

Remember this is not about you, but the greater goal of “goodwill toward men”. During a particularly difficult, emotional time for him, the character Walter in A Raisin in the Sun says, “Never mind how I feel…” (Hansberry 1193). You see, there are times when our goal of eradicating racism must supersede our individual personal insecurities and misgivings. We have the potential to make a difference in our neighborhoods and our communities when we strive to be bridge builders toward a community of oneness!

Friends and colleagues, as we work toward the greater good by challenging ourselves to do our part to eradicate the subtle forms of racism exhibited in our own words and actions, we may sometimes fail. Someone may choose to take offense. However, our skills will continue to grow, we 13

will become more effective, and we will not be discouraged. We will help each other succeed, and in our unity, lift each other up. Remember what Mama said in, “A Raisin in the Sun”: “There is always something left to love.” (Hansberry 1205).

WORKS CITED Alexie, Sherman The Lone Ranger and Tonto Fistfight in Heaven. Ed. Joseph P. Terry, Pearson, 2013. 1261, 1262.

King, Martin Luther Jr. Letter from Birmingham Jail. Ed. Joseph P. Terry, Pearson, 2013. 1301, 1302, 1304, 1307.

Hansberry, Lorraine A Raisin in the Sun. Ed. Joseph P. Terry, Pearson, 2013. 1193, 1205.

MICHELLE SHANKS is an undergraduate student at Bellevue University.

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BEST UNDERGRADUATE FORMAL COMPOSITION

First Prize Katrina Kilgas Dunkin’ Donuts Case Study: Why America Runs on Dunkin’

Second Prize Taylor Fluellen A Study in Longevity

Third Prize Colin Rubino

Performance Enhancing Drugs and the Baseball Hall of Fame: Are They Compatible?

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KATRINA KILGAS

Dunkin’ Donuts Case Study: Why America Runs on Dunkin’

BA 463: Global Brand Management Professor Randa Zalman Bellevue University Spring 2017

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Dunkin Donuts Case Study: Why American Runs on Dunkin’ Dunkin’ Donuts is a pastry and coffee retailer that has grown into a household name because of its commitment to its customers, its brand positioning, and its strong value proposition. In this paper, I will be discussing an overview on Dunkin’ Donuts, how it differentiates or compares to competitors, how it has maintained brand consistency, what its value proposition is, as well as how the brand has evolved and increased market share. It is a best-in-class example of how to develop a strong brand identity and scale a business successfully.

Overview Dunkin’ Donuts founder Bill Rosenberg opened the doors of his first store in Quincy, MA in 1950. The store was very successful, and in a short five years he began franchising.

The brand began by selling the ideal breakfast pairing of donuts and coffee. Its menu has evolved but it did so slowly. “Munchkins® (donut holes) were released in 1972, and muffins were added to the menu in 1978.

Bagels were added in 1996, while breakfast sandwiches were added in 1997 (Maeda, 2011).”

Today it offers a wide variety of baked goods, including croissants, biscuits, English muffins and Danish pastries. Its breakfast sandwiches now include flatbreads and wraps; while the drinks category has expanded into iced coffees, specialty coffees (lattes, cappuccino, etc), frozen drinks (smoothies, Coolatas®), iced tea, fruited ice teas, and soft drinks. It has also expanded the menu into lunch, including grilled cheese, klatches, chicken and tuna salad, and chicken and steak snack wraps.

According to their press kit, Dunkin’ Donuts now has more than 11,500 Dunkin’ Donuts restaurants worldwide through a nearly 100 percent franchised model. It has a presence in 41 states across the United States, as well in 40 countries (Dunkin’Donuts, 2017c). Dunkin’ Donuts moved into non-traditional locations when joining forces with Proctor & Gamble and Hess in 2007, and the company went public in 2011. Today, “Dunkin’ Donuts is the world's leading baked goods and coffee chain, serving more than 3 million customers each and every day” (Dunkin’Donuts, 2017a).

The brand has evolved into having a stronger digital presence, including that of a well-structured website, social media presence, and mobile app with ordering functionality.

Points of Differentiation and Parity

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The only way to reach the level of success Dunkin’ Donuts has achieved is through strong brand marketing – brand positioning, brand equity, and brand mantra. Included in this would be defining and establishing points of differentiation.

It is also important to know one’s points of parity – a “me too” characteristic. Sure Dunkin’ Donuts has good tasting products, but so do the likes of its primary competitors, Starbucks, Krispy Kreme and Tim Horton’s. Sure Dunkin’ Donuts have quality products, but again, so do many other companies. The companies also all offer baked goods and retail packaging for home brewed coffee, including availability in K-Cups for Keurig.

Dunkin’ Donuts prides itself on providing high levels of customer service. This is also, to me, a point of parity as many of its competitors also focus on customer service and the guest experience.

So what makes Dunkin’ Donuts different? Dunkin’ Donuts positioned itself as the brand for “every man” or for the hard working American. This is a key differentiation from a brand positioning perspective. For instance, Starbucks created its own lingo for ordering coffee. This can be perceived as pretentious, or annoying to the non-regular Starbucks-goer. This is why Dunkin’ made the conscious choice to keep it simple. The company opted for simple language (small, medium, large), not only for the ease of ordering but for the ease of training employees. This shows it knows who it is and don’t need to pretend to be something it is not.

Although Starbucks and Dunkin’ both have an extensive food menu, the two menus do have points of differentiation. Starbucks’ sandwiches are positioned as gourmet, while Dunkin’ Donuts’ sandwiches are more fastfood style, staying consistent with the brand’s market positioning. Dunkin’ Donuts is clearly differentiated as a hybrid of categories - coffee category and fast food.

Accessibility is also a big point of differentiation. Dunkin’ Donuts consistently offered a competitive price point, as it was important to Bill Rosenberg that the average Joe could afford to buy a quality cup of coffee.

Although I mentioned “quality products” is a point of parity, the scientific testing done by Dunkin’ Donuts throughout every stage of the supply chain (which creates quality products) does also deliver a key point of differentiation: consistency. Consistency delivers high levels of comfortability, trust, confidence, and best of all, loyalty. Freshness would be another point of differentiation. The tight industry standards of only allowing a pot of coffee to sit around for 18 minutes ensures its quality products always taste their best.

The brand also prides itself on offering convenience as the brand strives to offer convenience to consumers by way of location (corner

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locations, near airports, etc.), as well speedy purchases (including drive thru service).

Brand Consistency Dunkin’ Donuts has created a strong brand and maintained consistency throughout the years – targeting average, hardworking Americans who are on the go. Although the brand messaging has evolved throughout the years, at the heart of each campaign is a message that speaks to the middle class American consumer – a message that tells them this brand understands you, this brand cares about you, and this brand is here to keep you fueled at a fair price so you can work hard all day.

“In 1982, the company began its famous ‘Fred the Baker’ commercials.

Fred, played by Michael Vale, became one of television's most enduring and endearing pitchmen. He was the face of the company until 1997 (Maeda, 2011)” and symbolized the brand persona - the “every man” or real, hardworking person that the brand wanted to be associated with. He was also pivotal in brining personality to the brand and helping consumers develop an emotional connection to the brand.

The slogan most consumers recognize today, “America Runs on Dunkin’®” launched with a television campaign in 2006. This maintained the authentic messaging and clearly defined brand essence moving forward.

In 2008, the brand launched a defining campaign, which helped the company take the lead in the coffee category. The campaign was “Dunkin’ Beat Starbucks,” and the purpose was to inform consumers that the results of an independent taste test showed that a “significant majority of U.S. coffee drinkers preferred Dunkin’ Donuts coffee over Starbucks” (Mastrangelo, 2009). In 2009 the brand launched its “Breakfast NOT Brokefast” campaign. The newest iteration of the popular “America Runs on Dunkin’®” campaign declared that in these challenging times, a fast and delicious breakfast needn't cost Americans more than pocket change” (Mastrangelo, 2009). This clearly was meant to poke fun at and separate the company from premium brands, such as Starbucks, and Brandweek actually named Dunkin’ Donuts “Marketer of the Year” for this campaign.

Although this didn’t stray from its branding strategy, the timing was perfect given the economic downturn. It gave Dunkin’ Donuts the opportunity to reach consumers that had not previously been open to its messaging.

The consistency of the branding strategy has clearly paid off given how it has delivered such strong brand recall and awareness. According to the CBIG Awareness Omnibus Study, Dunkin’ Donuts has a 94 percent brand awareness – “and that is even in markets where Dunkin’ doesn’t have stores yet” (Dunkin’Donuts, 2017b).

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This consistency has also developed a strong brand affinity amongst consumers - consumers feel a strong emotional connection with the brand.

“I remember stopping in here with my father on Saturdays for coffee and a doughnut before heading in to town,” Quincy resident Robert LaFleur said.

“Dunkin’ Donuts has been like a centerpiece of my family” (Rienwald, 2011). I have several friends from the East coast that will only eat donuts from and/or drink coffee from Dunkin’ Donuts.

This sentiment of heritage and brand consistency delivers loyalty.

According to the Dunkin’ Donuts press kit, the company has been recognized as number one in customer loyalty in the coffee category by the Brand Keys Customer Loyalty Engagement Index. It must be doing something right.

Value Proposition The company’s mission, as stated on its franchise site is to “deliver high quality food and beverages quickly, affordably and conveniently in a welcoming environment” (Dunkin’Donuts, 2017b). The company values are stated as: honesty, integrity, fairness, responsibility, transparency, respect, and humility. The mission statement and core values have helped develop the Dunkin’ Donuts customer value proposition.

A value proposition should articulate why a customer should do business with a company or buy its products. It should be at the core of why the company exists, how its products can add value to a customer’s life, and how the company is different from the competition.

Speed and convenience are two factors that go into the value proposition. According to Scott Murphy, senior vice president of operations, “It is important to us that even premium menu items and more complex menu items don’t disturb the speed of service at the drive thru, which is why we place great emphasis on training in all of our restaurants to ensure our guests are receiving the best quality and service possible (Oches, 2016).”

One way they have worked to maintain this commitment to speed, aside from employee training, is by leveraging and developing digital technology. Dunkin’ Donuts On-the-Go Ordering was an addition to its app that allowed guests to place orders up to 24 hours in advance of pick up. The store then confirms with the app user once the order is ready for pick up at the drive thru.

“On-the-Go Ordering is a key example of our efforts to provide guests with an enhanced experience, and as we continue to look for ways to distinguish our brand, drive-thru consistency and convenience will be something we focus on,” Murphy says (Oches, 2016).

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Market Share With entrants to the coffee category market, including chains such as Starbucks and Krispy Kreme, or even local specialty shops, Dunkin’ Donuts has had to rethink its strategy. Had it maintained its focus on its core products – donuts & coffee (regular & decaf only), or even its core target market – the company would have failed. Dunkin’ is a great example of a company that has adapted to the changing times to not only survive but thrive.

Dunkin’ Donuts accomplished this by expanding its product offerings (product mix) to grow into new market segments. According to the case study video, whenever the brand has elected to introduce new products into the product mix, the company has conducted extensive consumer marketing studies to ensure the products will be well-received.

This is another testament to customer commitment.

Andrea McKenna, Director of Advertising & Sales Promotion, led the team in developing an integrated marketing program with a new positioning “coffee and…” featuring coffee, with a secondary emphasis on the namesake product. She helped introduce new products in coffee and expanded the category to hot, cold, iced, flavored, and frozen choices with various roasts. She also introduced complimentary baked goods as “addons” to coffee and expanded purchase cycle to other times of day with appropriate new products that included lunch items. The result was an expanded target market (including multi-generational appeal), increased frequency of purchases, ultimately resulting in increased profits (Perez, 2017).

Another reason to consider improving the product mix was the declining sales in donuts due to the expansion of the more health-conscious consumer. The result was the DDSmart® product offerings. This line of products offers a reduction in calories, fat, saturated fat, sugar, or sodium by at least 25 percent. Featured menu items include oatmeal, multi-grain or whole wheat bagels, turkey sausage, egg whites, and reduced fat muffins. I believe there is still an opportunity to keep growing the low-calorie menu options as I do not foresee this market segment declining. Adding more vegan or gluten-free options should be a consideration for the brand.

The brand has been expanding domestically and internationally.

“Dunkin' Donuts opened 55 stores across Europe last year, boosting its continental footprint to more than 220 locations, according to the company. The store openings are part of expansion plan in Europe that began at the end of 2014” (Groden, 2016).

In 2015, Dunkin’ Donuts expanded its market share by opening in four European countries— Denmark, Georgia, Iceland and Poland—for the first time. When Dunkin' launched the expansion, it told Bloomberg 21

that it planned to open more than 1,000 stores across the continent that catered to local tastes (Groden, 2016). The same article stated the brand intended to recruit franchisee groups for Belgium, Finland, France, the Netherlands, Norway, and Turkey. South Africa, China, Brazil, Mexico, and Austria have also been target markets for market share expansion.

Obviously, the slogan “America Runs on Dunkin” won’t work in international markets. The CEO, Nigel Travis, has a strategy for expanding internationally – it is to re-brand the franchise in every new country. This might even mean changing the brand’s namesake menu completely. For instance, in India, Dunkin' Donuts introduced a burger called the “Tough Guy Burger” (Schlossberg, 2014).

Another big opportunity for the brand would be to create more of a presence on the west coast. I also see on the franchisee website that the brand is actively recruiting franchisees in west Texas (Midland/Odessa area).

Consumer packaged goods was another market growth opportunity for the brand. As mentioned previously, Dunkin’ Donuts has its own line of K-Cups for Keurig single cup coffee brewing at home. This segment is a big growth opportunity for the brand.

Finally, the brand has also launched various digital marketing campaigns to reach new, younger market segments via the mobile app, social media channels, and a rewards program that incentivizes mobile app purchases. An opportunity for the brand is to clearly define its marketing strategy to Millennials and clearly differentiate itself from competitors like Starbucks.

All too often brands try to be everything to everyone; as a result their brands lose effectiveness. Dunkin’ Donuts is an example of a brand that knows who it is and doesn’t stray from its customer focus on product development and market expansion. From its advertising tone and messaging to its value proposition, Dunkin’ Donuts is a great marketing case study of how to be a first-class marketing leader that knows how to evolve with and capitalize on the changing market conditions.

REFERENCES Dunkin’ Donuts. (2017). About us. Dunkin’Donuts. Retrieved from https://www.dunkindonuts.com/en/about/about-us Dunkin’ Donuts. (2017). Franchisee Website. Dunkin’Donuts. Retrieved from http://www.dunkinfranchising.com/franchisee/en/brandPower.ht ml

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Dunkin’ Donuts. (2017). Press kit. Dunkin’Donuts. Retrieved from https://news.dunkindonuts.com/presskits/dunkin-donuts-presskit Groden, C. (2016, February 11). Dunkin' Donuts has big plans to expand in Europe. Fortune. Retrieved from http://fortune.com/2016/02/11/dunkin-europe-expansion/ Maeda, W. (2011). History of Dunkin' Donuts. Retrieved from http://archive.boston.com/business/gallery/dunkin_donuts_histo ry/ Mastrangelo, A. (2016, September 16). Brandweek names Dunkin’ Donuts a 2009 Marketer of the Year. Dunkin’Donuts. Retrieved https://news.dunkindonuts.com/news/brandweek-names-dunkindonuts-a-2009-marketer-of-the-year Oches, S. (2016, October 03). Inside Dunkin’ Donuts drive-through strategy. QSR: Limited-Service, Unlimited Possibilities. Retrieved from https://www.qsrmagazine.com/reports/drive-thru-2016-dunkin Perez, M. (2017). Case study: Dunkin’ Donuts. Repositioning with new product categories. Chief Outsiders: Fractional CMOs for Accelerating Growth. Retrieved from https://www.chiefoutsiders.com/dunkindonuts-re-positioning-with-new-product-categories Reinwald, C. (2011, November 30). Original Dunkin’ Donuts in Quincy goes retro - The Boston Globe. Retrieved from http://www.bostonglobe.com/business/2011/11/29/dunkinoriginal-flavor-back/6YdwVPXY0iQjrIQDU7P8HN/story.html Schlossberg, M. (2014, December 30). Dunkin' Donuts is plotting a huge expansion. Business Insider. Retrieved from http://www.businessinsider.com/dunkin-donuts-is-expanding-likecrazy-2014-12

KATRINA KILGAS is an Omaha, Nebraska native. She currently resides in Gretna, Nebraska and is married with two children. In her free time, she coaches baseball and flag football. Her professional aspiration is to work as a senior marketing officer for a Fortune 500 company. Her passion is B-toB and digital marketing.

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TAYLOR FLUELLEN

A Study in Longevity A comparative study of life longevity between Arctic and Tropic sharks: with special emphasis in Somniosus microcephalus (Greenland shark), Galeocerdo cuvier (Tiger shark)

Bellevue University Biology Senior Thesis 24

On April 2, 1513, Ponce De Leon first set foot on Floridian soil, becoming one of the first in a number to lay conquest to the new world.

Yet through his pilgrimage, one legend ironically surpasses the test of time and stands resolute: the fountain of youth. In fact, Ponce De Leon is so synonymous with these mythic waters, Francisco Lopez De Gomora’s La Historia General de Las India’s (1551) records how the General so adamantly looked for waters which the locals claimed could reverse the trials of aging and even “put a stopper to death” that he would take many personal trips to Bimini where they claimed it waited to be found. (1) With the advancements in medical science, the rise of life expectancy experienced in the modern age has only heightened our collective desire as a species to find new ways to prolong our lives. In 2004, the “EMBL/EMBO Science and Society Conference on Time & Ageing— Mechanisms & Meanings” focused on the nature of time in relation to aging as well as a further examination of our universal desire to cheat death.

The uniquely human desire to live eternally was plainly evident in the ancient Egyptians’ all-consuming desire to preserve the human form forever, even to the point that we can study the body hair and tattoos of pharaohs four thousand years later. At the beginning of the 20th century, the life expectancy of the western world was around 50 years of age. Only a few generations later, this number would rise to 75-plus years. (2)

The current life expectancy in the western world. (3) 25

This massive rise in the life expectancy of the population was due simply to the evolution of the population’s general understanding. Hygiene practices improved, immunization practices skyrocketed, and infant mortality rates dropped, all the while launching modern humans to the forefront of understanding the relativity of human aging. (2) When discussing ageing we are referencing the trials and wear that our bodies are subject to through the course of our lives, the same wear and tear Ponce de Leon longed to remedy. This desire to remain young and fit is just as relevant now as it was when de Leon began his search for answers 503 years ago. Coincidently, as the General was making his historic voyage to the tropics, 5,436 kilometers to the north, deep beneath the Arctic Ocean around the Greenland coast, an animal was born and more impressively is still alive today, belonging to the classification of Somniosus microcephalus: the Greenland Shark. (4)

Somniosus microcephalus: The Greenland shark. (5) A simple question one might ask is “what makes a fish what it is?”

The common response might sound a little like this: a fish lives in water and receives oxygen by filtering it out of water through its gills, and it has fins to steady and propel it through its environment. Its body is covered by scales, skin or boney plates, its heart has two chambers, and finally, it lays eggs. All this is the vernacular scientists use to describe the fish. (6) That being said, sharks are classified in this same fish category, yet all the above scarcely could describe this animal adequately. For example, sharks don’t have skin, nor do they have scales or bone plates. Rather, they 26

evolved to have flesh that’s ten times the strength of cowhide, and each “scale”—for lack of a better word—has a pointed end that is sharp enough to cut a man’s hand. (6)

The “skin” of a shark under a microscope. You can visibly see the incredibly sharp pointed ends (7).

The shark’s outer layer is in fact made of specialized material similar to its teeth; it’s often described as having the feel of sandpaper. This acts as a form of protection from other sharks and also gives the animal firmness denied to them by their lack of a bone endoskeleton. (8) Sharks, however, are housed in a subgenus belonging to fish known as ‘Elasmobranchs’ originating from the Greek word for “beaten metal and gills”. (6) The classification of animals allows for an easily referenced road map to the animal kingdom. This framework is used to categorize all life on Earth and can be broken down in a few easy steps.

When connecting the dots of ancient ancestors, it is important to look at each genetic step within a classification. (9) When looking for a specific fish, for example, the first question one can ask is if it has a skull. This will narrow the search. All these animals below this specific adaptation (under the fish classification) are connected to this first development, meaning they all share lineage with the first skulled fish. The branching at this point is home to the lamprey and hagfish, wormlike living fossils. Next we look to the jawed vertebrates which house the breaking points of the cartilaginous, boney, and ray-finned fish. (10) In every regard, it would be forgiven of one were to believe that the shark, though they hold the highest regard in oceanic predation, are rather below fish on the evolutionary scale. As far as evolution is concerned, boney fish surpasses that of the cartilaginous variety, but not for the predator’s lack of ability or abundance of habitat. It’s denied top billing because of its more primitive makeup. The shark has changed very little since it first appeared on the scene some 400 million years ago. (11) When the first fish developed around 450 million years ago during the Ordovician period (12, 13), the notochord (the precursor to the modern 27

vertebrae) was the newest advantage nature had to offer. The development of the notochord would further the evolutionary success of the first fish, who would then spilt to form new advantages in conquering the prehistoric seas (14). The many evolutionary trials would ultimately come down to two victors, the boney and cartilaginous fish (each housing its own unique subdivisions); yet, the blue prints that encircle all fish and their prehistoric and modern decedents began with a common ancestor. (6) The jawed fish first emerged during the middle of the Paleozoic era. According to findings by Byrappa Venkatesh, Mark V. Erdmann, and Sydney Brenner in their paper Molecular synapomorphies resolve evolutionary relationships of extant jawed vertebrates, regardless of appearance or morphology all fish, including the ones possessing a cartilaginous endoskeleton, are in fact devoid of having any separate lineage from the first jawed fish of the oceans (8,9,13). Even though bone is seemingly the more advantageous of adaptations, cartilage flourished just as fulsomely in sharks, rays, and chimera. Both bone and cartilage are specialized structures of connective tissue and both have cells which are embedded in what is called an extracellular matrix. However this matrix is where the differences between cartilage and bone occur. (9) While bone does have its advantages suited to many environments, cartilage is especially suitable for sharks in many ways. Its light weight is perfect for an animal in need of added buoyancy. It is also avascular and more flexible then hard bone, perfectly suited for contorting and making sharp turns when on the hunt. (11, 15) But probably the most important distinction one can make from the skeletal structure of the shark is that, unlike that of bone, cartilage is resistant to compressive forces, the perfect adaptation of a species that thrives in the dense and extreme pressure of the deep ocean. The further down one goes, the more crushing ocean pressure can become. Bars are the unit in which ocean scientists (oceanographers) measure pressure. When at sea level that equals to about one bar of pressure; however, when under water, any diver knows that the pressure increases with every meter one travels down. For every ten meters one travels down, the pressure increases about one bar. At a depth of 460 feet (or 140 meters) below sea level, the pressure increases to around 14 bars (or 200 psi) (12). Boney humans are unsuited for the massive pressure the ocean exerts, which illustrates one of numerous examples of how sharks evolved to function in this kind of environment. Humans must breathe specialized air which limits our attainable depths while sharks of every caliber can function in the deepest part of the ocean. This is the beauty of cartilaginous fish: because of their biomechanical makeup they are able to not only handle these circumstances but flourish in them. (16) Another adaptation that developed within cartilaginous fish is the evolution of an adaptive immune system. Adaptive immunity is generated 28

when lymphocytes have the ability to cut parts of DNA and then mold new combinations as a result of altering the genome (9). These small changes in the DNA can create a multitude of possible combinations generating a huge range of possible sequences. In addition, this adaptive immunity generates an immunological memory so that after an initial response to a pathogen, the body is prepared for a future enhanced response. This whole process depends on many factors; for instance, age affects stem cells and as we age and mature, new gene sequences develop as a result of maturing stem-cells (8). Location and environment play a role as well, and what an individual is exposed to will factor what proteins recognize as antigens (Ag) and how the immune system adapts. Fish that have a cartilage endoskeleton are the oldest animals in the animal kingdom to have the ability to generate RAGbased Ag receptor diversity. This allowed the two branches of fish to fully develop and conquer their environment, becoming the dominant species in not only the primordial seas but the entire prehistoric world as well. These creatures, older than trees and dinosaurs, had the capability of an adaptive immunity that would not be surpassed until the development of the human system some 200,000 years ago. This was confirmed by a study via transcriptome analysis of a nurse shark, where results showed that this species, and theoretically all of its cousins, possessed the primordial remanence of an adaptive immunity. This was obviously shocking due to the lack of T cells found in cartilaginous fish. T cells are the major type of lymphocytes in humans. (17)

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The immune system is divided into two categories innate and adaptive immunity. Innate Immunity is the body’s non-specific defense to an antigen. The response usually takes a few hours and uses physical barriers to deter attack. Defense includes the skin, blood chemistry as well as immune cells that will attack foreign invaders. The next type of immunity is adaptive; this antigen specific immune response is more complex. This system acts like a computer processing and recognizing the offender before it finally creates an army of cells designed specifically to destroy the antigen. The adaptive immunity also processes a memory to further fight off the antigen should it reappear. (18) The magnitude of this discovery in laymen’s terms is that 420 million years ago the common ancestor of the shark had a subsystem that allowed its body to eliminate pathogens as well as stunt their growth. (14, 15, 19) This might be why sharks are very unlikely to ever develop degenerative diseases such as cancer. It was long believed that sharks were immune to cancer.

After more thorough research, this myth has been dispelled. However, sharks do processes an incredible cancer shield that has allowed them to prevent the onset of the diseases. (8, 20) Dr. Eric Velazquez, a professor of medicine at Duke Global Health Institute, recently conducted a study with live cells extracted from Cacharius glaucus, also known as blue shark, a strictly pelagic Pacific species that is hunted by game fishermen almost daily causing great harm for its population (21). Dr. Velazquez has become a vocal protector of sharks based on his claim that we can learn so much from their (as he describes it) “perfect” immune system. We might one day develop a cure for not only cancer but also HIV. When this animal was injected with the HIV/AIDS virus, the animal’s body (20) completely oxidized the virus out. This method of defense is found in all species of sharks. This theory alone further highlights the importance of the survival of these creatures. After all, if there was ever an opportunity to cure these deadly debilitating diseases, it is with the conservation and study of these mysterious animals.

Of the thousands of specimens in the Smithsonian Institution’s aquatic tumor collection, which range eons, less than twenty are actually from sharks, while only two of those are thought to have been malignant.

To support the uncontrollable growth of tumors, they secrete a hormone called angiogenin. This hormone causes blood vessels to reroute blood to the tumor to feed it the necessary nutrients to sustain its fast metabolism.

New research in cancer prevention conducted by Dr. Robert Langer of MIT has revealed that sharks and other cartilaginous fish produce an angiogenin inhibitor that denies the tumors ability to excrete angiogenin. (6, 9, 15) This causes the tumors to essentially choke and die, drowning in their own waste products. Recent studies on Carcharhinus falciformis, commonly known as the silky shark, show that in their early stages sharks 30

don’t have specialized anti-bodies. This is similar to human embryos, for this changes only as humans grow. (9, 13) This is known as broad spectrum serum antibodies. As a human infant develops, its antibodies become more specialized, allowing for these antibodies to become better adapted to the verity of pathogens they are exposed to. Once the anti-bodies are specialized, they cannot change function. Sharks, however, keep this nonspecific immune response throughout their lifetime. This allows them to detoxify harmful compounds without prior exposure. Studies show that when sharks are injected with carcinogens, coliform bacteria, and fungal toxins in lethal concentrations, these animals have detoxified the pathogens with what appears to have no lasting effects. (22)

However strong their immunity and defenses sometimes it isn’t enough; this picture taken off the coast of South Africa of a Great White shark with a tumor protruding from her mouth. It is unclear if the tumor is malignant or benign. This observation further dispels the myth that sharks are immune to cancer. Yet the rarity of this occurrence only raises more questions about their biochemical makeup. (23) Stemming from the evolution of the Acanthodes bronni (the first true sharks), 440 known species of sharks developed. All possessed varying traits and abilities, but each shark remained entirely unique. These species 31

have dominated their ecosystem and subsequently lived in every sea-based environment (as well as some freshwater locations). From the warm shallow tropics to the deep open seas, they most surprisingly even adapted to the sub-freezing waters of the Arctic Ocean. (24)

Acanthodes bronni (24) There is a natural misconception to believe that since we are vertebrates, all vertebrates fit into the same box as us, whether in ability, durability, or even longevity. Take any 100-year period, and it is easy to believe that all vertebrates share a similar life span. The perfect animal to dispel this belief is the Greenland shark. (12)

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This graph shows the estimated lifespan concluded by carbon dating in reference to the Greenland shark, illustrating that the oldest recorded specimen was estimated to have been born around the early to mid-1500s. (25) Somniosus microcephalus, otherwise known as the Greenland shark, is a rather curious animal. Growing to around 7 meters, relatively the size of its more famous cousin the great white, the Greenland shark has a very long tubular body with a rounded snout and a domed head, as referred to on page 4. This alien-looking creature gives off the appearance of a lost Soviet submarine coasting through the Arctic seas. Living in freezing waters and covered by a near constant foot of ice, this animal is incredibly sloth-like, yet it somehow is capable of hunting fast-moving prey such as seals, squid, and even birds. (24) Upon dissections, polar bear and reindeer remains have been recovered—which is all the more shocking given the fact that nearly every Greenland shark is blind. This blindness is due to a copepod parasite known as Ommatokita elongate which will burrow into the animals cornea rendering the whole optic organ useless. (20) So how exactly does this almost lethargic blind shark, living in nearly total darkness, hunt such fastmoving prey? There are many theories centering around methodical and almost relentless behavior which brings to mind the fable of the tortoise 33

and the hare. In 1999, a month long study conducted by Dr. Greg Skomal found that these animals don’t spend all their time on the ocean floor (24) but often stalked the seal population with a presumably superior sense of smell as they navigated the cold waters (24).

Another hunting mechanism the Greenland shark has tucked away in its arsenal is the same one that all species of shark possess: the amazing ability of electro-sensors. Electroreception is the ability to navigate and discern the Earth’s magnetic fields. It is comparable to echolocation with the ability to discern sound waves as means of hunting, similar to that of wales, dolphins, and bats. Our own sonar systems mimic this ability. Sharks however can read, for lack of a better word, the electro pulses that other animals and prey emanate (12, 17, 22 ). This is done by using an extra sensory organ housed along its snout in jelly-filled pores known as the Ampullae of Lorenzini, which are the little freckles or holes people see along the snout of sharks. Sharks are able to rely on this organ as well as others to hunt and capture their prey. In the case of the Greenland shark with its acute sense of smell accompanied by the Ampullae of Lorenzini, the lack of visibly may not be as damning. (22, 26)

This illustration maps out the pores that allow all sharks to sense the world around them on an electromagnet scale. (27) Marine species as a whole usually have long lives. From dolphins to whales to octopi, it is generally accepted that 250+ years is a perfectly natural life span; however, determining an actual age has been almost impossible in the past. It has been proven difficult to determine the age of sharks because with a vast majority we don’t even know where they reproduce or their population numbers, let alone how old they are. (17) The seemingly ideal scenario would be to put a shark in an aquarium and observe its life in a controlled environment. However, most sharks don’t survive long in captivity. Also, in captivity animals are fed on a regular basis, assuming they are willing to eat. A ten-foot tiger shark held in Florida’s Marineland in 1996 didn’t eat for five months after capture. Many such sharks die of starvation or engage in activities of self-harm like 34

ramming into the walls and glass of their aquarium. For reasons such as these, studying captive animals would most likely not show accurate results.

It is also important to note that many of the sharks on display are already on the brink of death, dying from injuries sustained when captured. The only way to truly understand these animals is to study them where they ought to be, in the sea. (6) Until recently, the most common method of dating marine life such as sharks was the band rule. As with trees, scientists would take a sample of bone or cartilage and examine the rings within it also known as bands. The number of bands was thought to convey age. This method trivial at best due to the fact that as classified, sharks have a cartilage structure which breaks down over time. The only remanence of ancient sharks is their jaws and teeth. Cartilage does not commonly fossilize and cannot survive fossilization in the ocean. This and other reasons have discredited the band rule as a peer-accepted method of determining age. (6, 11, 26, 28) The beauty in science lies in how the answer is always on the horizon. Sharks are notoriously difficult to date because of their migration patterns and because they go to places and depths where we simply cannot follow. However, in a recent study modern science may have found an answer using the same methods scientists use to date prehistoric beasts. We can extract the DNA from bones from long deceased animals such as the wooly mammoth. All archived fossils have huge value in DNA genetic and genomic analysis. This has long been envied by shark scientists believing this method moot due to the animal’s lack of bones. However, though sharks have a cartilaginous skeleton, their teeth and jaws are hard bone.

(That is how we know of ancient sharks such as the megalodon, the ancient 50-foot monster that terrorized the seas 2.6 million years ago.) Geneticists have now proven that DNA can be extracted from the jaws and teeth of a shark, alive or long dead. In a study by Nielsen et al, the team simply asked themselves: why not use this same method of DNA extraction that is used on ancient animals on a shark? The results were astounding (4, 19, 28) the team used six different methods to extract DNA from a Tiger shark’s jaw for temporal genomic studies, and all methods resulted in great success.

Next, they ran similar tests with white shark jaws from a trophy hunt in 1912 which yielded a significant amount of DNA. The conclusions were that the age of the sample did nothing to deter adequate findings, nearly all samples even those that where 100 years old. The team therefore concluded that archived shark samples as well as fresh ones can be used for genomic or genetic testing and also allowing shark scientists to expand elasmobranchs DNA yield (19). We can conclude from this that by studying DNA samples from ancient and living sharks we can learn more of their genetic makeup and even go so far as to replicate their impressive immune 35

capabilities (13, 19). This gives scientists means to determine the longevity of ancient species of sharks, and by doing so they can compare the life longevity of modern and prehistoric species.

However, new information discovered by lead scientist marine Biologist Julius Nielsen from the University of Copenhagen used carbon dating to determine the age of a specific female Greenland shark as well as 28 other individuals, and the results where incredible. The idea to resort to carbon dating came because the band theory proved useless since the specimen’s vertebrae had no rings to measure. Taking a leaf out of archeology’s book, the team decided to give carbon dating a try; this would only be applicable to fresh specimens, though, because without a fresh sample there is no true way to determine age as a result of bone structure— or lack thereof. Since carbon dating is the process of extracting DNA from fossilized material, the issue with carbon dating ancient sharks is that they do not have any fossilized bones to date. Apart from their teeth, the cartilage skeleton will completely brake down over time. A beautiful adaptation that these animals developed to conquer their environment leaves scientists very little to study. (2, 4, 10) Using the pulse carbon-14 method that was produced during the early 1950s, the team of scientists were able to determine the age of the animal by means of observing a heavy isotope left behind by American nuclear bomb testing. Noticing the abundance of carbon-14, the team concluded that they were actually looking through a window to the past. By examining the bomb pulse and seeing how this particular pollution had been introduced to the ecosystem in the early 50’s and had completely infiltrated these waters by the mid 60‘s, this proved that the inert anatomy developed at a particular time. For example, eye lenses will have an abundance of this element.(4) in many cases, nuclear radiation affects cell composition by weakening cell walls; it can also inhibit their functionality, causing all manner of problems for an organism.

Because of this technique, the team was able to deduce that two of their specimens, both only 2.2 meters in length, were born in the 1960’s while a smaller individual was born in 1963. This proved that any animal that was considerably larger than the individuals born in the 60’s that did not have this elemental remanence would have been considerably older than the bomb blasts factoring in how slow these animals age. This resulted in the discovery that not only is this the slowest growing vertebrate in the world. It also concluded that they only reach sexual maturity at nearly 150 years of age, and, most intriguingly, that of the animals sampled, the oldest was carbon dated to be nearly 500 years old! (4).

The next level of inquiry is what allows this particular species to have such an extended life span. Of the other 440 different species of shark, the only one that has any merit of longevity of life is the Carcharodon 36

carcharias, the Great White shark living at an estimated mere 75 years. In fact the universal average maximum age of sharks is 50 years in the wild. (In captivity that drops an average of 13+ years depending on species). The first captive great white shark was brought to the Okinawa Churaumi Aquarium in Japan in early January of last year. It died after only three days in captivity. Judging by its 11-foot (about 3.3 meter) stature, it was estimated to only be around three years of age. (20) Greenland sharks are a staple in Greenland, Iceland, Inuit and Nordic culture and cuisine. Although the meat of the Greenland shark is mildly poisonous, the natives discovered that if it is boiled in vinegar for a few days it becomes somewhat edible, but consuming it is not worth it unless one is massively desperate. (20) The earliest studies done on the Greenland shark were from the 1900’s. In those studies, fishermen began a yearly shark tagging experiment (in which the dorsal or tail fin of a shark is pierced with some manner of equipment to judge age, sex, longevity and migration) only to discover that the Greenland shark had been rumored by the locals to have a mysteriously long life (24). An article from Science magazine presenting findings from the University of Denmark says that “In the 1930s, a fisheries biologist in Greenland tagged more than 400 (sharks), only to discover that the sharks grow only about 1 centimeter a year, a sure sign that they’re in it for the long haul given how large they get.” Since they are roughly 7 meters in length, this takes a significant amount of time. In 2014, a female Great White was recorded off the coast of South Africa as being a recordbreaking eight meters long, completely discrediting the notion that the largest Great White stops growing after 4-7 meters. (20) What allows for this particular species to have such an incredible life span? Neilson and his colleagues determine that its environment must play role in the creature’s longevity. Cold water is theorized to slow down the animal’s growth (the Greenland shark only growing around a centimeter a year) as well as their biomechanical activity (4). A geneticist at the University of Michigan, Shawn Xu, postulates that perhaps its arctic environment is somehow slowing its metabolism. The basic hypothesis was that it simply lives its life in slow motion. However, recent studies on nematodes done by Dr. Xu proved that extreme cold can affect specific aging genes (29). The experiment showed that certain antiaging genes are activated when presented with a frigid environment that will allow for the nematodes to better fold proteins as well as rid themselves of DNA damaging molecules—both factors which might extend life. He suggests that this could easily explain what is going on within the Greenland sharks cells. (3) In connection to our own desire for an abnormally long life, this relates to the once farfetched notion of freezing humans in the hopes of 37

extending life, also known as cryogenics. In fact this is essentially what the nematodes were being subjected to. The present theory that the same thing is essentially extending the life of one of the largest species of shark seems to only add fuel to the fire that a human might survive such a process. In 2016, the English High Court allowed a 14-year-old cancer patient to be cryogenically frozen in the hopes that when woken she might reemerge in a world where she could be cured of her illness. She said, “I want to live and live longer and I think that in the future they might find a cure for my cancer and wake me up.” (30) While the Greenland sharks lifespan is a marvel of nature, this adaptation for a seemingly eternal life is not found throughout the shark population. In fact the common maximum age of any shark species is around 45-50 years (11). For species such as the blue shark and tiger shark, it is significantly shorter, ranging anywhere from 15-25 years. Occasionally, a tiger shark might live to see fifty. With special emphasis on the tiger shark in comparison with the Greenland shark, we might be able to discern how these similar, but vastly unique, creatures poses such massive differences in their longevity of life. (31) The tiger shark is easily recognized by its rounded snout and silted nostrils and also by its dark grey stripes that fade with age. It is these stripes that inspired its name. This shark was first universally named in 1635 as the “Tiger of the Sea.” This apex predator commonly migrates along the coast between the Atlantic, Caribbean, Pacific and Indian oceans while still maintaining a presence in freshwater river mouths and estuaries. Tiger sharks prefer shallow temperate tropical waters; however, they have a presence in the deep open ocean surrounding the Polynesian and Hawaiian islands. In a study conducted by the University of Hawaii, 15 Tiger sharks were surgically implanted with ultrasonic transmitters in the hope that the team could study the migration patterns of this wide traveling species. (31) These transmitters would send pulse signals to buoys strategically placed throughout the island chain for around 800 days. The results showed that these animals come and go in no real pattern but that the juveniles seem to stay in deeper water, most likely to avoid larger sharks that would cannibalize them. (11) This species is slightly smaller than its Artic counterpart, only growing between 4-6 meters in length. Again in contrast to the slow growing Greenland shark, the tiger shark is almost rapid in its maturation.

Past studies of growth show that it seems the animals that frequent the Hawaiian coast don’t mature as equally as the same species in another part of the ocean. However, many of these studies come under scrutiny for using “invalidated vertebral ring counts.” Consequently, after further review it was concluded that in fact the growth rates of the Hawaiians tiger shark population are equal to the growth rates of tiger sharks living elsewhere.

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When pondering its rapid growth, scientists deduce that the vast array of prey and the tiger shark’s infamous diet contribute to this unique adaption (11). Modern accounts tell of car bumpers, license plates, and bags of money that have all been removed from the stomachs of tiger sharks. This species is notorious for eating anything and everything including turtles, dolphins, fish, rays, house pets lost in shipwrecks and hurricanes, and even other sharks. The tiger shark is the second most dangerous shark to humans. Its insatiable hunger leads to its dominance in both its environment as well its metabolism (20).

Tiger shark (32) Another distinction between the Greenland shark and the tiger shark lies in how metabolism relates to longevity. As stated above, the frigid waters and lack of speed that the Greenland shark displays lead scientists to believe that its metabolism is equally quelled. Conditions are completely opposite when observing the tiger shark. It’s a fast-moving, aggressive animal that has been known to hunt anything that it comes into contact with (including humans) (11). Upon dissection, as far back as the 1700’s, a barrel of nails and a medieval suit of armor have been removed from a tiger shark’s stomach. This is the only shark capable of such bazar tastes because it has the adaption that the muscle wall of the stomach is three times thicker than any other shark (12). That gives it the rare ability to break down just about anything and extract nutrients from litter and other waste products.

Its metabolism has been compared to that of an Olympic swimmer. It is constantly moving and living in a tropical environment and has no issues finding its next meal. One can make the logical leap that its shorter lifespan 39

and quicker metabolism are results of simply location. The tiger shark evolved to dominate warm tropical waters, and there is no need to live a long life when food is abundant and you reach maturity quickly. If the Greenland shark lives life in slow motion, the opposite is true for the tiger shark: it lives in the fast lane. (19) To understand another factor pertaining to how one species can outlast generations of another, we might have to look to ourselves. The Greenland shark lives in solitude, alone and adrift in a sparsely-populated area, very rarely having contact with people. In fact this animal is left relatively alone partly due to its extreme habitat but also because this fascinating animal has a trait undesirable to shark hunters, a trait that has allowed it to escape the fate that many of its relatives. The flesh of the Greenland shark is actually mildly poisonous and the skin contains such high levels of urea that not only does it smell like a urinal when examined, but when consumed it causes symptoms of inebriation or even paralysis (9). Urea is a byproduct that is formed by protein metabolism within the liver. Because urea contains ammonia, it must be filtered from the liver and blood and excreted in urine, and the conversion to ammonia is what makes urea poisonous. (9) These factors have protected the animal from the shark fishing industry’s eye.

However, one of the main reasons nearly every species of shark is on the endangered animals list is because of the barbaric practices of shark finning and illegal shark fishing from ocean sanctuaries (20). The predominantly Asian cultural pseudo-shamanism belief that the shark fin, which is the key ingredient in shark fin soup, somehow aids in male virility has created a very lucrative, very cruel and very illegal business that has reduced every major shark species by almost 90%.

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A victim of shark finning (33) The practice of shark finning involves catching sharks, slicing off their fins, and then simply throwing away the wounded sharks, leaving them to drown or be eaten alive by other animals. Therefore, the Greenland shark with its poisonous skin has the ultimate defense against the horrible act. Additionally, it is in the same family as the dog fish shark so it has very small fins: an almost non-existent dorsal fin and very short pectoral fins. It is thought that it has developed this anatomy because of lack of use. So its location and its difference in anatomy have aided it in avoiding this act of human cruelty. (6) Yet the tiger shark has not been so lucky, because its habitat puts it into close proximity of people, and because of its fast-moving nature, it’s dorsal and pectoral fins are much larger. Having those larger fins is a key factor in its predation methods, but they also make it a key target for shark fishermen. In a 1993 study from the University of Hawaii to determine population numbers, a team of biologists set out to tag 420 tiger sharks of which only 50 returned to the island waters during the one year study.(31) Perhaps it’s not only the environment that the Greenland shark prowls that aids in its mysteriously long life, but the lack of attention it has received from people that has given it the ultimate protection. Both species are the apex predators of their given environment, both possess acute senses that have evolved over more than four million years to be the dominant presence in marine predation, arguably taking into account how little the environment changed through the course of history resulting in an almost perfect makeup (13). Everything about these animals makes them 41

superior for their lot in life. From jaws that were birthed from the first jawed fish to its skeletal makeup perfectly adapted to the crushing pressure of the ocean and its amazing ability to adapt to every ecosystem the water has to offer, sharks are only rivaled by our own ability to adapt, including their superior immune system that was also dominant until we arrived on the scene. Still, in comparison to the tiger shark, it seems the Greenland shark has every advantage. (34) The difference in longevity between the tiger and Greenland sharks seems to come down to two main factors. First of all, the Arctic environment that the Greenland shark has evolved in and adapted to breathes life into this ancient animal as the cold water slows the metabolism and allows this animal to flourish past what was always perceived as the breaking point of life. While the tiger shark lives in the temperate waters of paradise with a metabolism any woman would die for, it simply does not have the biochemistry to support a long life. Secondly, the Greenland shark has the advantage of a remote environment, something the tiger shark lacks while living in warm, subtropical waters where its contact with people is extremely common. The latter is forcing us to examine our own contributions to this animal’s fate.

If someone dedicates their life to the conservation of whales, elephants, or polar bears, they are seen as heroes, champions of both nature and the environment. If that same person saves sharks, they are seen as crazy or thrill seekers looking more for an adrenaline rush then as real scientists or environmentalists. However, these ancient animals hold such promise for modern science. An individual animal nearly as old as recorded history itself is shedding new light on the science of aging and longevity.

New studies are re-examining the idea that extreme cold can prolong a life to ages never dreamed of. The supreme immunity that sharks posses is on the forefront of curing cancers and HIV among other diseases and pathogens. If we were able to synthesize this or mimic it in any way, imagine the impact it could have on our own lives. Imagine being able to remove toxins as the silky shark does, have a metabolism mimicking that of the tiger shark, or witnessing the birth of your great, great, great grandchild.

All this and more might be gained through the study and conservation of sharks. May we have time to understand the science behind these phenomenal features before they disappear. Protecting these animals out of both respect and desire to push ourselves to new heights could be the catalyst for the next stage human evolution.

SOURCES 1) Juan Ponce de LeĂłn Spanish explorer Written By: The Editors of Encyclopedia Britannica 42

2) The Greenland shark: A new challenge for the oxidative stress theory of ageing? By Costantini D1, Smith S2, Killen SS2, Nielsen J3, Steffensen JF3 3) Life expectancy at birth graph, OECD, 2007 4) Eye lens radiocarbon reveals centuries of longevity in the Greenland shark (Somniosus microcephalus). Nielsen J1, Hedeholm RB2, Heinemeier J3, Bushnell PG4, Christiansen JS5, Olsen J3, Ramsey CB6, Brill RW7, Simon M8, Steffensen KF9, Steffensen JF9.

5) Image of Greenland shark, Extreme Marine, Bangor University 6) Focus on sharks by Sara R. Riedman, Elton T. Gustafson, AbelardSchuman (pg. 36-42, 131-142, 178-192) 7) Shark skin image, Hightech.com 8) Molecular synapomorphies resolve evolutionary relationships of extant jawed vertebrates Byrappa Venkatesh*†, Mark V. Erdmann‥, and Sydney Brenner 9) Modern genetic analysis by Anthony J. F. Griffiths, William M. Gelbart, Richhard C. Lewontin, Jeffery H. Miller Freeman and Company 1999, 2002 (pages 491-497) 10) Evolution of the Earth 7th addition by Donald R. Prothero, Robert H. Dott, Jr, McGraw Hill, (pg. 51, 270, 299-304) 11) The shark almanac by Thomas B. Allen the Lyons Press, (pg. 55, 17, 37) 12) The American museum of natural history OCEAN the definitive visual guide, DK, 2014, by, David Peart, Dr. James P. McVery, Sue Scott (Pg. 168169, 192-194, 206-209, 228-229, 328-323) 13) Zoology By Stephen A. Miller, John P. Harley, McGraw hill (pg. 46, 299-305, 316) 14) Elephant shark genome provides unique insights into gnathostome evolution by Byrappa Venkatesh,1,2 Alison P. Lee,1 Vydianathan Ravi,1 Ashish K. Maurya,3 Michelle M. Lian,1 Jeremy B. Swann,4 Yuko Ohta,5 Martin F. Flajnik,5 Yoichi Sutoh,6 Masanori Kasahara,6 Shawn Hoon,7 Vamshidhar Gangu,7 Scott W. Roy,8 Manuel Irimia,9 Vladimir Korzh,10 Igor Kondrychyn,10 Zhi Wei Lim,1 Boon-Hui Tay,1 Sumanty Tohari,1 Kiat Whye Kong,7 Shufen Ho,7 Belen Lorente-Galdos,11,12 Javier Quilez,11,12 Tomas Marques-Bonet,11,12 Brian J. Raney,13 Philip W. Ingham,3 Alice Tay,1 LaDeana W. Hillier,14 Patrick Minx,14 Thomas Boehm,4 Richard K. Wilson,14 Sydney Brenner,1 and Wesley C. Warren14 15) Estimation and analysis of biological parameters in elasmobranch fishes: a comparative life history study Michael G Frisk, Thomas J Miller, and Michael J Fogarty Published on the web 10 April 2011.

16) The complete mitochondrial DNA sequence of the shark Mustelus manazo: evaluating rooting contradictions to living bony vertebrates. Y Cao, P.J. Waddell, N. Okada, M. Hasegawa

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17) Shark with lowest-known metabolism is a sluggish success February 2, 2016 by Hayley Rutger / Mote Marine Laboratory.

18) Classification of immunity chart, slideshare.net March 30, 2014 19) Extracting DNA from 'jaws': high yield and quality from archived tiger shark (Galeocerdo cuvier) skeletal material. By Nielsen EE1,2, Morgan JA3, Maher SL2, Edson J4, Gauthier M5, Pepperell J6, Holmes BJ2, Bennett MB2, Ovenden JR2.

20) Super Shark Encyclopedia and other creatures of the deep by Derek Harvey, DK| penguin random house, New York, New York 2015 (pg.

37,147-148, 155) 21) Picture of Blue shark, university of Florida 22) Organ halogen contaminants in Greenland shark(Somniosus microcephalus) By Anna Strid 23) Shark Tumor image, live science.com 24) Acanthodes bronni image heritagedaily.com 25) Greenland shark life longevity graph taken from realclearscience.com 26) Biology of the Greenland shark Somniosus microcephalus. By MacNeil MA1, McMeans BC, Hussey NE, Vecsei P, Svavarsson J, Kovacs KM, Lydersen C, Treble MA, Skomal GB, Ramsey M, Fisk AT. 27) Ampulla of Lorenzini image from sharkproject.org 28) Comparative studies of high performance swimming in sharks II. Metabolic biochemistry of locomotor and myocardial muscle in endothermic and ectothermic sharks. By Bernal D1, Smith D, Lopez G, Weitz D, Grimminger T, Dickson K, Graham JB. 29) First insights into the nature and evolution of antisense transcription in nematodes, Christian Rรถdelsperger, Kevin Menden, Vahan Serobyan, Hanh Witte and Praveen Baskaran, Shawn Xu 30) Article published by the Telegraph written By Gordon Rayner, Chief Reporter; Lexi Finnegan and Henry Bodkin 31) Growth and Maximum Size of Tiger Sharks (Galeocerdo cuvier) in Hawaii by Carl G. Meyer,1,* Joseph M. O'Malley,2 Yannis P. Papastamatiou,3,4 Jonathan J. Dale,5 Melanie R. Hutchinson,1 James M. Anderson,1 Mark A. Royer,1 and Kim N. Holland1 William Hughes, Editor 32) Tiger shark image by Daniel Botelho, Dive magazine 33) Image of shark finning victim bonnet head shark, Bali Animal welfare association 34) The shark handbook 2nd edition, Cider Mill Press, by Dr. Greg Skomal (pg. 60, 77-88,178-188, 275) My name is TAYLOR FLUELLEN, I am a senior at Bellevue University, studying Biology. I grew up as a Navy brat traveling from place to place. My life was a menagerie of near constant change, and throughout all of this the ocean has always been my touch stone. The sea and its inhabitants have 44

always been my passion. Sharks became an obsession later, and through great fascination and study they have not only become my career choice but my life’s purpose as well.

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COLIN RUBINO

Performance Enhancing Drugs and the Baseball Hall of Fame: Are They Compatible?

For years now, some of Major League Baseball’s biggest stars have been left out of the Hall of Fame for a reason they all have in common, performance-enhancing drugs. Performance-enhancing drugs, or as commonly stated, PEDs, have had the power to keep household names such as Barry Bonds, Roger Clemens, Mark McGwire, and Sammy Sosa from earning Baseball’s greatest honor. But for what reason? Is it because the members of the BBWAA, the people who make the Hall of Fame selections, are out to make the players pay for their decisions to cheat? Or is it to serve as a lesson for the future generation of ball players; that cheaters never prosper? Whether it’s one or the other, the overall belief of the selection committee is that these players should not be allowed in to the Hall of Fame. However, there are other sides that believe otherwise. And while the Hall of Fame selection committee might think they have quality reasons for excluding these players, it’s only a matter of time until the committee recognizes the other great viewpoints that suggest including them. A list of these viewpoints might include the importance each player played to the excitement and growth of the game, each player’s ability to flat out play ball, and the lesson that each player could pass on to the future generation of players. As soon as the Hall of Fame election committee understands these concepts, all will be right with Major League Baseball, PEDs, and all the people who are caught in-between.

Whether he or she liked the player or not, anybody who watched Major League Baseball in the 1990’s or 2000’s could agree that Barry Bonds, Sammy Sosa, and Mark McGwire were all reasons to turn on the TV. More importantly, even, these players were the main causes for the dramatically increasing attendance numbers in ballparks across the nation (Lindholm, 2014). Baseball was starting to reclaim its history of being America’s most popular sport, all because the game became exciting again. As more balls began to fly out of the park, people suddenly found more reasons to pile inside of them. The 1998 baseball season shows exactly that, an increase in homeruns with an increase in attendance to accompany it. Not only did two 46

players annihilate the previous homerun record of 61 set by Roger Maris, but Mark McGwire even managed to hit 70, to Sosa’s 66 (Hersh, 2015).

To add to the excitement, these two players competed on rival teams in the midst of one of baseball’s toughest divisions. For the fans, it felt like they were being introduced to a new era of baseball, where it was normal to hit 50 homeruns or more at distances never seen before. It was new, it was exciting, but it was still baseball. Baseball saw a large increase in popularity when players began playing the game of baseball at a higher level than ever before.

Assuming the consumption of PEDs was the extra step to becoming the best, if it were not for the players who took that extra step, teammates and opposing players would have never had a higher level of play to strive for. In 1999, the average batting average for all the players across the MLB peaked at .271. Being that 1999 was right in the middle of the steroid era, many are not surprised by the increase in batting averages across the league. In 2015, however, the average batting average had dropped to .252, and the pitchers have reclaimed their dominance (baseballreference.com, 2016). Can it be concluded that facing better hitters has forced pitchers to step up their game over time? Or has the lack of recent PED use caused hitters to be overmatched by their counterparts on the mound? Everything is cause and effect within baseball, so it is impossible to say that hitters as impactful as Barry Bonds, Mark McGwire, and Sammy Sosa did not change the course of baseball forever. The same argument can go for pitchers such as Roger Clemens, who was also accused of using performance-enhancing drugs. In a league where an athlete’s 47

performance writes his paycheck, nobody can afford to be overmatched.

Considering the pitchers whose jobs could be put at stake by the firepower of the opposing hitters, it would be foolish to assume that only hitters took part in the doping. For 24 years, Roger Clemens was an effective pitcher in the Major Leagues (MLB.com, 2016). While there is no doubt that part of his success can be attributed to the use of PEDs, there is also no doubt that his success helped other players become better.

Think ahead 20 years from now, assuming all records stay the same, a scenario where a kid interested in the history of baseball asks his father why the person with the most homeruns in the history of Major League Baseball is not in the Hall of Fame. The kid claims, “but I thought the best players were supposed to be in there?” The dad may think for a second and say to his son, “That is true, they are. But these people are not the best because they cheated to get there.” As the kid ponders his dad’s statement, he wonders if it is fair to judge someone’s whole career on the fact that he willingly (or unknowingly) made the decision to cheat and if his cheating was the reason for all of his success. Similar to the kid, many people today debate the same controversial questions. For example, Barry Bonds has been called one of the best hitters in MLB history, yet he cannot even find himself a place on the list that essentially puts it in writing. It may not seem like a big deal now because most people recall seeing Barry Bonds play, but it will be harder for people who did not live during his time to comprehend his true legacy as a hitter. John Smoltz and Pedro Martinez, two of the most celebrated pitchers of the 20th and 21st centuries, have been recorded saying Barry Bonds is the best hitter they ever had to face.

That is coming from two Hall of Famers who pitched a combined 39 years in the Major Leagues (MLB.com, 2016). Bonds, who has earned seven MVP’s and is owner of the Major League homeruns record, has clearly shown why he deserves to be on that Hall of Fame list. Though, as reported

by Mark Townsend (2016) at Yahoo Sports, Bonds stated in a press conference that he “doesn’t really have an opinion about it,” when asked about his current Hall of Fame status. However, it does appear he has an opinion on the situation, as he goes on to say, “I know that I’m a Hall of Fame player… there’s not one player that can sit there and say that I’m not one. There’s not a coach that’s ever coached me that says I’m not one.”

Barry clearly believes that his production within baseball has spoken for itself, and that nobody can take away who he has been as a player. The same idea goes for Roger Clemens, who managed to claim seven Cy Young awards in his 24 years on the mound (ESPN.com news services, 2014).

During an in-game interview with the New England Sports Network, a television company owned by the Boston Red Sox and Boston Bruins, Clemens discussed his views towards his Hall of Fame situation. Although he claims he is unaffected by the failure to recognize his name in the Hall, 48

he believes he played the game the right way and that he should at least be recognized for that. Roger Clemens takes pride in playing the game of baseball because he loved it, not because he was caught up in making the Hall of Fame (McDonough, 2015).

If the statistics of these legendary players remain in the record books, then why are their names being ignored in the place that has been created to acknowledge those statistics? The fact is, these players played in a poorly regulated, juiced-up era of baseball. What is most unjust is discrediting the accomplishments of great players who played during a time where PEDs weren’t uncommon. Realistically, the majority of players were probably caught up in some sort of PED use at some point in their careers.

They just did a better job at not being caught. There have been cases where former players have come out and spoken up about former teammates taking PEDs, and since that time some of those accused players have been inducted in to the Hall of Fame without any of their wrongdoing being publicized (Neyer, 2016). Those players did not get in because their actions were ignored; instead, they made it in because nobody found out about them. Drug testing had yet to become a major thing, so it was not irregular for players to get past the screenings. George Mitchell, an employee for DLA Piper Global Law Firm, submitted a report to the Commissioner of Baseball concerning the use of performance enhancing drugs by players in Major League Baseball. George claims that former players estimate between 20% and 30% of baseball athletes used large doses of steroids while an even greater number of players used smaller doses. The testimony reported by Mitchell speaks on an era that was not held captive by mandatory drug testing, as it was not established within Major League Baseball until 2004.

And even once drug testing became mandatory, consumers taking specially formulated human-growth hormones were able to slide by undetected by urine tests (Mitchell, 2007). The report essentially proves how the drug testing program that was in effect before any renovations were made was unreliable for exposing all who were breaking the rules. If this were the case, it can be assumed that countless high profile athletes escaped punishment, and in result escaped the infamy that players like Bonds and Clemens would later endure. For the committee to exclude legendary players from the Hall of Fame infamous for their use of PEDs, the committee must also agree that everyone inside of the Hall of Fame is clean. In that case, all it would take is one or two members from the current Hall of Fame to come out and admit their guilt, and the BBWAA would be forced to reconsider their criteria for voting players into the Hall of Fame.

Here’s a fact true to life: actions yield consequences, and consequences yield lessons. In the case of the cheating players who feel like they have been wronged out of their spot in the Hall of Fame, they can attest to that better than almost anyone. Their misguided actions may have 49

led to initial successes, but in the end, they would all have to face the ultimate consequence bestowed upon them by the voters. Voters like Tom Verducci, a TV commentator and writer for Sports Illustrated magazine, believe their vote “is an endorsement of a career and how it was achieved,” and that “voting for a known steroid user is endorsing steroid use.” Tom brings up a good point in that people should not advocate steroid use, but he is forgetting that there can be exceptions to certain ideas. People like Tom encourage making decisions based on what’s on the surface rather than taking a deeper look into the situation. His judgment of each player is based off of their use of PEDs with no consideration for the reasons that may have caused them to take them, such as the era they were competing in or the legal health restorations they were looking for (Verducci, 2014). After all, it is important to teach the future generation that a lot of thought and consideration has to go into the process of decision making for the decision to be correct.

If players like Barry Bonds, Roger Clemens, and Sammy Sosa could be inducted into the Hall of Fame, they would be more likely to use their years of controversial headlines and news stories to shed light on the dangers of PED use. Some may argue that these players could do the same thing now, but even more effectively considering they still have not earned the Hall of Fame honor. What baseball does not realize, though, is that these players are still upset over that decision, and it is causing them to be less vocal concerning the situation. Any person who has been denied credit for something he or she has accomplished knows how horrible the feeling is. Soon, that topic becomes something he or she no longer likes to discuss.

The same goes for the situation baseball is dealing with concerning PEDs and the players that have been ridiculed for using them. Once the affected players get what they want, being their induction into the Hall of Fame, they will be much more likely to come out and speak publicly on the issue of PED use in baseball. In order for the message to really get across to kids and players of this generation, it is essential for the players who have experienced the trauma to be the ones communicating the message.

Famous Big Leaguers are the people that kids look up to and idolize; if they whole-heartedly say something is wrong, then those kids are going to believe that it is wrong. Otherwise, you have kids growing up angry at the idea of a drug test rather than accepting that it is in place for everyone’s safety and the sport’s integrity. All of this goes on to support the hypothetical solution that was mentioned earlier: If members of the current Hall of Fame came out and admitted their use of PEDs, the PED-using ballplayers currently being withheld would most likely be inducted in to the Hall of Fame, as well. As for now, that has not been the case, possibly because those people are afraid they will be stripped of the honor if they say something. But in reality, members of the Hall of Fame who are coming 50

out with information as big as that could essentially serve as the bridge between the acceptance of PEDs in the baseball Hall of Fame.

“Cheaters never prosper” is a statement quoted often, by many. If one is the BBWAA, she takes this statement and she lives by it. The voters of who makes it into the Hall of Fame have made it aware to everyone who is concerned, that they will not send players who have been caught using PEDs to Cooperstown. If one is the BBWAA, does he allow any exceptions for this rule? The answer is yes. According to the evidence, it would almost be unethical not to allow exceptions. For years, players like Barry Bonds and Roger Clemens have been scrutinized for their use of PEDs, and in result, have been excluded from the Hall. In 2016, however, it has become apparent that the criteria in which the voters base their votes on is flawed. Bonds and Clemens played in an era where drug testing was practically non-existent, an era where almost half the players were assumed to be taking some sort of PED. It is unfair to put a lot of weight on a player’s cleanness, when it cannot be proven whether or not everyone who has been previously inducted is clean himself. Along with that, the voters are forgetting the importance a lot of these Hall of Fame-potential players played to the game of baseball and the skill that they possessed while doing so. The news of PED use has distracted the voters from the other aspects of each player’s game, and has in a sense created a bias towards voting for those players. History has shown that it is hard to change someone’s view once they set it in stone, but that’s not to say it isn’t possible. A possible solution to the ignorance of the BBWAA might be the thing they fear most: current Hall of Fame inductees admitting their own use of PEDs during their time of play. Not only would it force the voters to reconsider all of their previous selections, it would more importantly cause them to take a second look at who they didn’t include. While the BBWAA could take a step backward and choose to expel whoever admits their guilt, the more beneficial course of action would be to accept that era of baseball for who it is and proceed to make right what was wrong. In that scenario, legends like Barry Bonds, Roger Clemens, Mark McGwire, and Sammy Sosa would all be able to sleep peacefully through the night, knowing their name and face rightfully resides within Major League Baseball’s Hall of Fame.

REFERENCES Baseballreference.com. (2016). Major League Baseball Batting Encyclopedia. Retrieved from http://www.baseballreference.com/leagues/MLB/bat.shtml ESPN.com news services. (2014, November 25). Randy Johnson on Hall of

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Fame ballot. Retrieved from http://espn.go.com/mlb/story/_/id/11929826/randy-johnsonpedro-martinez-john-smoltz-hall-fame-ballot Hersh, P. (2015, October 12). Sammy Sosa-Mark McGwire home run chase? We should have known better. Retrieved from http://www.chicagotribune.com/sports/columnists/ct-essay-cubscardinals-spt-1012-20151012-column.html Lindholm, S. (2014, February 10). Major League attendance trends past, present, and future. Retrieved from http://www.beyondtheboxscore.com/2014/2/10/5390172/ major-league-attendance-trends-1950-2013 McDonough, C. (2015, July 23). Roger Clemens: Hall of Fame status 'does not make a difference in my life'. Retrieved from http://nesn.com/2015/07/roger-clemens-hall-of-fame-nod-doesnot-make-a-difference-in-my-life/ Mitchell, G. J. (2007, December 13). Report to the commissioner of baseball of an independent investigation into the illegal use of steroids and other performance enhancing substances by players in Major League Baseball. Retrieved from http://files.mlb.com/mitchrpt.pdf MLB.com. (2016). Roger Clemens stats. Retrieved from http://m.mlb.com/player/112388/roger-clemens MLB.com. (2016). Pedro Martinez stats. Retrieved from http://m.mlb.com/player/118377/pedro-martinez MLB.com. (2016). John Smoltz stats. Retrieved from http://m.mlb.com/player/122477/john-smoltz Neyer, R. (2016). Yes, there are already steroids in here‌ Retrieved from Just a bit outside: Passionate, nuanced, authentic website: http://www.foxsports.com/mlb/just-a-bit-outside/story/baseballhall-fame-steroids-candidates-010115#fb-root Townsend, M. (2016, February 20). Barry Bonds makes strong statement regarding Hall of Fame status. Retrieved from http://sports.yahoo.com/blogs/mlb-big-league-stew/barry-bonds-

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makes-strong-statement-regarding-hall-of-fame-status213732561.html Verducci, T. (2014). Why I'll Never Vote for a Known Steroids User for the Hall of Fame. In M. Haerens (Ed.), Opposing Viewpoints. Doping.

Farmington Hills, MI: Greenhaven Press. (Reprinted from Sports Illustrated, 2013, January 8) Retrieved from http://ic.galegroup.com.ezproxy.bellevue.edu/ic/ovic/Viewpoints DetailsPage/ViewpointsDetailsWindow?failOverType=&query=& prodId=&windowstate=normal&contentModules=&displayquery=&mode=view&dviSelectedPage=&displayGroupName=Vie wpoints&limiter=&currPage=&disableHighlighting=&displayGrou ps=&sortBy=&search_within_results=&p=OVIC&action=e&catI d=&activityType=&scanId=&documentId=GALE%7CEJ301090 7225&source=Bookmark&u=nebraska_bell&jsid=c319c891afb736 78b5d35c4b73bcfe25

COLIN RUBINO is a sophomore student, working towards a bachelor's degree in sports management with a plan of earning a master’s degree in business management. His plan is to pursue a career in baseball for as long as the sport will allow him, but his ultimate plan is to eventually find an enjoyable job within the world of sports that will allow him to live comfortably with his family.

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BEST TECHNOLOGY PROJECT

First Prize Sahra Henningsen GameOver1

Second Prize Mahalaxmi Kottapalli Dinosaur Amusement Park

Third Prize Michael Lagreca Dinosaur Amusement Park

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SAHRA HENNINGSEN

GameOver1 Please find Henningsen’s project at http://professorkarla.com/home.aspx.

Process Journal Weeks 1 & 2 I started this journal late; even though, I did keep track of my thoughts on notebook paper. I usually did this while I was working on the assignment. I would just jot down what I was thinking or what I was doing, such as when I was getting stuck on particular areas of the assignment, which did happen quite often. So, my thought processes here are that I am supposed to create a project that reads and writes data along with working and functional 404 and 500 pages. The project needs to be useful to a company. I had some serious trouble coming up with ideas for this. However, I figured out what I am going to do! I am going to create a website that will allow managers to edit information in the database without having to actually open a database and alter data through query writing.

Today, I tried to create a basic website. For some reason, I cannot seem to create one accurately; even though, I have done this numerous times! I am actually going to just go online and download paint.net to create or alter a free banner. I need to find something that will make my website pop. I have been pondering on what to name the website, what it should entail, along with the color schemes that I think will look good for it. So far, I am thinking of blue and yellow. I know this sounds bad, but if you put both colors together they really pop! I will post a couple of screenshots of the colors I have been looking at.

BLUE AND YELLOW COLOR SCHEME (see below left): GREEN AND CREAM COLOR SCHME (see below right):

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I like how they contrast against each other, how they seem to pop out.

However, I think the dark green and beige/cream would look a bit more professional. Between the two choices, here are the colors that I have chosen: DARK GREEN AND BEIGE/CREAM:

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I know how important it is to have colors contrast against one another in the website. It helps those users with visual impairments to distinguish between all parts of the site.

Okay, I have figured out why I was having an issue with the creation of the web page. I wasn’t creating the page using empty content; instead, I was creating the page with forms already held within it. I had to go through and delete the folders that I had created due to the fact that I needed to clean up the website folders that were no good. So, after a few days of a struggle, and going back into the basics of the book, the beginning, I was able to create the web site! I couldn’t believe the issue was something that was so small. So, I have named my website Game Over! I would like to point out that I am sure my instructor recognizes this name. I had her as my instructor for another class, E-Commerce, and I created a database in SQL Server Management Studio so that I could take screenshots for a final project in that class. So, I had a database that I could use! So, I created my default page, the employee page, company page, and product page. I was going to see if I could fit all of my code on just one page, but the final 57

project entails more than that, I think. I will work on the default code tomorrow or the day after.

It has been a few days since I worked on this project. I am behind on the lab assignments due to the fact that I want them to look perfect, and there always seem to be issues with my code. Anyway, I worked on the Home page today. I was going to go for the basic web form, asking what the user would like to alter, the company information, the employee information, or the product information. After coding it, though, and looking at the results in the design tab of the Default.aspx page, I realized that I was going to have to approach this in a different kind of way.

I decided I wanted the user to be able to see the data in a table type setting without any unnecessary information getting in the way. Thinking back to our chapter 11 assignment, I realized that the best way to go about this would be to create a web page with tabs at the top. The user could read the home page, choose which tab to click according to the information she wishes to add, edit, delete, or view. In order to accomplish this, I will need to add a site.master page. I will work on this and post the code for that page here in pieces as I complete the work.

Okay, here is the code that I have for the sitemap page: <%@ Master Language="C#" AutoEventWireup="true" CodeFile="site.master.cs" Inherits="GameOver" %> <!DOCTYPE html> <html xmlns="http://www.w3.org/1999/xhtml"> <head runat="server"> <title>Welcome to Game Over!</title> <link href="Styles/Home.css" rel="stylesheet"/> <asp:ContentPlaceHolder id="headPlaceHolder" runat="server"> </asp:ContentPlaceHolder> </head> <body> <header> <img src="Images/GameOverBanner.png" /> <h1>Game Over!</h1> <h2>Here to serve every gaming need!</h2> </header> <section> <form id="formMaster" runat="server"> <nav id="mainMenu">

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<asp:Menu ID="Menu1" runat="server" DataSourceID="SiteMapDataSource1" Orientation="Horizontal" StaticEnableDefaultPopOutImage="False" BackColor="#006600" DynamicHorizontalOffset="2" FontNames="Verdana" Font-Size="90%" ForeColor="White" StaticSubMenuIndent="10px"> <DynamicHoverStyle BackColor="#FFFFCC" ForeColor="Green" /> <DynamicMenuItemStyle HorizontalPadding="10px" VerticalPadding="4px" /> <DynamicMenuStyle BackColor="#FFFFCC" /> <DynamicSelectedStyle BackColor="#FFFFCC" /> <StaticHoverStyle BackColor="#66FF66" ForeColor="#333300" /> <StaticMenuItemStyle HorizontalPadding="10px" VerticalPadding="4px" /> <StaticSelectedStyle BackColor="#507CD1" /> </asp:Menu> <asp:SiteMapDataSource ID="SiteMapDataSource1" runat="server" ShowStartingNode="False" /> </nav> <div id="mapPath"> <asp:SiteMapPath ID="SiteMapPath1" runat="server" FontNames="Verdana" Font-Size="90%" PathSeparator=" : "> <CurrentNodeStyle ForeColor="Green" /> <NodeStyle Font-Bold="True" ForeColor="#284E98" /> <PathSeparatorStyle Font-Bold="True" ForeColor="#507CD1" /> <RootNodeStyle Font-Bold="True" ForeColor="#507CD1" /> </asp:SiteMapPath> </div> <asp:ContentPlaceHolder id="formPlaceHolder" runat="server"> </asp:ContentPlaceHolder> </form> </section> <footer> </footer> </body> </html>

Now, this code includes the Web.sitemap that I also created. I needed to create the tabs for my main page, so this is an important aspect for this step. I had some issues with the workup on this part. I ended up putting it off for a while since I really needed to catch up on my labs and weighty posts.

Anyway, here is the code that I think I may insert into my Web.sitemap page: 59

<?xml version="1.0" encoding="utf-8" ?> <siteMap xmlns="http://schemas.microsoft.com/AspNet/SiteMap-File1.0" > <siteMapNode url="Home.aspx" title="Home" description="Home Page"> <siteMapNode url="Company.aspx" title="Company" description="Company Maintenance" /> <siteMapNode url="Employees.aspx" title="Employee" description="Employee Maintenance" /> <siteMapNode url="Products.aspx" title="Product" description="Product Maintenance" /> </siteMapNode> </siteMap> I will probably have to return to the program and try this out here in the next few days. I hope this works, as the assignment is having some issues. I have been trying to locate the database. I went ahead and coded the database name into the Web.config. Pretty easy since the database is called GameOver.mdf, and I just need to do a command prompt search to locate it.

I found the database! I was actually preparing to create a new one. Here is how I found it: c:\Program Files\Microsoft SQL Server\MSSQL11.MSSQLSERVER\MSSQL\DATA\GameOver.mdf and I checked everywhere I thought. So, I added this to my project, and it is nice to see it all come together! Oh yeah, I added the sitemap code from above, and there were no errors so I am assuming that it is ok so far. Now, I need to work on the default page. I want the main page to contain all of the wording for the website since the other pages will contain the database work. So, here is some code that I am considering inserting into the home page: <section> <h1>Game Over!</h1> 60

<p> The purpose of the website is to add, edit, delete or view Database information. This provides, quick easy ways to Access the database without the need for an administrator. </p> <br /> <p> Company Information contains database for company </p> <br /> <p> Employee Information contains database for employees </p> <br /> <p> Product Information contains database for products. </p> </section> Okay, seeing code written out like this after some time caused me to not like it. I reread what I wrote, and I see some errors and the information isnâ&#x20AC;&#x2122;t all that necessary. It also sounds cold and way to blunt. If I was an employee, I would not want to see this. Here is an updated version: <section> <h1>Welcome to Game Over!</h1> <p> This is a company site that is specifically made for Game Over employees. The purpose of this site is to let the employee alter prices and data easily into the database. This makes it so the employee can quickly change prices, add or delete products, quickly edit staffing or company information in the database. </p> <br /> <p> To view company information, please click the Company page at the top. </p> <br /> <p> To add, edit, or delete employees, please click the Employee page at the top.

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</p> <br /> <p> To add, edit, or delete products, please click the Products page at the top. </p> </section> Looking at this code makes me feel a bit better. Itâ&#x20AC;&#x2122;s not as cold and it contains more words to explain the purpose and goal of the website. I definitely like this better. I have the code for the main page now. I am going to insert it in and run the page. I canâ&#x20AC;&#x2122;t wait to see what it looks like! I think I have my first error, and I have barely begun my project. This makes me very nervous!

I think I know how to fix this; I can see the error. For some reason, I called the class Home. I think that was originally what I was going to call the page instead of default. I kind of like having Home instead of default because it seems to click in my head better. I am going to rename it to home, I think.

Okay, here is the code that I have used for the home page. After I post this image, I am going to post up the database tables and fields that I am using so the instructor can have a visual aide of the database while going through the rest of this document.

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<%@ Page Language="C#" AutoEventWireup="true" CodeFile="Home.aspx.cs" Inherits="Default" %> <asp:Content ID="headContent" ContentPlaceHolderID="headPlaceHolder" runat="server"> <link href="Styles/Home.css" rel="stylesheet" /> </asp:Content> <asp:Content ID="formContent" ContentPlaceHolderID="formPlaceHolder" runat="server"> <header> <img src="banner.png" /> </header> <section> <h1>Welcome to Game Over!</h1> <p> This is a company site that is specifically made for Game Over employees. The purpose of this site is to let the employee alter prices and data easily into the database. This makes it so the employee can quickly change prices, add or delete products, quickly edit staffing or company information in the database. </p> <br /> <p> To view company information, please click the Company page at the top. </p> <br /> <p> To add, edit, or delete employees, please click the Employee page at the top. </p> <br /> <p> To add, edit, or delete products, please click the Products page at the top. </p> </section> <br /> <footer> <p>&copy; 2017, GameOver Inc.</p> </footer> 63

</asp:Content> Huh, tabs didn’t work. I think there is an issue somewhere. I will look over it the next time I work on the database. I have absolutely no idea… well, here is the issue! I have it inheriting the old page name! Pretty quick fix, just need to make it inherit Home instead! <%@ Page Language="C#" AutoEventWireup="true" CodeFile="Home.aspx.cs" Inherits="Default" %>

Huh… The tabs are still not showing up… I can’t seem to figure this out easily. I guess I am going to need to step away and re-read chapter 11 again.

Okay, I have found the issue. The top part of the page, as shown in the small image above, is incorrect. I need it to have the site.master in it. Here it is fixed. <%@ Page Title="" MasterPageFile="~/Site.master" Language="C#" AutoEventWireup="true" CodeFile="Home.aspx.cs" Inherits="Home" %> Now it is coming together! (I am inserting the Banner image here into the assignment so I have it documented. I have forgotten to do this when creating the journal. I didn’t have the image in until the very last step of the database. This image will show the completed pages, so just keep that in mind that I have added this in on the last day that the assignment is due.

Sorry about that!) Here is the image (see image below, next page):

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Ok, here is a screenshot of the database, the tables, and the fields (see image below, next page).

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So, in order to create the form, I will need to create an edit item template, an insert item template, an item template, the buttons for the form, the queries for the database, the delete parameter, the insert parameter, update parameter, and validation. Then for the code behind file, I will need to create the list view for the items deleted, the items inserted, and the items updated. Since all the tables will be created in the same way as the product, it will be the same for company and employee. So the steps that I plan to follow for products will be reproduced in company and employee also.

Okay, now, in writing the products table, I had to reference the chapter 16 assignment. I didnâ&#x20AC;&#x2122;t want to create the Gridview; I didnâ&#x20AC;&#x2122;t like it. I liked the chapter 16 form table, so this is what my goal is for the product page, company page, and the employee page. However, I have run into errors as usual. I guess there are four errors. Here, I screenshotted these errors. I bet

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they are obvious, but I have absolutely no idea what I did wrong (see below).

I have googled the issue, the parse error. I am so confused and lost. I think I may be stuck. I still have two other pages to create! So, the error is on line 89. I checked out line 89. I see the error that I have created. I have the RequiredFieldValidator8 twice, 9 twice, 10 twice, and 11 twice. This page now runs clear. Here is the correct code: <tr>

/>

<td class="column1">barcode:</td> <td class="column2"> <asp:TextBox ID="barcodeTextBox" runat="server" Text='<%# Bind("barcode") %>' Width="200px"

<asp:RequiredFieldValidator ID="RequiredFieldValidator9" runat="server" ErrorMessage="Barcode is a requried field."

Text="*" ControlToValidate="barcodeTextBox" ValidationGroup="New" CssClass="error"> </asp:RequiredFieldValidator> </td> </tr> <tr> <td class="column1">Title:</td> <td class="column2"> 67

<asp:TextBox ID="titleTextBox" runat="server" DataSourceID="SqlDataSource2" Text='<%# Bind("title") %>' Width="200px" /> <asp:RequiredFieldValidator ID="RequiredFieldValidator10" runat="server" ErrorMessage="Title is a required field." Text="*" ControlToValidate="titleTextBox" ValidationGroup="New" CssClass="error"> </asp:RequiredFieldValidator> </td> </tr> <tr> <td class="column1">release_date:</td> <td class="column2"> <asp:TextBox ID="release_dateTextBox" runat="server" Text='<%# Bind("release_date") %>' Width="200px" /> <asp:RequiredFieldValidator ID="RequiredFieldValidator11" runat="server" ErrorMessage="Release date is a required field."

Text="*" ControlToValidate="release_dateTextBox" ValidationGroup="New" CssClass="error"> </asp:RequiredFieldValidator> </td> </tr> <tr> <td class="column1">publisher:</td> <td class="column2"> <asp:TextBox ID="publisherTextBox" runat="server" Text='<%# Bind("publisher") %>' Width="200px" /> <asp:RequiredFieldValidator ID="RequiredFieldValidator12" runat="server" ErrorMessage="Publisher is a required field."

Text="*" ControlToValidate="publisherTextBox" ValidationGroup="New" CssClass="error"> </asp:RequiredFieldValidator> This was an easy error to fix; indeed, after doing some research online and viewing someoneâ&#x20AC;&#x2122;s discussion on stack overflow, I was able to detect right 68

away that the validator numbers were causing the issues. I know I need to watch this while working on the other two pages since they will require numerous RequiredFieldValidators. I have less than two weeks for this project. I really have to put this off for a while; I am still behind on the labs.

Okay, I am working on the company.aspx and the code behind file. The issue that I have for this page is that I cannot seem to edit or insert data into the database. I have been trying to find the issue, and it seems to be pretty clear that my error page, default error page, E404 pages work. So my testing on those pages is accurate and works correctly. I just want to inject here, before I go any farther: I chose to leave the banner out of the product, company, and employee tables due to the main objective that I had at the beginning of the project. I wanted the database alteration to be clean and without distractions. The banner is very distracting, and cool to look at, so I am leaving it out. I will continue to investigate, but I have less than a week left and am getting nervous.

Error found. I didn’t realize since the database wasn’t created recently that the company column company_number is auto-incremented. This was causing some serious errors. So, I left the insert code alone, and I am currently trying to figure out how to go about working on being able to edit the table. I am planning on checking out stack overflow because they are absolutely wonderful with these types of problems! As soon as this error is fixed, the project will be mostly done. I will break off topic after I fix the issue and do a quick go over for my error pages since I forgot to write about them in here and my css pages, seeing as how I really need to create them!

Okay, I found out through stack overflow that I would have to alter the database to accept temporary alterations to the auto-incremented column.

That just doesn’t sit well with me. I will play around with the database, as there has to be some way around this. I am almost out of time, and I don’t know if I can figure it out before the due date. I saw someone commenting on stack overflow that there are other ways around it, but I haven’t been able to figure it out as of yet. And the project is due in the morning. And it is NOT finished. This may be an all-nighter.

I figured out the issue. I just need to keep edit and eval instead of bind.

That was it, and it was so simple. Same with insert. I will post a photo of this after I finish writing this. Of course I should mention that I fixed this and did encounter another error just now. I also had to change the code in the queries, as it was still trying to insert data into a column that wasn’t available to have data inserted into it. The parameters had to be altered also.

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This page also works! Now, before I talk about the last page, I will discuss the error pages. I will post images of the code I created for them plus any code behind for them. There are three error pages that I created. Those error pages are DefaultError, E404, and Error. The code for DefaultError is (see image below, next page):

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The code for E404 is (see image below):

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The code for Error is (see image below):

These are easy to write and didnâ&#x20AC;&#x2122;t really involve too much work. I had no errors with these pages. The CSS was my favorite part of the assignment.

There are 5 CSS sheets. The sheets are Company.css, Employee.css, Error.css, Home.css, and Products.css. I will post the script for this, and after screenshots I will continue on to the last part of the project. The Employees page, I am approaching dawn of the last day.

Company.css (see image below, next page):

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Employees.css (see image below):

Error.css (see image below, next page):

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Home.css (see image below):

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Products.css (see image below)

Here it is: Dawn of the Last Day I had so much experience with the first two pages, product and company, that I really didnâ&#x20AC;&#x2122;t run into much issues with this page. I havenâ&#x20AC;&#x2122;t tested it as of yet, but I am about finished writing it. I am also about finished writing this Journal, and it is 9:28pm. I would have been finished sooner, but the error threw me. Okay, I think I may have found the problem. I am providing a screenshot here for the instructor to see. First, I have a screenshot of the Visual Studio, showing the Data Connections, the source, and the solution explorer. I want you to view the Data connections part on the employee table (see image below, next page).

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If you look closely, you can see that one of the columns was written incorrectly, and I didnâ&#x20AC;&#x2122;t take this error into account when I wrote out the code for the page. In this next picture, I have shown the error and clicked it to highlight it (see image below, next page).

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This wasnâ&#x20AC;&#x2122;t a very challenging error. I had made some simple syntax errors, easily fixed, some misspelled words, easily edited, and now the assignment has been completed, along with this journal. As the last step I want to do, now that the assignment is completed, I want to show you my classes! I almost forgot! For company.cs, employee.cs and gameLibrary.cs, I needed to create classes for them. The screenshots are below!

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Okay, now I am going to paste in screenshots of each page of the website, showing the completed site with the home page in one shot, the products in another (I will create errors to show some of the error pages), another of company, and lastly, the employee (see image below, next page).

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I showed some of the validation along with the 404 and 500 errors. This was a difficult assignment, but it really put everything together for me and taught me how to get in deep to the code, more so than just the assignments. Even though I struggled through this project, and there may be some issues that I may not have found as of yet, I have completed the requirements, and enjoyed learning this. Thank you for this experience!

To see the actual project online, please visit professorkarla.com.

My name is SAHRA HENNINGSEN. I transferred here in 2015 after receiving my Associate of Applied Science in Information Technology Programming for Database/Web. I graduated on June 3rd with my Bachelor of Science in Web Technologies.

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MAHALAXMI KOTTAPALLI

Dinosaur Amusement Park Task 1 Park Area 5 primarily focusses on Innovation center, Imax theater, Main street, Gift shops, Dinning, Hotels and Night clubs.

Problems that can occur in these areas are as follows: Safety Issues  Injury or any emergency health care problem  Fire at the location  Natural disasters earthquake, flood, hurricane  Food and Water contamination Technical Issues  System Failure  Equipment or cable failures  Bad design of acoustics systems may affect kids or people with heart disease  Credit card machines stopped working  Long wait lines  Disruptions in the movie theater Security Issues  Outbreak of violence  Theft  Children getting lost amidst busy crowd  Personal belongings getting stolen  Security issues such as (drug use, fights, sexual harassment’s, etc.)  Power Failure Logistics issues  Short of employees to handle people on a busy day  Long wait lines frustrating visitors 84

 

Uncleaned streets Takes long time to order food and to be served

Plot Objective for Park 5 The main objective is to operate Park 5 facilities (IMAX, Innovation center, Hotels, night clubs, gift shops and main street) seamlessly with minimal disruptions while facilitating an enhanced customer’s satisfaction.

Stakeholder Function Divisional Vice President

Stakeholder Name Bill Gates

Innovation Center Director

Frasier Crane

Health and Security Director

Jessica Fletcher

Gift Shop Owner

Monica Geller

Hotel Owner Night Club’s Director/ Owner

Norman Bates Arnold Schwarzenegger

Sanitation Supervisor

Adrian Monk

Systems Engineer

Steven Spielberg

Facilities Maintenance Supervisor

Michael Corleone

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What does s/he do?

Reports to the CEO who owns all the parks.

Responsible for all the financial allocations for Park 5 Operations.

Manages the Innovation Center, oversees the daily operations Responsible for safety and security issues for Park 5 environment Solely responsible for managing the gift store Manages the Hotel Owns the night club that entertains the visitors In charge of maintaining a hygienic environment in all Park 5 facilities Responsible for construction, maintenance and expansion of computer systems Responsible for preventative maintenance of equipment and infrastructure, also responsible for logistics

Visitors/Customers

Clark Griswold Family, Ray Barone Family

Visit Park 5 facilities for recreation and entertainment

Stakeholder Map

KEEP SATISFIED

MANAGE CLOSELY

Bill Gates

Frasier Crane Monica Geller Norman Bates Arnold Schwarzenegger Jessica Fletcher

MONITOR

KEEP INFORMED

Clark Griswold Family Ray Barone Family Adrian Monk Michael Corleone

Steven Spielberg

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Task 2 – Park Area 5 Security and Risk problems possible in this area are as follows: Safety Issues  Injury or any emergency health care problem  Fire at the location  Natural disasters earthquake, flood, hurricane  Food and Water contamination Technical Issues  System Failure  Equipment or cable failures  Bad design of acoustics systems may affect kids or people with heart disease  Credit card machines stopped working  Disruptions in the movie theater Security Issues  Outbreak of violence  Theft  Children getting lost amidst busy crowd  Personal belongings getting stolen  Security issues such as (drug use, fights, sexual harassment’s, etc.)  Destruction of Assets  Disgruntled Employees  Power Failure Regulations for Park area 5 For the purpose of this project, I have adapted state and federal regulations from the USA for Park 5.

1. 23 NYCRR 500: Innovation center, Hotel and other facilities (as appropriate) shall maintain a cybersecurity program designed to protect the confidentiality, integrity and availability of the Covered Entity’s Information Systems. The cybersecurity program shall be based on the Covered Entity’s Risk Assessment and designed to perform the core cybersecurity functions.

2. American National Standards Institute (ANSI) Section A117.1: Buildings and facilities relating to innovation center, gift shops and 87

IMAX theatres must comply with ANSI building and facilities Standards.

3. FDA Food Code Section 8-201.14: Restaurants must comply with the Food Safety Plans (HACCP) and procedures that are submitted as specified under of FDA retail food code (provides guidelines to produce wholesome and safe food).

4. 29 CFR 1910.141(a)(4)(ii): All sweepings, solid or liquid wastes, refuse, and garbage shall be removed in such a manner as to avoid creating a menace to health and as often as necessary or appropriate to maintain the place of employment in a sanitary condition.

5. 29 CFR Section 1910.38(c)(1): Procedures for reporting a fire or other emergency. There are preferred procedures for reporting emergencies such as dialing 911, or an internal emergency number, or pulling a manual fire alarm but there are many other possibilities.

6. In movie theatres sound from a film or preview or advertisement shall not exceed 85 deci bells.

7. 29 CFR Section 1910.141(b)(1)(iii): Portable drinking water dispensers shall be designed, constructed, and serviced so that sanitary conditions are maintained, shall be capable of being closed, and shall be equipped with a tap.

NIST CSF for Park Area 5 Functions

Categories

Subcategories

IDENTIFY

Asset Management: The data, personnel, devices, systems, and facilities that enable the Park 5 to achieve business purposes are identified and managed consistent with their relative importance to the Parkâ&#x20AC;&#x2122;s objectives and risk strategy.

Maintain inventory of computers, security devices such as cameras, motion sensors, video monitoring devices, software applications, hardware and equipment cables within the park.

Cybersecurity roles and responsibilities for the entire workforce at Park 5 (stakeholders e.g., Hotels, customers, visitors, Dining, gift shops, Imax theatre, Innovation center) are established.

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Informative References

Risk Assessment: The Park5 understands the cybersecurity risk to its operations (including mission, functions, and reputation), assets, and individuals.

Governance: Policies and procedures to manage and monitor the Park 5 regulatory, legal, risk, environmental, and operational requirements are understood and inform the management of cybersecurity risk.

PROTECT

Access Control: Access to assets and associated facilities is limited to authorized users, processes, or devices, and to authorized transactions.

Awareness and Training: The Park5 personnel (employees, stakeholders) are provided cybersecurity awareness education and are adequately trained to perform their information security-related duties.

Data Security: Information and records (data) are managed consistent with the Park5 risk strategy to protect the confidentiality, integrity, and availability of information.

Information Protection Processes and Procedures: Security policies (that address purpose, scope, roles, responsibilities, management commitment, and coordination among Park5 entities), processes, and procedures are maintained and used to

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Assets like buildings, computer systems, dinosaurâ&#x20AC;&#x2122;s skeletons, theaters, monuments, etc. are identified and documented.

Internal, external threats and potential impacts should be identified and documented.

Park 5 information security policy is established; roles and responsibility are aligned and coordinated.

Legal and regulatory requirements regarding cybersecurity, including privacy and civil liberties obligations, are understood and managed.

Identity and credentials are scrutinized for authorized devices like swipe cards, mobiles, employees and visitors.

Network integrity is protected, incorporating network segregation where appropriate Mandatory training must be provided to the employees and users as per the designated role.

Data at rest and in transit must be protected.

Protections such as VPNâ&#x20AC;&#x2122;s, data encryption, deploying a firewall must be implemented.

Ensuring data integrity techniques are used to verify software, firmware, and information integrity.

SDLC methods should be implemented.

Information and data should be tested on a regular basis and backup plans should be performed periodically.

Response plans, recovery plans, set of procedures to recover and protect in case of disaster must be

manage protection of information systems and assets

DETECT

Security Continuous Monitoring: The information system and assets are monitored at discrete intervals to identify cybersecurity events and verify the effectiveness of protective measures.

Detection Processes: Detection processes and procedures are maintained and tested to ensure timely and adequate awareness of anomalous events.

RESPOND

RECOVER

Response Planning: Response processes and procedures are executed and maintained, to ensure timely response to detected cybersecurity events.

Communications: Response activities are coordinated with internal and external stakeholders, as appropriate, to include external support from law enforcement agencies.

Recovery Planning: Recovery processes and procedures are executed and maintained to ensure timely Improvements: Recovery planning and processes are improved by incorporating lessons learned into future activities.

Communications: Restoration activities are coordinated with internal and external parties, such

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maintained.

Personnel screening, background checks must be performed as required.

The network is monitored to detect potential cybersecurity events.

Video monitoring, surveillance cameras, metal detectors, security personnel must be maintained to monitor for threats, thefts, unauthorized personnel, suspicious activities, harmful or explosive material.

Event detection information must be communicated to the personnel responsible.

Detection procedures and processes should be continuously improved.

Response plan must be executed during or after an event.

Personnel know their roles and order of operations when a response is needed.

Information must be shared with users, stakeholders consistently with response plans.

Recovery, backup plans should be executed during or after an event.

Recovery plans, budget plans, faster improvements methodologies such as agile, scrum, should be incorporated for future progress and enhancements.

Lessons learned should be documented and strive for continuous improvements.

Recovery activities are communicated to internal stakeholders and executive and management teams.

as coordinating centers, Internet Service Providers and other vendors.

Public relations should be managed.

My most influential Stakeholder is Bill Gates as, he holds higher authority and power to make decisions, approve financial budgets in regards to the Park 5 requirements and initiatives. I would persuade him by educating and informing about the potential risks and security threats that may arise due to an inadequate design of security systems owing to limited funds.

Following are the list of considerations to avoid defects while designing an IT system: 1. Any data received from untrusted client must be adequately validated before processing. When designing systems, understanding source of the code before execution is crucial. These precautionary measures will decrease the vulnerability to security threats and attacks.

2. As the park attracts lot of visitors from various parts of the country it is important to make sure to develop robust authentication systems that cannot be bypassed or tampered by unauthorized users.

3. Following authentication, authorization should be conducted.

4. To make sure that data and control instructions co-exist in the same system, this may create opportunities for untrusted data to affect the flow of a software system.

5. Develop procedures that identify how data can be validated explicitly.

6. Cryptography must be used correctly as it ensures the authentication, confidentiality, data integrity and accountability of the source data.

7. As park area5 mainly focuses on gift shops, dining, Imax theater etc. consumers will be providing their personal and credit card information, if we fail to protect sensitive data of the visitors this will create dissatisfaction and also may lead to litigation issues.

8. Understand the significance of integrating external components changes your attack surface.

9. Software security must be robust in design as well as meet functional requirements.

A software security systems designed by taking into consideration the above factors will be robust and less vulnerable to cyber threat and attacks. The park area 5 comprises of Innovation center, Imax theater, Main street, Gift 91

shops, Dinning, Hotels and Night clubs where huge number of people visit and spend considerable amount of time on a daily basis hence, itâ&#x20AC;&#x2122;s essential to consider security and risk when designing the IT systems for this park area.

REFERENCES New York State Department of Financial Services, 23 NYCRR 500, § 500500.23 (2017). Retrieved from https://www.governor.ny.gov/sites/governor.ny.gov/files/atoms/ files/Cybersecurity_Requirements_Financial_Services_23NYCRR5 00.pdf Pretz, K. (2014). Ten Recommendations for avoiding software security design flaws. The Institute: The IEEE News Source. Retrieved from http://theinstitute.ieee.org/special-reports/special-reports/10recommendations-for-avoiding-software-security-design-flaws U.S. Department of Labor. (2017). Occupational safety and health administration. Retrieved from https://www.osha.gov/ U.S. Food & Drug Administration. (2017). Food guidance & regulation.

Retrieved from https://www.fda.gov/downloads/Food/GuidanceRegulation/UC M189448.pdf Young, W. R. & Gordon, A. (2014). Excessive noise at movie theatres: Testimony and supporting documentation relating to SB 287. An Act Concerning the Maximum Decibel Level at Movie Theatres. Retrieved from https://www.cga.ct.gov/2014/PSdata/Tmy/2014SB-00287R000304-William%20Young-TMY.PDF Task 3 1) Problem Statement for Park 5 1. Problem to be solved: To enhance and increase the security for the concerns that will impact employees and visitors and at the same time minimize the risk factors for Park Area 5.

2. Affects: All the Locations of Park5 (i.e. Innovation center, Imax theater, Main street, Gift shops, Dinning, Hotels and Night clubs), Stakeholders, Visitors and Employees.

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3. Impact: Security issues like theft, violence and risk concerns like power failure, fire etc.

4. Successful Solution: Take proper security and risk measures by following the NIST framework which would help to resolve the present and as well as prevent from future concerns. Also, creates a smooth experience for all the stakeholders, visitors and employees.

2) Business Process Model illustration for your Park Area, based on the needs established in Task 1, created with your tool of choice.

No

People

Yes

Safety Issues?

No

Systems

For Safety & Security Issues, Contact Health and Security Director Technical Issues

Yes

For Technical Issues: No

Contact Systems Material Assets

Yes

Yes

Security Issues

Resolution of issues?

No (Critical Issues)

Engage Divisional Vice President

Yes

Resolution of issues?

Escalate to third party for resolution

Start

End

No

3) Business Capability Model illustration - Future State - remember to focus on *What* - created with your tool of choice (these are a bunch of boxes with labels, essentially) (see image below, next page):

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Safety Issues Injury or any emergency health care problem; Fire at the location. Natural disasters earthquake, flood, hurricane; Food and Water contamination

Technical Issues System Failure; Equipment or cable failures; Bad design of acoustics systems may affect kids or people with heart disease; Credit card issues

Security Issues Outbreak of violence; Theft; Children getting lost amidst busy crowd; Personal belongings getting stolen

Functional Capabilities

Detect and Manage Risks

Risk Communication

Understand building code Compliance with OSHA regulations Compliance with Food Code Provide Tornado Shelters

Preventive Maintenance for Facilities Adequate Refrigeration/Freezers for Food Storage Emergency First Aid Services

Training and Awareness Periodic Updates for Executive Leadership Media/Press Releases

Installation of Firewall Systems Validation and Verification Quality Control of Acoustic Devices Data Backup

Security Continuous Monitoring Detection of Fraud Recovery of Data

Emergency Evacuation Procedures Lost and Found Department Digitalized Communication

Enforcement of Law and Order Education and Awareness for Visitors

Engage Key Stakeholders Media/Press Releases Training and Awareness

Response Planning Communications to key stakeholders

4) A collection of user stories for your stakeholders, as detailed in Task 1, in the format “As a [Type of User], [Function to Perform] so that [Business Value]”: 1) As a Divisional Vice President, would make appropriate decision on financial allocations and special situations as needed for operations of park5 so, the business processes could run smoothly and successfully.

2) As an Innovation Center Director, Manages the Innovation Center, oversees the daily operations for operations of park5 so, will ensure all the processes work seamlessly 3) As a Health and Security Director, supervise the safety and security issues of park5 so, employees and visitors can stay safe and have a memorable trip.

4) As a Gift Shop Owner, handle the gift store so, visitors could shop souvenirs, articles, and other gift items as memories forever.

5) As a Hotel Owner, manages the hotel, so that the rooms do not get over booked and customers/visitors enjoy their stay at the hotel.

6) As a Night Club’s Director/ Owner, manage the night club so, visitors get entertained without any disturbances (ex. Violence, drugs etc.).

7) As a Sanitation Supervisor, review the daily sanitation logs for Park5 so that Park5 is supporting a hygienic environment.

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8) As a Systems Engineer, work with computer systems so that the organizations systems run efficiently as required by the business.

9) As a Facilities Maintenance Supervisor, look at the inspection reports so the logistics are sufficient and the maintenance is done as needed.

10) As a Visitors/Customers, enjoy Jurassic Park vacation so, could cherish their memories for long time.

Task 4 Park Area 5 primarily focusses on Innovation center, Imax theater, Mainstreet, Gift shops, Dinning, Hotels and Night clubs.

1. IT-related ethical issues Park Area 5 might have but not limited to are as follows: 1) 2) 3) 4) 5) 6)

Privacy Increased Pressure on IT experts Cybercrime Security Accuracy Social Interaction

For each IT related ethical issue, a listing of the general stakeholders involved: IT Ethical Issue

Involved Stakeholder

Comments

Privacy

Systems Engineer, Visitors/Customers

Increased pressure on IT experts

Systems Engineer, Security Director

Video monitoring for crowd movement, face-recognition if necessary may create an outcry from public. Also, personal information is collected from customers for registration, so data needs to be handled in a sensitive manner Big organizations that continuously operate 24 hours will require a standby IT team to facilitate business continuity.

This pressure results into stress and work overload which sometimes results into imperfection and compromise in ethical values

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Cybercrime

All the stakeholders

Security

All the stakeholders

Accuracy

Systems Engineer (Steven Spielberg) and Divisional Vice President

Social Interaction

All the stakeholders

Personal information credit card information stored on the servers/data centers may be susceptible for cyberattacks Digital assets are vulnerable and need protection Complex interactions between systems and databases may multiply the error in the downstream process. It is important to detect unforeseen errors and mitigate unforeseen errors for business continuity Interaction using social technology is not the same as human interaction, online communication often gets out of control. Increasingly, technology-to-people communication through smart machines will affect social interactions.

A plan for how you will resolve each IT-related ethical issue: IT Ethical Issue Privacy

Resolution Personal identification information, such as social security number and account identifiers, all have to be maintained and accessed by authorized personnel. Systems that track this data can be secured, but at some point, data must leave those systems and be used. Operational policies and procedures must be in place to appropriately handle the data.

Utilize historical experience to plan tasks in a timely manner. Identify appropriate resources that can support the team and be available when needed. Reward programs for employees exceeding expectations and helping transition of process in a smooth manner.

Protect your computers: (1) Install antivirus programs on your computers (2) Install firewalls (3) Upgrade Operating Systems (4) Install intrusion detection Hire a security expert who can highlight and resolve inadequacies in the system. Having security in place through identification mechanisms (passwords, biometrics), encryption and backups should be considered minimum prerequisites.

Assess negative outcomes and the mitigations of costs and effects of errors in advance; Develop contingency measures and perform a periodic review of the efficiency of contingency measures.

Management or system owners be held accountable if unforeseen errors occur

Increased pressure on IT experts

Cybercrime

Security

Accuracy

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Social Interaction

Any digital communications, announcements, and advertisements through Park 5 website to customers must be scrutinized for accuracy and political correctness.

4. A memo (at least 250 words) to the head of your Park Area about why the IT-related ethical issues you've identified are essential to address it's great if you can appeal to a higher sense of purpose, but feel free to address more real world concerns such as reputation loss, stock price loss, and revenue loss in general.

To, Bill Gates Head of Park Area5 Regd: IT related Ethical issues resolution Dear Mr. Gates: I would like to bring to your attention few potential IT related ethical issues that need to be addressed to establish credibility with our customers and also manage business continuity. Information technology continues to dynamically change at a fast pace, as a result, there arises some serious ethical challenges relating to privacy, security, copyright infringement and cybercrimes. These issues need to be addressed efficiently to maintain our customer base to sustain in a competitive environment. Recently there was an incident with a big food chain restaurant (Arbyâ&#x20AC;&#x2122;s) that suffered mass credit card thefts due to malware in their computerized cash registers and this resulted in loss of customer trust. As we will have our visitors swipe their cards in all the areas of Park5, we need to take an extra step to avoid these kinds of issues. I realize we have been highly focused and working effectively to improve on the security and risk factors, however at the same time we need to educate all the employees, key stakeholders and visitors to understand the importance of digital ethical issues too. Based on my assessment, I feel that Park5 IT related ethical issues fall under the following categories in scope: (1) Privacy, (2) Increased Pressure on IT experts, (3) Cybercrime, (4) Security, (5) Accuracy, and (6) Social Interaction. Following are some contingency measures I would like to propose the following to address the identified ethical issues: 1) Start ethical education training programs for employees and key stakeholders to have accurate understanding about ethical issues and their consequences on a periodic basis as the technology keeps changing.

2) Identify our status quo capabilities and address any potential gaps.

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3) Prepare guidelines for the actions to be taken and escalated in case of any ethical incidents happened.

4) Post Sign boards with privacy and security measures for visitors/customers visiting the park.

5) Install a drop box (or start 1800 hotline) for employees to report any violation of company’s IT ethical policies.

I would appreciate if you could review the above proposed measures and grant us permission at the earliest possible so that business operations can continue seamlessly in Park 5. Please do not hesitate to contact me if you have any questions or would like to discuss the proposed options further.

Best Regards, Mahalaxmi Kottapalli REFERENCES Krebs on Security. (2017, February 17). Fast food chain Arby’s acknowledges breach. Retrieved from https://krebsonsecurity.com/2017/02/fast-food-chain-arbysacknowledges-breach/ Ramey. K. (2012). Five Ethical challenges of information technology. Use of Technology. Retrieved from http://www.useoftechnology.com/5ethical-challenges-information-technology/ Relkin. J. (2006). Ten ethical issues confronting IT managers.

TechRepublic. Retrieved from http://www.techrepublic.com/article/10-ethical-issuesconfronting-it-managers/ Task 5 Park Area 5 primarily focuses on Innovation center, Imax theater, Mainstreet, Gift shops, Dinning, Hotels, and Night clubs.

1. Image(s) or video of at least one prototype for a user facing application for your Park Area.

I have included a PowerPoint file that includes screen shot captures of my prototype. The prototype features can be fully accessed in the “Slide Show” Mode. The prototype is built for visitors who would like to book a hotel in Park 5 during their visit to Jurassic World.

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User Facing Prototype for Booking a Hotel at Park5 Jurassic World:

1) Slide 2 to 6 illustrates a simple user-facing prototype for the visitors to book a hotel room at Jurassic pak5 Sheraton Hotels 2) They could search for the days of stay and make a decision on the basis of the rate and the number of rooms and amenities required.

3) Once the reservation is done and payment is made the visitor receives an email confirmation.

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2. A report of the testing of your end user stakeholders on the prototype (if you can't find friends/relatives/coworkers to play along, fake this as best you can).

I would like to present a report of the testing about the Hotel booking at Park5. For this report purpose, I have chosen 2 of my friends and my brother to test this user facing application. Their reviews and suggestions have been pointed out and mentioned below: 1) Friend #1 gave positive feedback about the prototype. He mentioned the prototype was easy to navigate and the hotel room can just be booked in few clicks. He also said the style of the home page was very clear and precise and his family were able to book the hotel room, access the amenities and register on the website without much of hassle.

2) Friend #2 reviewed the website and suggested few options: a. Include an option for using Promo codes or apply discount coupons b. Follow-up with the customers with a survey email to understand how was the customerâ&#x20AC;&#x2122;s experience while they stayed at the hotel. c. Incorporate user reviews on the hotel website d. Try to add more features to hotel website to make it more marketable (ex: pet friendly, spa offering, attractive packages).

3) My brother tested the application and pointed out that it is easy to follow and navigate through the prototype. He mentioned that the design was very simple at the same time also serves its intended purpose. He however mentioned, that should probably also focus on adding features that will help people with disability.

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3. A report of at least 250 words on how you plan to handle user experience (UX) for the IT related aspects of your Park Area, including accessibility for disabled stakeholders Planning to handle user experience (UX) requires strategy and vision which are again contingent upon identifying business goals and impact on stakeholders. A preliminary understanding of key elements “where you are now”, “where do you want to be”, “what do you need to get you to your goal” etc., is part of good business strategy to enhance user experience.

Needless to say, such kind of strategies always requires collaboration with cross functional team and possible key stakeholders (Archer 2017).

For all the areas in Park 5 I have a diversity of business interests (ex: innovation center, Hotel, night clubs, gift store etc.,) so I am planning to consider the following as part of my UX design strategy: 



  

Systems created for the purpose of user communication must keep the visitors informed real-time and allow receipt of feedback in an appropriate timely manner. Special attention must be given to language that goes into the communications such that it is simple yet effective to translate the messages that are related to or may have an impact on Park 5.

Error messages often have a negative impact on the users, while these situations are inevitable, work as efficiently as possible to design elimination of “error-prone” conditions. If errors happen, error messages must be simple, clear and concise enough to understand and not be left to user’s imagination.

Objects, actions, and options must be made visible so as to minimize the user’s memory load.

Given the complexity of the infrastructure for Park 5, information regarding “Help and Documentation” must be available as appropriate.

Park 5 caters to a broader and diverse set of visitors, special care must be taken for people with visual impairments, learning difficulties and hearing loss to facilitate the same enhanced user experience as everyone else. Also, my brother suggested the same when he reviewed my prototype so this will also address his concerns. Desta (2014) has suggested several best practices to make website designs “disability friendly”, some of which I would like to apply for Park 5. These include: (1) Use Alt tags 102



(2) Create subtitles and transcripts (3) Put periods in abbreviations (4) Utilize color control (5) Use accessibility guide and (6) know your audience.

I am also going to work with System Engineer Steven Spielberg and modify the website design in consistent with the suggestions of Friend #2.

I assume after considering the above steps and procedures the entire team will be able to enhance the user experience visiting and accessing IT features of Park 5.

REFERENCES Desta, Y. (2014). Nine simple tips for making your website disabilityfriendly. Mashable. Retrieved from http://mashable.com/2014/04/22/website-disabilityfriendly/#tEVOgWhx.Pq6 Nielsen, J. (1995). Ten usability heuristics for user interface design. NN/g Nielsen Norman Group. Retrieved from https://www.nngroup.com/articles/ten-usability-heuristics/

My name is MAHALAXMI KOTTAPALLI (Laxmi), and I am currently residing in Omaha, Nebraska. I am married and I have two kids (a son and a daughter). I have a Bachelor’s degree in Computer Applications and an MBA with an emphasis in IT & Human Resources from India. I was always passionate to experience the U.S. education system and finally got an opportunity to kick-start my studies further at Bellevue University. I am currently enrolled in Computer Information systems with emphasis in Database concentration. It’s been a great journey so far, and I look forward to completing my MS program at Bellevue University.

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MICHAEL LAGRECA

Dinosaur Amusement Park Task 1 1. Problems the park area might have  Safety o Dinosaurs escaping  Due to human procedural error  Due to dinosaur outsmarting our set procedures  Due to someone intentionally helping dinosaur escape  Due to technical failure o Dinosaur’s roar damaging visitors’ hearing  Indominus Rex roar is 140-160 db.  Asset protection o Visitors feeding dinosaurs o Visitors taunting or otherwise hurting the dinosaurs o Dinosaurs damaging things o Terrorists or foreign government executing a heist to use dinosaurs as weapons o Dinosaurs getting sick o Food supply could be stopped or slowed  Being on an island, shipments can’t come in if there is bad weather  Mechanisms that deliver food could fail o Hurricane could damage anything and everything o Volcano could erupt o Earthquake Main theme that emerges from the above list is: 104



We need to keep our dinosaurs safe and our visitors even safer.

2. Cast of characters  Elsa Springer, Executive – approves funding.  Andre Jennings, Director of Aviary  Colton Shepherd, Director of Raptor Paddock and T. Rex Paddock  Alton Pearce, Director of Indominus Rex exhibit  John Mangano, Director of Research and Development  Owen Grady, Subject Matter Expert  Dinosaurs o Pteranodons o Dimorphodons o Tyrannosaurus Rex o Indominus Rex o Velociraptors  Visitors o Isaac Sims, Boy who loves dinosaurs o Robert and Josephine Sims, Isaac’s parents 3. Stakeholder map

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4. Stakeholder Commitment Scale Chart

Task 2 1. Possible security and risk problems  Unauthorized physical access o Into any of the dinosaur areas o Into any of the paddock control rooms o Into any network or electrical closet  Unauthorized digital access o To control any dinosaur doors o To control any feeding mechanisms o To steal intellectual property regarding dinosaurs’ care and creation o To cripple our system and render it unusable o To access employees’ personal information 2. Five regulations my park must follow  Animal Welfare Act o Passed in 1966, this law requires that minimum standards of care and treatment be provided for certain animals bred for commercial sale, used in 106









research, transported commercially, or exhibited to the public. o Reference: United States Department of Agriculture https://www.nal.usda.gov/awic/animal-welfare-act Captivity of Dangerous Animals o This is a standard put in place by the International Center for Exhibition Safety (ICES). It states that any captive animals posing a serious threat to the public should be completely separated from the public, with virtually no possibility of coming in direct contact with them. o This standard includes the requirements that there be multiple doors between the animal and the public.

These doors should be manually controlled only. They should not be controllable through any network.

The Endangered Species Act o Passed in 1973, this law restricts the handling of animals listed on the endangered species list. This law is currently a gray area for our park, as none of our dinosaurs are yet on the list. However they do meet some of the requirements, so this is something our legal team is keeping a close eye on. o Reference: United States Fish & Wildlife Service https://www.fws.gov/endangered/esalibrary/pdf/ESA_basics.pdf Occupational Safety and Health Administration (OSHA) o According to the regulation and standards of OSHA, subpart K, “Medical and First Aid,” our park must ensure first aid kits are available in case an incident occurs. o Resource: https://www.osha.gov/SLTC/medicalfirstaid/ Subduing of Dangerous Animals o This is another standard put in place by the International center for Exhibition Safety (ICES). It states that any enclosure that holds animals posing a serious threat to the public should have quick access 107

o

to both lethal and non-lethal options available to authorized security personnel.

This also requires a 24-hour security presence at all dinosaur locations.

3. NIST CSF Chart.

4. Document persuading my most influential stakeholder why it is important to consider security and risk when designing the IT systems for my Park Area: Hello Ms. Springer, I am writing you today because you need to be made aware of some of the security concerns that have come to light after some recent analysis. As you know, we do our best to follow all standards and laws applicable to our unique park. There are several regulations that we should consider, but with the extremely dangerous dinosaurs we have in Park 3, I recommend we consider extra measures as well.

Let’s take for example, the standard Captivity of Dangerous Animals which I’m sure you are familiar with. The point I’m concerned about is that we need to ensure there is virtually no way these animals can escape. While I am satisfied with the security we added for our three paddocks I’m still concerned about the lack of security in the aviary. There are many more challenges to overcome with such a wide area to keep 108

sealed. Our nets are strength tested to withstand most threats, but this should not be our only source of protection. The aviary is currently our only enclosure without multiple redundancies. I suggest that we implant each of our Pterandons and Dimorphodons with devices that will deliver a lethal injection if they ever happen to make it outside the aviary boundaries.

These devices do not rely solely on our parkâ&#x20AC;&#x2122;s network, so if there were an incident and we lost all systems, these could still communicate independently with global positioning satellites and ensure our problems are not multiplied. I understand this seems like a harsh strategy, but it would be better to have it and not need it than to need it and not have it.

Thank you for your consideration of these matters. I have attached more information that you might find useful while weighing these concerns against the many other issues throughout our park. Please let me know if you have any questions and I will be happy to go over them with you.

Thank you, Mike LaGreca Task 3 Part 1 â&#x20AC;&#x201C; A formal problem statement

Part 2 â&#x20AC;&#x201C; Business Process Model (see image below, next page)

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Part 3 â&#x20AC;&#x201C; Business Capability Model (see image below, next page)

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Part 4 – Collection of user stories for stakeholders      

As an executive, I need visitor analysis tools so that I can strategize the most profitable park.

As the Director of Aviary, I need sophisticated tracking equipment so that I always know where my flying dinosaurs are As the Paddock Director, I need secure doors so only authorized personnel with approved reasons can access them.

As the Director of Research and Development, I need additional robotic tools so I can increase my output.

As a Tyrannosaurus Rex, I need a gazelle so that I do not grow lazy like I do with cows.

As a visitor I need an interactive park map so that I can quickly identify the places of most interest to me.

Task 4

Part 1 – Brainstormed list of IT-related ethical issues my Park Area might have

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1. As our cost of creating dinosaurs goes down, the executives are talking about staging raptor fights and livestreaming them so they could make extra profits from the gambling.

2. One of the raptor trainers has been leaving his RFID badge next to the paddock access doors for convenience.

3. Guestsâ&#x20AC;&#x2122; mobile devices could be hacked by other guests while logged into our open Wi-Fi. 4. One of the security guards has been using the CCTV security cameras to watch pretty girls in the park.

5. Executives have asked us to deactivate the automatic sirens for a level 1 breach when a dinosaur has escaped through the first layer of containment, but has not yet escaped to the outside park. They say that sirens would just cause unnecessary excitement and customers may not then feel as safe.

Part 2 â&#x20AC;&#x201C; Add a listing of the general stakeholders involved 1. Raptor Fights I. Raptors II. Elsa Springer, Executive III. Visitors, Robert Sims IV. Raptor trainers, Owen Grady 2. RFID badge left by paddock access door I. Raptors II. Visitors, Sims family III. Raptor trainers, Owen Grady 3. Open Wi-Fi hacking I. Visitors, Sims family 4. Inappropriate CCTV use I. Security Supervisor, Rob Koley II. Visitors, Sims family 5. Automatic siren deactivation I. All dinosaurs, T-Rex, Raptors, Indominus Rex, Pterandons, Dimorphodons II. Visitors III. Director of Research and Development, John Mangano

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Part 3 â&#x20AC;&#x201C; A plan for how I will resolve each IT-related ethical issue 1. Raptor fights While it would be awesome to see, it would be unethical to make a profit by forcing any two animals to fight. With managementâ&#x20AC;&#x2122;s desire to reach a larger audience by livestreaming the fights online, there would be many different sets of laws to abide by. In some countries or states, this sort of thing may be banned outright. In other areas, there may be heavy regulations to how the operation is handled. I would resolve this issue by presenting these challenges to the board. If that didnâ&#x20AC;&#x2122;t work I would try to get a survey of public opinion and convince them that we would lose popularity among families, our biggest target audience.

2. RFID badge left by paddock access door This is a serious offense because it makes the park vulnerable to a potential dinosaur escape. The employee would be suspended for a week after the first offense and he would be warned that the second offense would cost him his job. In addition to that, we need additional security measures to ensure that if this happens again, security will not be so severely threatened. I propose we install retina scanners at each of these doors.

3. Open Wi-Fi hacking I would have our security team encrypt the network.

4. Inappropriate CCTV use There is not a technological solution to this issue because security guards need to have the freedom to view any of the cameras where they find something suspicious. Therefore this solution needs to be strictly managerial. I would advise the security supervisor to address the issue with the guard and make sure knows it is inappropriate and that his actions are weakening the strength of our security force. If the problem persists, further action may be taken.

5. Automatic siren deactivation.

The first solution is to try diplomacy. The executives who want the Level 1 automatic siren deactivated are apparently not as concerned about the safety of our visitors as they should be. They need to be convinced that, even though the alarm may be overkill, it is necessary for ensuring the utmost safety for our guests. If the 113

diplomacy does not work, maybe we need to take matters into our own hands and leave the alarm enabled anyway.

Part 4 – A memo to the head of my Park Area about why these ITrelated ethical issues are essential to address Ms. Springer, I am writing you today to inform you of a few ethical concerns that have been brought to my attention recently. A few of these issues were isolated and have already been taken care of. There are two issues, however, that do require your attention and consideration.

First, there are a few incidents you need to be aware of. One of the raptor trainers has been leaving his RFID badge next to the internal access doors. This basically left the door wide open for anyone who already had access to the inner layer. Because of the gravity of his unethical actions, he has been suspended for one week. Since we can’t risk this happening again, we have now installed retina scanners on all inner paddock gates to add an extra layer of security.

There was some concern that our customer-access Wi-Fi network was not secure enough. We have added encryption to this network to ensure our customers’ personal devices are kept safe while they are visiting our park. There was also a security guard who was using our CCTV monitoring system inappropriately. This has been addressed by his supervisor.

I know there has been some discussion among executives about staging raptor fights and having them livestreamed to add revenue through gambling. As the IT security lead, I do not feel like this is an appropriate use of our web servers. The customers this will attract will be entirely different than the family-oriented type we currently target. Whenever money can be won or lost, the security of our system will be tested much more. More importantly, staging raptor fights may offend some of our most loyal regular visitors and it could end up negatively impacting our bottom line.

It has also been brought to my attention that you have requested that my team deactivate the level 1 alarm siren. I understand that our redundancies are such that if there is ever a level 1 breach, we should still be able to contain the escape so there may not need to raise the alarm and frighten our visitors. Now I’d like you to consider the fact that our security is already so tight that if we ever had even a level 1 breach, something must have gone terribly wrong to begin with. If something happened that enabled a dinosaur to make it past the first level of security, there is a grave chance that our next layers could fail too. It may just be a matter of time.

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That is time we can give to our visitors to seek shelter while they have a chance.

I am asking that you change your mind about these two issues and to convince the other executives to change their minds too. Forcing raptors to fight is not only wrong, but it will also impact our customer base and eventually, our bottom line. Deactivating the level 1 alarm will only add more risk to our system, risk which is unacceptable in a an extremely dangerous park such as ours. I hope you will consider the ethical consequences of these two. Please let me know if you would like to meet and discuss these issues further.

Thank you, Mike LaGreca Task 5 Part I â&#x20AC;&#x201C; Image of Prototype

Part 2 â&#x20AC;&#x201C; End user prototype testing report As an end-user who currently manages the Aviary, I was very excited to test this prototype. This software will revolutionize the way we track our pteranodons and dimorphodons. We have already had all of this data available in other systems, but it is very time consuming to switch among several windows to get all the information that is available here on one screen.

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It was easy to quickly realize that I could just click on any one of our pteranodons or dimorphodons and see them highlighted on the map and have more details appear below. As I tested every aspect of this software that I would use, I was unable to detect any errors or defects. This is going to make it much easier to cycle through and make sure the aviary is running safely.

Andre Jennings Part 3 â&#x20AC;&#x201C; Plan for handling user experience for IT-related aspects of Park 3 There are several aspects to consider when designing a system with User Experience in mind. It is important to make the software usage selfevident to ensure users do not have to spend a disproportionate amount of time learning how to use it. The software needs to be easy to use as this will consequently save time and money. Finally, we will need to ensure any disabled users will have appropriate access.

This particular tracking tool is the first of many. We plan to roll out a similar tool for all park areas, starting with all the dinosaurs of Park 3.

Since each of these packages will be based on the same model, there will be no additional training required if someone transfers from the T-Rex paddock to the Velociraptor paddock. The transition will be seamless.

The main way we are making this software easy to use is that we are putting the most pertinent information on the screen right away. That means the user can begin to use the software right away without so much as a single mouse click. Further detail can be obtained by simply clicking any dinosaur ID. Considering accessibility is important, not only for the courtesy of it, but also because the law requires it. Since we do have one paddock employee who is legally blind, we will need to ensure this software utilizes all the latest accessibility options for him. When the low-vision options are enabled, each section will be magnified and read aloud when the cursor hovers over it. As another option, any significant changes in any of the readouts will automatically be read aloud so that the user can still be aware of everything going on.

All of these considerations will make this software easy to use, learn, and access. The usersâ&#x20AC;&#x2122; experience will leave a positive impression and make them feel comfortable every time the system boots up.

After receiving his undergraduate degree from Bellevue in 2012, MICHAEL LAGRECA is pursuing a Masters in Management Information Systems now. His biggest struggle is maintaining a healthy work-life balance 116

while going through school. He is grateful to his wife, Bridget, for all her support while he takes the time to pursue this goal.

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Copy Master Complete Marketing Plan

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BRIAN Oâ&#x20AC;&#x2122;MALLEY

A Case for Leadership Development: Analyzing Leadership Development in the Omaha Restaurant and Foodservice Industry

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Abstract Leadership Development is a critical component to the success of any organization or industry. Despite that, leadership effectiveness experts at the Ken Blanchard Companies state, “...developing leaders into their full potential remains one of the great challenges for organizations today.”

(2005) Analysis of data indicates a significant gap between the expectations desired and the reality faced by both cooks and leadership personnel in the Omaha area restaurant and foodservice industry. Restaurants are believed to have personnel that demonstrate excellent leadership capacity, yet more than 70% of cooks stated that the reason they left their last job was because, “management didn’t care about making it better,” which is a key component of the continual improvement culture expected of excellent leaders (See appendix D for additional details). The proposed Applied Leadership Academy at the Institute for the Culinary Arts (ICA) at Metropolitan Community College (MCC) will provide an additional resource for Omaha area restaurant and foodservice operations wherein they can find the support necessary to develop the leadership capacity and managerial skills of their employees. The potential impact from the success of an Applied Leadership Academy reveals a decrease in overall turnover rate in direct correlation to an increase in employee satisfaction.

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A Case for Leadership Development: Analyzing Leadership Impact in the Omaha Restaurant and Foodservice Industry History and Background Information Omaha Restaurant and Foodservice Industry The restaurant has been an important part of the Omaha economy since the very earliest days of settlement and growth. During the roaring expansion of the livestock exchange, Omaha came to be known for its incredible beef and ornate palaces for dining. The waves of immigrants that brought with them a rich tapestry of culinary traditions flocked to Omaha, generation after generation. This foundation has rooted the Omaha restaurant and foodservice industry with an incredible diversity of cultures and cuisines. The Omaha Restaurant Association (ORA) was founded in 1944 with the mission, “…to promote the highest standard of quality in the Omaha hospitality industry” (Warren, n.d., 2016). The ORA has continued to thrive as a centering force for developing the industry and its employees.

As restaurants have become valuable pieces of the culture, they have also become critical pieces of the economy, employing almost 10% of the entire workforce at any given time and providing jobs at some stage of life for almost 60% of all Americans. Additionally, the Nebraska restaurant industry generated $2.9 billion of revenue in 2016, with growth projected at 9.9% by 2026. Almost half of this revenue and employment happens in the fourcounty area served by Metropolitan Community College (NRA, 2016). It is this area –the eating and drinking establishments as well as the institutional foodservice providers in Dodge, Douglas, Sarpy and Washington counties – that is referred to in this case as the “Omaha area restaurant and foodservice industry”, which will be the primary focus for analysis.

Institute for the Culinary Arts at Metropolitan Community College Started in 1974 as the Food Services Technology program at Metro Tech Community College, the program has evolved several times along with Metropolitan Community College over the last four decades. Today the Institute for the Culinary Arts (ICA) is a well-respected, regionally significant educational institution with a powerful and growing influence in the local restaurant and foodservice industry. The vision of the ICA is to, “…be the benchmark for culinary arts, [and] hospitality… education” (Trebbien, et al. 2011). The ICA has made good on that goal. From 2014 through 2017, program leaders from seven different regional and national institutions spent their own extended periods of engagement to discover exactly what it was that made the ICA special. The results of those interactions led to an understanding of the strengths of the program. They 121

also highlighted some weaknesses. Most impactful however, those visits helped foster a new vision for the ICA moving forward – a vision where the institution can grow into a more vital player in the local restaurant and foodservice industry by expanding the offerings of the program. In short, the folks that came to the ICA to light a fire under their own programs ended up sparking a fire here that can’t be put out.

Time with these visitors was spent sifting through enrollment data, sharing best practices about curriculum, staging in the kitchen, comparing notes and telling stories. The ICA can now distill its story into seven bullet points, expressed in recruitment materials as the reasons to attend (See Figure 1). These reasons are expressed by the ICA leadership as our core strategic objectives. Along with the four values of the ICA – Excellence, Stewardship, Teamwork and Learning – they guide all decisions about curriculum and operations (See Appendix I for additional information about The Mission, Vision and Values of the ICA).

ICA’s Culinary Arts & Management degree options are accredited by the American Culinary Federation Education Foundation Accrediting Commission (ACFEFAC). The ICA has been rated among the top culinary schools in the United States – most recently having been named #8 on Best Choice Schools list of the 50 best culinary schools in the U.S. (Jacobs, 2016). “The Institute for the Culinary Arts at Metropolitan Community College consists of two AAS programs in Culinary Arts & Management and Hospitality & Restaurant Leadership. There are two Certificates of

Achievement in Culinary Arts and Baking & Pastry, as well as three career certificates awarded in Culinary Arts Foundations, Culinary Competition, and ManageFirst” (Trebbien, et al., 2012).

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Problem Identification Problem Statement The employee turnover rate in Omaha area restaurant and foodservice establishments is leading to lower levels of pay, decreased overall product quality, and increased strain on the employment outlook in ways that are not sustainable over the long term. A secondary problem that 123

is being addressed by this case is the decreasing enrollment and perceived diminishing relevance/impact of the curriculum at the Institute for the Culinary Arts.

Problem Importance Seeing employee turnover as a problem in any industry is pretty straightforward – it costs more to replace and train than to keep competent employees. It costs significantly more. Jack Altman, in an article for Medium.com interviewed, “Josh Bersin of Deloitte [and he] believes the cost of losing an employee can range from tens of thousands of dollars to 1.5–2.0x the employee’s annual salary. These costs include hiring, onboarding, training, ramp time to peak productivity, the loss of engagement from others due to high turnover, higher business error rates, and general culture impacts” (See Figure 2 for additional insight) (Altman, 2017).

Perhaps even more dramatically, Altman shares that, “[m]ultiple studies show that while under-compensation can definitely contribute to employee churn, over-compensation won’t make up for a bad workplace” (Altman, 2017). Finding a way to identify the levels and causes of employee turnover in the Omaha area restaurant and foodservice industry is the centerpiece of 124

the research and analysis presented here. It is Altman’s use of turnover rate as ‘a’, or perhaps ‘the’, key performance indicator for a well-managed workplace that so effectively defines the importance of it as a problem.

Turnover costs are staggeringly high and the margins in restaurants are razor thin. Coupled with higher-than-average turnover rates, there is a recipe for disaster. “The [national] turnover rate in the economy's hospitality segment in 2015 rose to 72.1 percent, up from 66.7 percent in 2014” (See Figure 3) (Ruggles, 2016).

Looking at the data from the National Restaurant Association is important because it gives us a valuable yardstick to see how the Omaha area is performing compared to national averages. If the 2015 National Average was 72.1% turnover, and the 2016 average follows the five year trend of about 3% increase per year, then last year’s industry-wide turnover rate could exceed 75%. Omaha area restaurant and foodservice operations are already exceeding this performance significantly. The average estimated turnover rate for the Omaha area restaurant and foodservice industry for 2016 was 50.75%. This is a fantastic number – better than the national average – but the analysis of the data shows a need for identification of the most severely struggling operations and the provision of some sort of support mechanism to strengthen their efforts at turnover rate reduction.

While the numbers in the Omaha metropolitan area are not readily available, it is apparent that this trend is being felt locally as well. There is a sage quote in business that is difficult to attribute to one person, which is 125

“people quit their manager, not their job.” In the restaurant industry that is seriously true. A 2014 study from the National Restaurant Association found that almost 60% of people that left restaurant jobs went to work in…wait for it…another restaurant!1 “Here’s something they’ll probably never teach you in business school,” wrote Gallup CEO Jim Clifton in the summary accompanying his organization’s 2013 “State of the American Workplace” employee engagement study. “The single biggest decision you make in your job—bigger than all the rest—is who you name manager.

When you name the wrong person manager, nothing fixes that bad decision. Not compensation, not benefits—nothing” (Lipman, 2015).

As the area’s most prominent provider of educational and developmental opportunities in culinary arts and hospitality, The Institute for the Culinary Arts has a unique responsibility to provide solutions to problems faced by the industries we serve. Turnover is an expensive proposition for all industries. While we cannot eliminate turnover entirely, finding ways to provide immediate relief and lasting reductions is critical.

Therefore, the critical question is, “Can the turnover rate in Omaha area restaurants be improved by increasing the leadership capacity and management skills of supervisory staff through their participation in the proposed Applied Leadership Academy at the Institute for the Culinary Arts?”

Research Methods Quantitative Analysis The implication in this case study strongly suggests the need for both inferential and simulation approaches to be taken in the accumulation of measurable data sets. An inferential approach, where there is, “mass data with uniform characteristics and with set standard variables[,]” (Gentile, 2015) is used to establish the current turnover rate for Omaha area restaurants. This predicts whether or not participation in the proposed Applied Leadership Academy at the Institute for the Culinary Arts will require the use of the simulation approach. It needs to be established that study participants can measure the value of a proposed new reality.

“Simulation involves the construction of artificial environments with which the researcher achieves his [or her] goal of finding the solution to the problems or drawing inferences” (Krishnaswami, et al., 2010). These approaches are packed into two instruments (See Appendices C and D to review both instruments) that have been administered to two distinct populations in the restaurant industry: line-level employees and restaurant leaders. Both instruments have inferential and simulation components in them, as discussed further below.

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Quantitative Data Collection Methods A survey of three questions and the completion of distinct versions of Creative Leadership Index twice have been administered to Line-level employees. All responses are quantifiable. The quantified data has also been analyzed with statistical tools to determine validity and provide insights for recommendations moving forward. This survey was administered online through the assistance of the member restaurants of the Omaha Restaurant Association. Members were asked to share a link to the survey with all members of their kitchen crews. Answers have been kept confidential, and no identifiable personal data was collected in order to promote open and honest feedback from participants.

Figure 4

The Creative Leadership Index was elucidated from information developed by John Maeda during his work as the president of the prestigious Rhode Island School of Design (See Appendix C).

Figure 5

Estimated Turnover Rate â&#x20AC;&#x201C; Omaha In the event that any program is to be implemented that will potentially impact the turnover rate in Omaha area restaurant and foodservice establishments, it is essential that we have an accurate assessment of the current turnover rate for restaurant employees in the area 127

concerned. The study is focused geographically on Omaha-area restaurants and foodservice establishments in order to have a definitive region to engage with possible solutions. There are valuable, valid data sets from national research, shared above, but it is evident that to use national data to measure the effectiveness of a local or regional program is inadequate.

While the ultimate recommendation may have a powerful impact for the specific operations that participate, the goal is to have an impact on the overall restaurant and foodservice industry’s culture. To do so will take some time, obviously, and to be certain that the future recommendations are impactful, an estimation of the region’s turnover rate had to be constructed.

Construction of this rate was undertaken through gathering data from Omaha-area restaurateurs and kitchen managers. (See Appendix C) Rather than providing a formula for calculating turnover rate, which may have generated significant confusion amongst the myriad participants, each respondent was asked to share the turnover rate for their operation and the formula they used to generate that number. While an agreed-upon formula seems possible, it was surprising to see that no two operations calculate the number in exactly the same way. Because of this, the responses varied widely and additional calculations were necessary to homogenize the data to a point where it was comparable. The standing method for calculating employee turnover rate as espoused by the National Restaurant Association is to count the total separations in a given period – one year in this case – and divided by the average number of employees over the same period (Anthony, 2007, 2013). Not all data collected provided enough information in order to be calibrated for analysis in this way. Of the 21 respondents, 15 completed the questions related to turnover. Of those 15, 4 calculated inline with the NRAEF method and 8 provided enough data to recalculate using the NRAEF method. The remaining 3 responses were considered invalid as they did not provide enough data in their calculation method for conversion. This exposes a potential area for improvement as this research moves forward – provide a common formula for use in calculating turnover rate – at least so that respondents share enough information so that the research team can calculate the rate accurately. The calibrated turnover rates in Figure 6 are expressed as individual percentages.

Figure 6

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The five number summary demonstrates that 25% of operations have turnover rates between 100% and 200%. While this is only one quarter of the total industry surveyed, it means that an incredible share of the industry turnover rate is being borne by a small number of operators. In addition, the third quartile has an enormous range: from 18% to 100%. The overall range indicates that there is a great deal of disparity amongst operations considering the turnover rate issue. Most of the reasons for this disparity will gain clarity and purpose through further analysis of the Cook’s Input Survey that follows.

NOTE: During informal conversations with respondents, it was discovered that there is perhaps a scale bias for smaller operations that should be taken into consideration. In an operation with a three person staff that has a chef and 2 other kitchen staff, if that crew loses two people, their turnover rate is 100%. In a 50 person crew, losing 2 people is only 4%.

While this does not seem to inaccurately skew turnover rate in aggregate, the cost variance from the impact of any individual loss at the smaller operation needs measurement in order to determine the value of retention and development programs. This specific deviation was not considered during this research.

Impact of the Comparative Leadership Gap – Omaha The Comparative Leadership Gap is an analysis of two pairs of different data sets from the quantitative instruments administered to both cooks and restaurant and foodservice operation leaders. In an effort to evaluate the importance of leadership to the retention rate, or at least to the employment duration, of a new employee, survey respondents were asked to share, “… the average length of time that you have stayed at a restaurant/food-service operation when there was POOR leadership?” (See Appendix C) Additionally, they were asked, “[w]hat is the average length of time that you have stayed at a restaurant/food-service operation when there was EXCELLENT leadership?” The distance between these two lengths of time has been calculated in order to estimate the answer to an unasked, but specifically implied, question that gets to the heart of a turnover-reduction strategy: ‘how much longer do you stay when there is excellent leadership?’

This values of time are plotted and defined in the following standard deviation. The lower boundary of each month’s range was used when calculating the difference. Of the 20 respondents to this question, 19 were useable. 1 respondent did not answer the second question.

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This curve (Figure 7) provides statistically solid reference that the cushion generated by having demonstrably strong leadership skills averages (mean) 13.47 months. 66% of respondents confirmed that they spend between 5.67 and 21.27 more months at an operation that demonstrates excellent leadership rather than an operation that demonstrates anything less.

Additionally, the second pair of values to consider when defining a Leadership Gap at the supervisory level is the variance between what senior management defines as the most necessary skills to possess for success and the measurement of what the supervisory-level leadership actual possesses.

To determine this number, each respondentâ&#x20AC;&#x2122;s answers in the Leadership Survey were cross-referenced between their own answers to the questions listed below. The higher the score, the greater the Alignment. The lower the score, the greater the Gap. Points were awarded as follows: 1-5 points for each leadership style as described in the 2nd question.

5 additional points if the supervisorâ&#x20AC;&#x2122;s highest point was in line with the leaderâ&#x20AC;&#x2122;s identification of the most impactful style for their particular operation.

10 additional points if that match is a 5 50 points total available Of the 20 respondents to these questions, all answers were able to be calculated and are shown in the table and graph in Figure 8 below.

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The plotting of the standard deviation shows a normal distribution, although more accurately this distribution would be skewed left. This demonstrates that the maximum range is from 0-50, skewed by the actual range being from 20-50. However, the statistical strength of the results is supported by having the first standard deviation fall entirely inside the actual range. This means these results accurately predict the responses of the broader industry when extrapolated and are therefore valid for use in decision making (Material developed with the Hay-McBer and Maeda) (Goleman, 1998) (See Appendix C and Figure 9). The Qualitative Research and Analysis that follows in the next section of this study is intended to provide insight into what respondents considered to be the essential traits of effective leadership behavior in the kitchen.

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Qualitative Analysis | Why Employees Quit The critical question of the case study implies an ability to define and measure leadership capacity as well as the management skills of supervisory staff throughout the Omaha area restaurant and foodservice industry. Data has been gathered on both topics and will be explored and evaluated through this section of the cases study. Here, the focus is on answering the question, “why do employees quit their jobs?” In his article, Six Reasons Your Best Employees Quit You, Louis Efron distilled a significant amount of industry research into 6 significant factors: 1. No Vision – “Successful managers sell their employees on a vision of the future.”

2. No Connection to the Big Picture – “…[T]here is a direct correlation between [knowing your purpose in accomplishing the mission] and employee retention, customer metrics, productivity, and profitability.”

3. No Empathy – “Take the time to listen to your people.”

4. No (Effective) Motivation – “[T]here is no greater myth in managing a team or company than believing financial compensation is a sufficient incentive to engage and retain top talent and drive high performance.”

5. No Future – “[E]mployees often don’t understand how to move either horizontally or vertically in an organization.”

6. No Fun – “[A]ttracting, engaging, and retaining top talent depends on reinventing their work environments, blurring the line between work and play.”

These results also expose themselves in the results from the questions ask of survey participants as to why they quit their last position. Such connectivity between the researched results of an experienced and wellrespected business publication such as Forbes, and the knee jerk responses of early-career line cooks is astounding. One significant difference is that the line cooks still identified pay as a significant reason to leave. This discrepancy, while addressed by Efron’s research, was discounted by his article because his research was usually conducted in places with significantly higher rates of pay. This disregard for pay as a reasonable motivation for turnover strengthens the position of this case – wherein reduction of the turnover rate in Omaha area restaurants and foodservice operations may ultimately lead to an increase in compensation. Results from the Cook’s Input Survey (See Appendix D) regarding why people leave their jobs is outlined below in Figure 10. Results are summarized and analyzed to indicate three things: 1. The percentage of respondents that identified the attribute among the top three reasons they quit their last job 132

2. The percentage of respondents that identified the attribute among the bottom two reasons, or that it had no impact, as to why they quit their last job 3. An analysis of the meaning of the difference between the two numbers

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Qualitative Analysis | An Ideal Supervisor The top 3 responses to the question about what would make an ideal supervisor were: 1. Would be a symbol of inspiration rather than a symbol of authority [85%] 2. Would learn from mistakes rather than simply avoid making them [60%] 3. Would be concerned with always being real rather than always being right [55%] Sadly, and not surprisingly, these were all behaviors that respondents identified as lacking in the supervisor at the position that they most recently departed. Developing a Leadership Program that can support the development of these characteristics in Omaha area restaurant and 135

foodservice industry supervisors and other leaders is the core of the answer to the Critical Question of this case study. These are the behaviors that cooks want to see in order to stay longer at a restaurant. Helping leaders see the importance of these characteristics, as well as supporting the application of relevant behaviors in live-time and real world settings is taking shape as the mission of the proposed program.

If the responses from the Cook’s Input Survey (See Appendix D) are credible, and the responses from the Leadership Survey (See Appendix C) are as well, then there is congruency between what senior leadership expects from supervisors and what cooks expect from those same supervisors. The problem is, they are not getting it. 36.84% of senior leadership identified Coaching as the preferred leadership style for kitchen supervisors to employ, more than any other single attribute of leadership. 21.05% found Pacesetting to be the most valuable. These both reconcile nicely with cooks’ expectations for quality leadership…but people are still quitting. A significant reason must be that supervisors are not delivering. The supervisors are neither meeting their bosses’ expectations of them as coaches or pacesetters, nor their employees’ expectations for leadership.

The direct contact a cook has in the restaurant makes a huge impact on the quality of their work life. Believe me. It’s huge.

Research Summary | Proposed Steps to Address the Problem If the top-line performance indicator is turnover rate, then all solutions implemented should positively impact turnover rate. The solution is twofold: 1. Develop an Applied Leadership Academy wherein participants will develop the leadership and managerial attributes necessary to meet the needs of their employees, therefore reducing the quit rate by providing a more professional and supportive workplace.

2. Specific to the content of the Applied Leadership Academy must be a project focused on turnover itself: how to measure, analyze and act based on the findings related to turnover in each participating establishment.

Additional data is needed from the line-level supervisors to help understand how they are being developed into leadership roles at the present time. It is difficult to capture information from the middle tier of restaurant management, because these are the busiest folks in the place.

Perhaps forsaking their input, and working on creating a system for senior leaders that would be able to be installed in individual operations would be impactful.

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As mentioned earlier, the overall recommendation, implied in the Critical Question of this Case Study, is the development of an Applied Leadership Academy. An original, brainstormed assumption of this academy was that it be specifically designed for kitchen supervisors. It is now apparent that the intended audience may well be more senior leadership. In this way, the mission of the program can itself be the implementation of leadership capacity and managerial skill development programs that these senior leaders can implement live-time during their progression through the academy. Perhaps the first managerial skill to foster will be how to calculate, track and make decisions based on employee turnover rate.

If the audience is going to be senior level people, the same recommended gathering of additional data relevant to how current supervisory personnel are developed would still be necessary. Additionally, connecting with potential candidates for involvement in the Applied Leadership Academy could yield data about program specifics that were not covered by these initial two surveys, or the third recommended supervisor survey â&#x20AC;&#x201C; programmatic structure information. There is evidence to suggest that there is interest in remaining connected in formalized professional development opportunities as demonstrated in this graph from the national restaurant association.

Figure 10a

If an academy is to be built, there are a ton of other logistics to care about. These are not necessary to know to determine the value of such a program, but to determine its feasibility as a business case. Therefore, it is recommended that the feasibility study be conducted concerning the proposed Applied Leadership Academy upon the conclusion of this case study if, and only if, the value of the program is confirmed at meeting its 137

primary objective of reducing turnover rate through increasing the leadership capacity and managerial skill of Omaha area restaurant and foodservice leadership.

Figure 10b

It is clear that there is some space for development for line-level supervisors in the Omaha area restaurant and foodservice industry. While the turnover rate appears to be doing better than the national average, the data may not be statistically strong enough to ascertain Omaha’s true-rate as there was both a limited number of responses, and the responses related to the turnover rate question varied wildly as to how they calculated – or explained how they calculated – their operation’s turnover rate. With additional solidification of this data set, a valuable benchmark and ongoing metric for use in any number of organizational or industry-wide performance improvement initiatives will be established. The first, and perhaps most permanent recommendation, is that the administering and sharing of ongoing industry research for the Omaha area restaurant and foodservice industry be slated for support and development by area institutions. Perhaps this is a joint venture between academic institutions and the chamber of commerce, with the restaurant, chef, and hotel trade associations providing access to individual and institutional members.

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However it can come together, it is necessary that there be ongoing metrics if any improvement initiatives are going to be measurably effective.

Figure 10c

Secondly, the picture of how to recommend a specific, industry-wide improvement initiative is taking shape. The quantitative data shows that senior leadership in restaurant and foodservice operations does have a positive impression of the line-level supervisors in place. It is easy to recommend that there is nothing to be done to improve the quality of those supervisors based on the quantitative results, but after the anecdotal feedback from the cooks is considered, something must be done. While the line-level supervisors are coming closer than expected to meeting their boss’s expectations for leadership style, their subordinates are not reporting the same positive interactions with supervisors. The desire to brush this away and blame the “newbies” in our industry is a fool’s errand…and is exactly what got us here in the first place.

Expected Results

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Future Performance Restaurant and Foodservice Industry There are three significant ways in which the future performance of the restaurant and foodservice industry will be impacted. First, individual operations that support participation in the Applied Leadership Academy 141

will reap the most direct and immediate benefit. As leadership capacity increases, Altman states that both retention and effectiveness will increase.

(See Figure 12) His case study shows that as companies demonstrated just “slightly better” people practices, quits dropped and sales per employee increased (Altman, 2017). Secondly, the expressed intended outcome of the Academy will be to conduct at least one area-wide research and consultation project per cohort. The subject matter of the first project, while it will be determined by the participants, will almost certainly focus on the variance in turnover calculation practices in the area. By generating a single-sheet “best practices” document that will be distributed to all area restaurant and foodservice establishments, the Applied Leadership Academy will also be making a broad contribution to the industry almost immediately. Additionally, and this is still part of number two, the cohort will compile and publish their reports for the year. This compilation will be made available for sale to area restaurants and foodservice operations so that everyone can grow from the work of the cohort. The monies raised in excess of the cost of production will be used to increase the sponsorship effectiveness. If the sale of 100 books brings just $16 apiece to the bottom line, that decreases the cost for next year’s academy members by $100 each.

Figure 12

Finally, the joy factor. By increasing the leadership capacity and managerial ability of academy members, they will change the workforce environment dramatically for their coworkers. This will decrease stress and turnover, and will increase engagement, productivity, and satisfaction.

These factors will increase the profits available to the operation to pay better wages. If turnover in a hypothetical 20 employee operation decreases from 50% to 25% - meaning that instead of replacing 10 employees each year, they only replace 5 – there are huge savings to spread around. All other things being equal, and using Altman’s lowest quoted estimate of $10,000/employee, the hypothetical return for a single employer could 142

exceed $50,000. If all of that is the result of changes implemented after attending a 9 month, $3500 Applied Leadership Academy, the ROI is better than any other single change that an operation could make. ($46,500) Assuming that the employer consumes half of the remaining return on other projects, that still leaves $23,250. If that money makes its way to the paychecks of the 15 employees that didn’t leave that year, that’s an additional $1550 on everyone’s salary. Small potatoes for most industries.

However, in the Omaha restaurant and foodservice world, where the average salary is under $30,000 per year, $1550 may buy an employer another year of service…decreasing turnover and strengthening cash position even more (See Figure 13).

Figure 13

Operational Changes Institute for the Culinary Arts 143

Developing and implementing a new program is a major undertaking. The organizational charts laid out in Appendix A should represent the current and future models for how the ICA will change in order to accommodate this new project. All changes are not represented on an organizational chart however, so some of the most knowable and impactful changes will also be detailed here. The following is a chart of behaviors that will need to be embraced in order for the Applied Leadership Academy to gain operational traction.

Overall, many processes and procedures at the college will evolve in order to create an efficient and sustainable program. These developments will stretch our capacity as an institution, and as a department, and will lead to the ability to accept and grow in new and different ways that are heretofore hidden from view.

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Forecasted Impact Omaha Restaurant and Foodservice Industry As discussed with some enthusiasm above, the impact on any given operation in the Omaha restaurant and foodservice industry will be greatest.

However, the rising tide from this advanced leadership development and direct industry engagement will soon lift all boats. There are an estimated 2000 eating and drinking establishments in MCCâ&#x20AC;&#x2122;s service area. Total employees equals almost 30,000. They are not all coming to the Applied Leadership Academy. If just .1% of all employees in the service area apply each year, there will be 30 applicants for 16 seats. The capacity of this project will not be measured by how many individuals ever enroll and complete the Applied Leadership Academy. It will be measured by the splash made by those who do. In ten years of operating the Academy, 160 members from an estimated 80 different restaurant or foodservice operations will have participated. If those 80 operations average 10 employees, and improve their employee turnover rate an average of 25%, there will be an additional $2 million of cash floating around in the business. If those operators use it to reinvest in the quality of their operations and people, then the remaining operators are going to be hurting to find competitive advantages. Perhaps the weaker ones close, tightening the labor market slightly, make jobs a little harder to come by, and increasing the propensity to stay at the job youâ&#x20AC;&#x2122;ve gotâ&#x20AC;Śthen the tide rises again. (See Figure 14)

Figure 14

Summary and Conclusion

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The Applied Leadership Academy at the Institute for the Culinary Arts will provide a counter-measure for two ongoing problems. One is being faced by the industry at large – excessive turnover rate – and the other is being faced by the ICA – low enrollment. The following table summarizes the results of the case study that led to the recommendation to build and implement the Applied Leadership Academy.

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Conclusion The material presented in this case is already starting a revolution.

The data presented is sparking more questions. The questions are driving demand for more creative solutions. The creativity required for these solutions is strengthening the industry’s critical thinking. The need to share these thoughts is solidifying the Institute for the Culinary Arts’ position as the premier provider of educational opportunities in Culinary Arts, Hospitality and Horticulture in the Midwest. As additional research and development endeavors are undertaken to determine the feasibility, build and launch the Applied Leadership Academy, the critical question of this case will remain the guiding principal: can the turnover rate in Omaha area restaurants be improved by increasing the leadership capacity and management skills of supervisory staff through their participation in the proposed Applied Leadership Academy at the Institute for the Culinary Arts?

The answer is YES! Our revolution has begun. The Applied Leadership Academy will come to life – at least as an experiment. It will change forever the way restaurateurs and other industry leaders view their leadership development programs. We will increase job satisfaction. We will reduce the turnover rate. Less turnover will increase the monies available for investment in people and products that will make operations great again. This will all happen because we have the power. Fueled by our passion and insight, we have the power to build this future for ourselves, our institute and our industry.

REFERENCES AND RESOURCES Altman, J. (2017) How much does employee turnover really cost?

Resources for Humans. www.medium.com/latticehq/ American Express. (2014)

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http://about.americanexpress.com/news/docs/2014x/2014Global-Customer-Service-Barometer-US.pdf Anthony, V. (2007, 2013) Hospitality Human Resource Management and Supervision. Second Edition. National Restaurant Association Education Foundation.

Blanchard, K. (2005) Critical Leadership Skills, Key Traits that can make or Break Todayâ&#x20AC;&#x2122;s Leaders. The Ken Blanchard Companies. www.kenblanchard.com Business Dictionary. (2017). www.businessdictionary.com/definition/human-capital.html Efron, L. (2013) Six Reasons Your Employees Quit You. Forbes Leadership. www.forbes.com/sites/louisefron/2013/06/24 Gentile, D. (2015) 16 Reasons Why People Leave the Service Industry. www.thrillist.com/eat/nation Goleman, D. Working with Emotional Intelligence (1). Bantam Books.

1998 referenced from http://www.humandimension.org/haymcber.html Hall, KC. (2016). Employer Reported Turnover Rates by Industry. Š Dolan Industries 2009-2015. www.compdatasurveys.com/turnovertrends-by-industry-2015 Krishnaswami, O.R., and Satyaprasad, B.G.. Business Research Methods (1). Mumbai, IN: Himalaya Publishing House, 2010. ProQuest ebrary. Web. 10 January 2017.

Lipman, V. (2015) People Leave Managers, Not Companies. Forbes. www.forbes.com/sites/victorlipman/2015/08/04/people-leavemanagers-not-companies/ Maeda, J. (2016) Characteristics of a Creative Leader. Creative Leadership. www.creativeleadership.com National Restaurant Association. (2016) www.restaurant.org/Downloads/PDFs/StateStatistics/2016/NE_Restaurants2016

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Omaha Restaurant Association. (2016). http://www.dineoutomaha.com/8790/Page.aspx O’Malley, B. (2017) Restaurant Leadership Survey | Essential Management Traits. www.quia.com/sv/767974.html O’Malley, B. (2017) Cook’s Input Survey | Supervisor Skills. www.quia.com/sv/767994.html Online Statistics Book. www.onlinestatbook.com Ruggles, R. (2016). Reporter’s Notebook Blog. Hospitality turnover rose to 72.1% in 2015. Nation’s Restaurant News. http://www.nrn.com/blog/hospitality-turnover-rose-721-rate2015 Trebbien, J. (2012) with faculty. Program Description. https://mccneb.edu/Academic-Programs/Programs-ofStudy/Culinary-Arts-Hospitality-and-Horticulture/Culinary-Artsand-Management.aspx Jacobs, K. (2016) 50 Best Culinary Schools in the US. Best Choice Schools. www.bestchoiceschools.com/rankings/culinary-schools/ For O’Malley’s Appendices, please see the individual link on the Bellwether webpage, accessing the document from Library archives.

-an

BRIAN O’MALLEY is a graduate student at Bellevue University.

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AMANDA KUNES

LugTag Marketing Plan An innovative project, please see the individual link on the Bellwether webpage, accessing the document from Library archives.

Additionally, this project is available at professorkarla.com. -an

AMANDA KUNES from Omaha, Nebraska born and raised. She received a Bachelor of Science in Mathematics from UNO several years back.

Currently, Kunes is working towards a Master of Science in the Management of Information Systems with an emphasis on Cybersecurity at Bellevue University.

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DEBORAH REESE

Copy Master Complete Marketing Plan An innovative project, please see the individual link on the Bellwether webpage, accessing the document from Library archives.

Additionally, this project is available at professorkarla.com. â&#x20AC;&#x201C;an

DEBORAH REESE is (coincidentally) a professional writer and current MS Management of Information Systems candidate. A returning student, Deborah previously earned an MBA from Bellevue University and earned a BA from Wesleyan University in Connecticut. Her experiences as an MBA student, including the encouragement of wonderful professors, motivated her to pursue writing professionally. Deborah is excited to (finally!) win an award for the first time after receiving several writing award nominations over the course of her academic career at Bellevue University.

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BEST GRADUATE CREATIVE EXPRESSION

First Prize Blaine Blasdell The Bioless

Second Prize Jessica Mohr The Art of Persuasion through Data

153

BLAINE BLASDELL

The Bioless Prologue Jay walked out and the wall slowly solidified where the door had been. Jay had just left after having a couple of micro-beers and talking about his future in the company. He worked on my team but was clearly my second in command. One day if I ever get moved up to the corporate he would be in my spot but was antsy and wanted to climb the ladder faster.

He was young and rash, but if he could keep his cool and stay focused on the upgrade projects, he had a good future ahead of him. Even with the digital implants to correct my horrible vision, my eyes were tired and a little off, so reading wasnâ&#x20AC;&#x2122;t going to work. And after the beers I felt even more tired and decided to call it a night. Tomorrow was Monday. URGH! Chapter 1 The morning started just like any other morning and I was sure the day at the tech company would go the same. The room slightly vibrated as the walls and ceilings illuminated like the sunrise in an open field.

Alarm Off! Groggily I forced myself up and got out of bed with the tale-tell sounds of the table sliding out from the wall. The smell of toasted bagel and coffee filled the room as it was being placed on the table before aI could reach it.

My Monday breakfast. Making my way to the table to quickly eat, the bed slowly disappeared into the wall being replaced by my air treadmill platform. After slamming my breakfast down I slowly moved over to the glass panel on the floor.

Mountain trail!

As the air pocket filled around my feet, I slowly started walking. The room was replaced by the mountain trail scene and sounds of the forest. Slowly gaining speed, the air resistance grew harder and the scene changed to a slight uphill climb with the sun peaking over the horizon. After twenty minutes, the end of trail was in sight and the scene faded back into my apartment. After quickly showering and changing into my business casual attire I remembered I hadnâ&#x20AC;&#x2122;t called for the car yet 154

Car! Upon opening the door, the cold air hit my face like an arctic blast. Seeing that my car was their running and already heated up I would plan to make a dash for it. Quickly shutting the door to sprint for the vehicle, I turned and slammed the door but felt my finger catch something. Damn! Hopping in the car’s only seat and smearing the small dot of blood onto my black dress slacks, I grabbed my Starbucks Soy Latte and sat back for the ride to work.

Feeling a bit sluggish this morning, I decided to relax and just sit back and not read or listen to the news on the holo-screen like I normally did. In a short period, I was out and asleep.

Chapter 2 What? Are we there yet?

Slowly waking I felt like I had been hit by a Mack truck. My voice felt off as I attempted to speak and my vision was blurry. My fingertips tingled and my body hurt. Maybe I had the flu or was coming down with something. I would see the medical droid after my meeting this morning.

“Unrecognized Voice Pattern, please identity yourself?”

Hmm. Not another glitch in the software! Really! The back lot of the tech company was visible as the vehicle came to a stop. How did we get here already?

“Unrecognized Voice Pattern, please identity yourself?”

Jasper Iota. 32593305.

“Unrecognized Identification – Entering biometrics mode. Please look straight ahead and remain still.”

What?

“Retinal scan beginning.”

“Failed – Place hand on console for identification.”

I reached forward and placed my hand on the console.

“Fingerprint – negative.”

“DNA – Unidentified.”

What is going on? This doesn’t make any sense. What kind of glitch was this?

Car – What is happening?

“Voice and Biometrics Failure – Routing vehicle to proper authorities.”

The vehicle picked up speed as the door handles disappeared in the panel.

Wait! This Jasper Iota code 32593305.

“Identification not valid – authorities have been notified and will be waiting.”

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Chapter 3 My heart was pounding as the vehicle entered the closest private security compound. The vehicle slowly pulled up to the gate, which opened as the car pulled through. After pulling through the gate quickly closed behind us. Inching forward, four android security personnel with full armament approached the car and opened the door, guns raised. The door opened.

“Get out! Move slowly to the platform.”

Wait, this is all a misunderstanding. This is my vehicle.

“Do not speak! Anything you say will be used against you.”

“Move forward to processing center and sit in the chair.”

Walking to the building the wall parted and allowed me to enter into a small office with one chair. The four droids followed me in to ensure my compliance. I moved to the chair and sat as the door quickly closed and turned into a wall again.

“Identify yourself” Jasper Iota. 32593305.

“Identification invalid. Prepare for biometrics processing.”

“Remain still and place right hand on arm rest. Do not move.”

Wait. This is a misunderstanding. I just left my apartment and was on my way to work.

“Remain quiet and still.”

“Voice Identification – Failed.”

“Retinal Scan – Failed.”

“Fingerprint Scan – Failed.”

“DNA Match – Failed.”

I could not fathom what was happening and grew more scared as each declaration was delivered. This can’t be happening. What is going on?

“As you have no means to identify yourself, you are deemed a trespasser and vagrant. With no identification, you have no money or account to pay for anything.”

“You have been sentenced. Punishment – exile. You will be mandatorily relocated. If you return, you will be permanently processed. Do you understand?”

What? No I do not understand! This doesn’t make any sense.

“Prepare for relocation.”

As I was about to get up, I felt a pin prick in my neck. I grew groggy again and the light faded away.

Chapter 4

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Again, feeling like a Mack truck had run me over, I opened my eyes slowly and tried to figure out where I was. I sat for a moment in what looked like a street with broken down and abandoned buildings on all sides.

The other place. Or at least that is what they called it in the bogeyman stories we heard as kids. They say they don’t even have electricity and monsters roam freely.

Sitting there figuring out what to do, I heard a strange sound approach and what looked like a large square vehicle, smelling of strange fumes, noisily and slowly approached. Three men got out of the large square with smiles on their faces and slowly approached.

“Looks like we have another one!” The new man stated.

The second one quickly replied, “Yeah, this is the getting to be a pattern. At least one every week now.”

The leader calmly spoke, “Don’t move. We will help you up. We have all been through this. Just take a deep breathe.”

They lifted me up and guided me to the back of the vehicle that apparently had four permanent doors. The first man went around to the front and stuck a silver device into the dash and turned it clockwise slightly.

A loud roar was hurt and a horrible odor emanated.

We sat in silence as the vehicle noisily made its way through the broken street dodging large holes which the leader apparently had to navigate on his own with a steering device. The noise was loud and talking would have been near impossible anyway. We quickly pulled up to what looked like an old building or structure of some sort. As they helped me in, I could see about twenty people in the faint flickering light of what appeared to be an artificial flame but I knew wasn’t. The helped me over to a table and sat me in a chair as the other three men sat with me.

What is going on? I tried to speak but my head still pounded, my eyes still blurry, and my voice still raspy.

The leader spoke, “You have been life hacked. Or at least that is what we are calling it. You are now one of BIO-LESS.” What? What do you mean?

Another one of the men spoke up, “As best we can all figure from our similar stories, somehow our lives have been stolen. We all received a cut or pinprick the day it happened. As best we can figure, with all of the digital implants like our retina and cornea corrections, as well as internal cholesterol regulators, someone has figured out how to hack them and change our DNA just enough.”

It all came crashing down on me. Jay being there the night before and talking about my position. The pin prick on my finger leaving the house. My heart pounded as I realized he had just gotten his promotion.

The leader started up again, “They changed our retinas so the scan wouldn’t work, they change our voice so it wouldn’t be recognized, blurred 157

our fingerprints, and modified the DNA just enough so the droid’s couldn’t read it. The first of us arrived a little over a year ago and now there are about thirty of us. One or two have died off from disease. None of us can see very well and we ae still figuring out the rest.”

“You are now one of us – The BIOLESS.”

Originally born in Nicosia, Cyprus to American parents living abroad, BLAINE BLASDELL currently works as an IT consultant and lives in Northern Virginia with his new wife and seven-year-old step-daughter. He enjoys reading and has a passion for landscape photography (www.photosbyblaine.com). He is currently about midway through his master's in Management Information Systems with a concentration in Cybersecurity.

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JESSICA MOHR

The Art of Persuasion through Data With the explosion of big data in the early 2000s, the world became fascinated by how this data could be used to essentially gain deeper insights on the average personâ&#x20AC;&#x2122;s thoughts as well as preferences. Almost overnight, work began on generating complex data models that could sift through vast amounts of personal data to identify these preferences. It wasnâ&#x20AC;&#x2122;t enough to simply collect and mine this data, however; instead, organizations began developing predictive models that would ascertain a number of factors such as items/services of interest, likely courses of action in response to certain stimuli, etc. The more personal data acquired, the more sophisticated the algorithms that are developed by multiple companies across various industries.

One sector that invested considerable efforts and resources into this was telecommunications giant Om Corp. Originally a small, local company that simply sought to provide strong technology and services for a fairer price than the current strangling monopoly in the area, Socrates quickly evolved into a powerful national entity. Its continued work with other corporations such as smart TV and phone providers as well as its seeming beneficence to special charity projects made this a popular company for consumers. (Their surprisingly low prices coupled with superior technology probably helped that as well). By the year 2040, Om Corp was practically indomitable with almost every household in the U.S. utilizing their phone, cable, and internet services. The company also expanded into web browsing and owned one of the most popular web browsers available that was already competitive with Google.

Om Corp wanted to take these services to the next level, however.

They wanted a more unique, customizable experience that really engaged their users. To this end they collaborated with the learning management platform Socrates. Socrates started out as a group of select faculty in the secondary and postsecondary education fields who wanted to use emotional responses, data analysis, and academic assessment to better understand student learning. They collaborated with a small group of data scientists and tech consultants who helped them devise a model whereby they could measure studentsâ&#x20AC;&#x2122; emotional reactions to their courses. Connected to sensors with a camera and facial recognition software reading their 159

responses, early student test subjects underwent observation as they progressed through online modules for their academic courses. Their navigation through these courses – including what links they clicked on, which resources they utilized, how much of their lectures they watched, etc.

– and subsequent attempts at homework were all tracked and then correlated with the students’ emotional responses. In other words, the technology was able to record which specific course content students found the most engaging, which concepts they particularly struggled with, and which resources they found completely useless to their learning process.

Reactions such as scowling and/or getting a jolt of anxiety while studying might indicate an issue with that particular concept or assignment while increased focus and productivity might imply more engagement. Coupled with current academic assessment methodology, these pioneering educational researchers were able to catalog and sift through this new data to find the weak spots in their courses. When they did, they implemented new content to see if this improved the student’s experience and gauge how to work with similar students in the future. By 2040 this research had crystallized into the sophisticated learning management platform - complete with webcams and wearable smart devices with embedded sensors - known as Socrates.

The success of Socrates in schools across the country drew Om Corp’s attention. The company’s founder and president Brian Lockwood immediately saw the potential in an adapted form of this technology for Om Corp and began a partnership with the learning-oriented new company.

Using their technology, he has redesigned his services to include a similar version of Socrates as part of every client’s cable and internet package complete with new remote controls containing embedded sensors. Instead of simply pushing the same products to all consumers through these mediums or hosting the same television lineup for everyone, however, the new application has made it so that everything is more customized to the individual user or household. Television shows are dictated not by the terms of the producing channels, but instead by the success of the program and any given user’s interest in that particular genre or subject matter.

Similarly, internet search results and recommended websites as well as news articles are based around the Socrates algorithm. Ecstatic over finally having more control of their television choices as well as more customized browser results, this initiative has been resoundingly successful with Om Corp’s customers.

Unbeknownst to their consumers, however, Om Corp had an ulterior motive in pursuing this endeavor. They capitalized on the opportunity to introduce a new form of advertising, one that can be likened more accurately to brainwashing. For the right (lucrative) price, a government or organization can target individual households with specific 160

media messages from commercials and specific news stories, to controversial video clips and highly questionable blogs. Om Corp has dubbed this persuasion marketing, and it offers this as an exclusive service to a core group of members – members with whom Om Corp already has secretive business dealings as well as highly sensitive information these entities wouldn’t want revealed. If they keep Om Corp’s marketing secrets, Om Corp will keep theirs.

Avery and Will Martin were two individuals of a wider community targeted by one of these members. Green Cow, a corporate farming entity, was desperate to claim the wide expanse of fertile land where the Martins and several other families lived. They had not been having much luck with offering to purchase land from the residents, however, or arrange partnerships with them to use their products. Desperate, Green Cow decided to take out a contract with Om Corp for use of its persuasive marketing services. The farming corporation knew that it could be any number of people in the area resisting their efforts – or all of them collectively – but they wanted to have a better idea of who the strongest as well as weakest links may be so they could target them accordingly. Using the Socrates platform, Om Corp was able to identify by their various internet data as well as TV history the specific neighbors who were adamantly against Green Cow. At the top of the list were the Martins.

The Martins helped spearhead local sustainability and environmental efforts in their area. Given that they resided in a primarily agricultural community, they were committed to encouraging and supporting the family farms around them. They refused to buy products from or engage with the corporate farm execs like Green Cow who routinely visited with offers to purchase their land or to sell their products such as genetically modified seeds. Resolute in their beliefs, the Martins began their own grassroots movement against the corporation and stirred up others in their community through articles they wrote to the town newspaper as well as meetings they routinely hosted in the area.

After Green Cow took out the contract with Om Corp, however, things changed. The Martins were suddenly barraged with information they had never seen or heard before – things that made them call into question their beliefs on this subject. Opinion stories and blogs began creeping into their newsfeeds about potential health ailments and diseases associated with toxic soil in their area. Documentaries promoting the benefits and positive history of corporate farming aired on television. Cooking shows using “fresh garden products” that hailed from the same land farmed by the company they despised became regular occurrences as did traveling and real estate shows whose underlying message subtly hinted at how nice life might be if the couple moved. Day in and day out the Martins endured a quiet

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deluge of skewed media and biased – if not outright false – data on Green Cow, corporate farming, and their land in general.

Confused, Will Martin began questioning the couple’s stance on Green Cow. He tended to believe most things he read online and he was particularly taken in by the documentaries he saw now on television.

Moreover, it was tougher to find conflicting data and alternate viewpoints now that his internet service was so individually customized by Om Corp.

Will started to wonder if maybe he and his wife, Avery, shouldn’t just consider selling their land and retiring somewhere by the ocean where they wouldn’t have to worry about farming or potentially toxic soil.

Avery, however, was completely undeterred. Well-educated and well-read, Avery distrusted the sudden change in their television and internet suggestions. She knew at least part or all of the information was grossly distorted and she remained firmer than ever that she was going to stay right here on her acreage until her last breaths. She’d grown up on that acreage and it was practically a part of her. She told Will that very same thing while watching yet another travel documentary on television that night, failing to notice that the green light of their webcam was on the whole time.

As was customary, Avery and Will went to bed that night with the television on. It was a habit they’d had since the earliest days of their marriage; Avery frequently woke up off and on throughout the night, and she found that something about hearing the low hum of chatter from the TV lulled her back into sleep more quickly. Since Will was a deep sleeper and immune to everything – light, sound, etc. – once his head hit the pillow, he didn’t mind his wife’s proclivity for leaving the TV on each night. So Will was fast asleep when Avery woke up in the middle of the night to the severely chaotic, intensely bright flashing lights being emitted from the TV set. The effect resembled that of a strobe light, something Avery had always despised as she suffered from photosensitive epilepsy. Avery was hanging partway out of bed trying to reach the remote on her nightstand when the seizure hit. Her husband was still fast asleep and blissfully unaware what was happening as Avery fell out of bed and cracked her head against the corner of the nightstand.

Will was broken hearted at Avery’s passing and he found he just didn’t have the same interest in their acreage anymore after Avery’s death.

Some of their friends and neighbors who were also committed to opposing Green Cow tried talking to him, but his heart was just no longer in it. He sold the property to a seemingly nice young man new to the area – one who coincidentally was a Green Cow executive – and moved to Florida to live near the ocean. He didn’t keep in touch with any of his wife’s old friends, so he didn’t know that the executive immediately sold the land to Green Cow who began farming it for their genetically modified products. The 162

neighbors put up some resistance, but all too quickly their efforts folded and they each sold their land to Green Cow. Ecstatic over their quick coup, Green Cow quietly paid Om Corp a hefty bonus for their work.

The story of the Martins and Om Corp reflects how data can be misused for truly nefarious purposes. While the Socrates technology was originally intended for genuinely benevolent purposes, it took no effort at all for another person to twist it into something malevolent. Data provided these fictitious companies with a means of better understanding their consumers not purely so they could help them and provide them with positive service, but also so that they could use the information against them when it suited the corporations. For this reason it is important that data be collected and managed very carefully â&#x20AC;&#x201C; information is a form of power, and organizations with immense databases of information have a great deal of power if they choose to process it. But with power can come corruption, so consumers must be careful with what data they provide in order to keep these companies honest.

JESSICA MOHR is a perpetual student with seemingly unbridled curiosity.

While dabbling in a variety of fields for her education - from philosophy to terrorism studies to criminology - she somehow found herself working with computer systems and loving it. She earned her M.S. in Business Analytics in 2016, and works as a Data Analyst specializing in learning analytics. She is now halfway through a second graduate degree in Management of Information Science with an anticipated graduation date of 2018. When she's not studying or trying to learn how to code her own video game, she can be found obsessing over science fiction movies and tackling her latest short story.

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BEST GRADUATE FORMAL COMPOSITION

First Prize Bradlee Robbert SpaceOAR Hydrogel Feasibility

Second Prize Amiram Zeiger

Cognitive Behavioral Therapy Versus Adlerian Therapy

Third Prize Alex Kellerstrass Speaking the Right Language: The Importance of Communications and Soft Skills Development

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BRADLEE ROBBERT

SpaceOAR Hydrogel Feasibility Abstract Rectal balloons are a treatment device that aid in the immobilization of the prostate gland during radiotherapy treatments for prostate cancer. Even though rectal balloons are relatively new treatment devices, it could be replaced by SpaceOAR hydrogel. SpaceOAR ÂŽ Systems is a temporary hydrogel that is placed between the rectum and the prostate gland to create a temporary space during the course of radiotherapy. The gel effectively reduces the radiation dose to the rectum; however, the gel does not have an established current procedural technology (CPT) code. The lack of a CPT code frightens healthcare administrators from endorsing the procedure because of its high cost.

This project evaluates the financial impact the University of Florida Health Proton Therapy Institute (UFHPTI) experienced when switching from rectal balloons to SpaceOAR hydrogel. Specifically, the project evaluates three dependent variables: (1) reimbursement of SpaceOAR and rectal balloons, (2) physician time devoted to implanting SpaceOAR, and (3) available new consultation appointments. This project retroactively reviewed information during the months of February through March of 2016. Two cohorts were evaluated. The first cohort was the first 29 patients that received SpaceOAR and the other cohort was 22 patients that received rectal balloons.

The project revealed that it cost UFHPTI $1,800 per rectal balloon patient and $2,539.96 per SpaceOAR patient. In addition, physicians spent an average of 43 minutes per SpaceOAR case and zero minutes for rectal balloon cases. Finally, using SpaceOAR did not have an impact on availability of consultation appointments. Ultimately, SpaceOAR did not have much of an impact on the flow of clinical care, but the cost of inserting the gel might not be sustainable without more reimbursements.

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SpaceOAR Hydrogel Feasibility In medicine, there is more to consider than just medical information. Organizations must determine how new procedures will affect revenue and resources used to deploy new methods. Fixed costs such as additional equipment and training and variable costs such as physician time and additional procedure materials will need to be included in revenue evaluation (Lewis & Asch, 1999). In addition, leadership will need to speculate about ancillary costs that are not easily identifiable. Finally, projected reimbursements must be evaluated. It is unreasonable to ascertain clinical procedures that insurance does not cover or reimbursement amounts are too low to cover expenses.

All of these aspects need to be evaluated by leadership at the University of Florida Health Proton Therapy Institute (UFHPTI) before changing clinical practices in the treatment management of prostate cancer.

Recently, UFHPTI switched from using rectal balloons to SpaceOAR ÂŽ Systems. Immediately, there was a higher cost in the material, but it was unclear the amount of time the medical team would devote to the procedure. This raised questions about the length of time these procedures would take and the impact it would have on the clinic and clinic flow. This quantitative research project reveals information about the impact SpaceOAR did have on revenue, physiciansâ&#x20AC;&#x2122; time devoted to the procedure, and availability of new patient appointments.

Organizational Review The University of Florida Health Proton Therapy Institute (UFHPTI) is an academic non-profit cancer center located in Jacksonville, Florida. It is one of 22 places in the country that offers proton therapy, and the only one in the southeast that is an academic non-profit cancer center.

The center treats approximately 150 cancer patients per day with both traditional (x-ray) and proton therapy during a 16 hour clinical day. Patients undergoing therapy are typically required to receive treatment once per day, Monday thru Friday, for six to eight weeks. Overall, UFHPTI will treat approximately 300 patients with traditional radiation and 700 patients with proton therapy per year. Of those 1000 patients, approximately 35% will be treated for prostate cancer, 25% will be children cancers, 20% breast cancer, and 20% all other diagnoses. In addition, approximately 50% of all patients undergoing therapy are local to northeast Florida, while the other 50% of patients live 100 or more miles from the center, including a large volume of international patients. The 50% of patients that travel from out of community are identified as medical tourists. Because of the large volume of medical tourists, UFHPTI has created programs that specifically 166

attract, retain, and support patients undergoing treatment. Many of these ancillary services are targeted support groups, survivorship celebrations, and social engagement activities.

Quality Assurance All medical facilities should have a robust quality assurance program. The University of Florida Health Proton Therapy Institute has taken quality assurance or more specifically continuous improvement (CI) very seriously. In most definitions of CI, it includes organizational effectiveness and enhanced customer satisfaction (Jha, Noori, & Michela, 1996). One significant way UFHPTI has used CI is through treatment time studies. The primary goal of the study is to confirm that therapists are being efficient in the delivery of care. Also, the secondary goal is to enhance patient satisfaction. For instance, the longer a treatment takes, the longer a patient has to lie still on a hard table in a cold room. Any reduction in treatment time positively impacts patient satisfaction and patient volume.

These studies are conducted over a week long period twice a year to measure the length of time it takes the radiation therapists to complete various functions of care. Therapists are required to start and stop an electronic clock on a computer program after various steps of treatment is completed. This program captures specific data that can be mined and evaluated. The access to this information has allowed for great improvements and efficiencies to care. For example, leadership was able to determine exactly how long it took to treat each type of cancer patient.

That information allowed UFHPTI to increase its treatment patient capacity from 95 to 100 patients per day, which has made UFHPTI one of the most efficient proton therapy centers in the nation.

Business Results Timed studies have equated to increased business results, but many companies implement tools for measuring their performance in order to stay in business (Gabcanovรก, 2012). Many of these companies use key performance indicators (KPI). Measuring treatment times is only one KPI that UFHPTI utilizes to examine business results. The organization evaluates a couple factors such as new patient appointments, website hits, reimbursement rates, and filled consultation appointments. All of these measurements are important for various reasons, but primarily they are key indicators to patient volume. For example, UFHPTI evaluates future patient volumes by measuring unique website hits, website requests for information, and phone calls. These are measured and calculated to achieve 167

conversion ratios. The number of contacts it takes to generate one consultation appointment is one of the common conversion ratios the data is use for. Currently, the conversion ratio is 9:1 for contacts to equal one consultation. It has been interesting to see the conversion ratio increase as more competition for proton therapy increases. The second ratio is consultations to treated patient. This ratio measures the number of consultations it takes to achieve one patient to undergo treatment. The current ratio is 3:1. This ratio has gone up over the years. Some of that is due to competition, but more is contributed to patients obtaining second opinions and being declined treatment with proton therapy based on their medical condition.

All the ratios are examples of how UFHPTI measures results.

Now, UFHPTI is evaluating switching from using rectal balloons to SpaceOAR for the treatment management of prostate cancer patients undergoing radiotherapy. The organization will use similar methods and procedures to evaluate the effectiveness of implementing SpaceOAR Systems. Continuous quality improvement will ensure that UFHPTI is utilizing resources to its fullest extent. Once UFHPTI has been able to streamline processes and procedures pertaining to SpaceOAR Systems, the organization will be able to determine if SpaceOAR is the right path for patient care.

Problem On April 16, 2015, Augmenix, Inc. announced the Food and Drug Administration (FDA) clearance of the SpaceOARÂŽ System, which is the first hydrogel spacer to protect the rectum in men undergoing prostate cancer with radiation (Augmenix, 2015). The medical evidence from clinical trials and various dosimetric studies indicate that SpaceOAR can minimize rectal toxicity for prostate cancer patients undergoing radiation therapy. Because of the potential clinical advantages, UFHPTIâ&#x20AC;&#x2122;s medical director wanted to start inserting the gel for the majority of prostate cancer patients that medically qualify for the procedure. Based on clinical flow, UFHPTI could inject approximately 100-200 prostate cancer patients with the SpaceOAR hydrogel. The major problem stems from the cost.

Historically, UFHPTI uses rectal balloons in the treatment management for prostate cancer. Each prostate cancer patient would receive a new balloon each day for 40 total balloons. In contrast, SpaceOAR patients would only receive the gel as a one-time injection.

When Augmenix raced to get approval for SpaceOAR from the FDA, it did not focus on successfully obtaining a billing code. The lack of an established billing code essentially made the supply of gel unreimbursable to the provider. This is a huge challenge because the supply cost of SpaceOAR is nearly $3,000 per unit (K. McIntyre, personal

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communication, December 9, 2015). After negotiation, UFHPTI and SpaceOAR agreed the price would be $2,565 per kit.

SpaceOAR gel is not the only cost to the procedure. Other ancillary products are needed for the procedure such as chlorhexidine swabs, spinal needles, lidocaine, and Emla cream. These items are not included in a SpaceOAR gel packet. Table 1 lists the supplies and estimated costs associated with each SpaceOAR procedure. These costs include the SpaceOAR gel and fiducial markers that are inserted at the time of the procedure. The total cost per SpaceOAR case UFHPTI should expect to spend is approximately $2,900 per case before reimbursement.

Another major problem is there is not a procedure code for the physicianâ&#x20AC;&#x2122;s expertise to place the gel. This means that the procedure does not carry any relative value units (RVUs). Without a procedure code or RVUs, UFHPTI physicians cannot bill for their time. The reimbursement ambiguity of SpaceOAR gel and the lack of a physician procedure code place a free standing radiation oncology center in a challenging position.

On one hand, the procedure can be beneficial for the patient. On the other hand, the cost of the procedure can quickly add up without appropriate reimbursement from payers.

The final financial problem is the ambiguity of reimbursement amounts for ancillary procedures associated with the SpaceOAR hydrogel.

During the procedure physicians perform a transrectal ultrasound, fiducial marker placement, peripheral nerve blocks, and ultrasound guidance for needle placement. All of these procedures have established CPT codes, however, the ambiguity of payment between private and public payers makes it challenging to forecast reimbursement results. Only public insurers publish their rates, so Table 2 lists the procedure, CPT code, and 169

anticipated published Medicare reimbursement amounts. These figures were used to help UFHPTI leadership evaluate the potential income from the ancillary services associated with the SpaceOAR procedure, but it does not include the $2,565 supply cost of the hydrogel. The hope of the leadership team is the ancillary reimbursements would offset the costs of the SpaceOAR gel enough to make SpaceOAR a cheaper option than rectal balloons.

Purpose The purpose of this project is to evaluate the effect on revenue when switching to SpaceOAR Systems from using rectal balloons in the management of prostate cancer treated at UFHPTI. The independent variables for this project are SpaceOAR hydrogel and rectal balloons.

Specific variables that will be evaluated are revenue, new patient consultation appointments, and physicianâ&#x20AC;&#x2122;s time spent with patients.

Ultimately, the results of this project will allow leadership to exam the clinical and financial impact of SpaceOAR procedures. Comparing the finances between SpaceOAR and rectal balloons will help leadership understand if SpaceOAR procedure is either profitable or cheaper than using rectal balloons.

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Hypotheses This project is a quantitative study that will retroactively evaluate data to measure the effects UFHPTI experienced when they switched from using rectal balloons to SpaceOAR Systems. The independent variables for this project are SpaceOAR hydrogel and rectal balloons. The dependent variables are revenue, physician’s time spent with patients, and new patient consultation appointments.

H1 – Treating patients with SpaceOAR hydrogel will have a negative correlation to revenue compared to rectal balloons.

H2 – Treating patients with SpaceOAR hydrogel will require more than 20 minutes of a physician’s time.

H3a - Treating patients with SpaceOAR hydrogel will have a negative correlation to the number of available new patient consultation appointments.

H3b – Treating patients with rectal balloons will have a positive correlation to the number of available new patient consultations appointments.

Literature Review Every year, the medical field improves procedures. Sometimes, these improvements are major advancements, while other improvements simply enhance procedures by making them cheaper, more efficient, and/or safer for patients. Often, these improvements will be quickly accepted in the medical field, while other times, it takes longer for providers or payers to accept some of the improvements. While physicians explore the medical efficacy of improvements in medicine, healthcare administrators need to evaluate the effects on a vast array of non-clinical issues such as patient flow, resource management, and reimbursements.

In radiation oncology, SpaceOAR ® Systems, a new treatment device, has been given FDA approval in the management of prostate cancer. Utilizing this new device will add cost to a radiation oncology center. Administrators will review the necessary resources to implement SpaceOAR into clinical practice. Part of the evaluation will be to review the additional fixed costs such as equipment and staff training, while variable costs such as physician time and additional procedure materials will need to be included in revenue evaluation (Lewis & Asch, 1999). These costs have to be balanced with procedure reimbursements and the need to understand how procedures will be paid for by payers (Schaum, 2000). It becomes clear that there needs to be strong communication and organization between administrative and medical providers to successfully adopt new procedures.

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This holds true when administrators and physicians evaluate new treatment devices for cancer patients undergoing radiation therapy. SpaceOAR hydrogel is a new treatment device that has shown medical promise, but needs to be evaluated on an administration level.

Radiation Therapy Radiation therapy plays a critical role in the management of lung, breast, and prostate cancer (Swartz & Petereit, 2010). Radiation therapy is used as a primary treatment or in conjunction with other treatment options such as surgery. For the nearly 220,000 newly diagnosed prostate cancer patients in 2010 (Perlroth, Bhattacharya, Goldman, & Garber, 2012) seeking either curative or palliative care, radiation therapy can be used with great effectiveness. Physicians and physicists are constantly evaluating best practices and evidence-based medicine to improve the therapeutic ratio, which is to reduce radiation doses to surrounding normal tissue and maximize doses to the target to ultimately lower chances of side-effects caused by the radiation (Hoppe et al., 2012). The problem with radiation therapy is that with every dose of radiation delivered to a patient, there is the possibility of serious damage to normal tissues (Beasley, Driver, & Dobbs, 2005). Over the last decade, explorations with multiple technologies including radiation machines, immobilization devices, and tumor tracking methods have led to reduced toxicity and improved outcomes for prostate cancer patients undergoing radiotherapy.

Rectal Toxicity and Rectal Balloons When radiation is used in the management of prostate cancer, the rectum is a critical structure that touches the posterior part of the prostate gland. In essence, a portion of the rectum will receive the entire curative dose of radiation. The curative dose of radiation can be problematic to normal tissue leading to secondary side-effects such as rectal bleeding.

There have been many ways to reduce this dose of radiation, but part of the problem is the prostate gland tends to move during treatment. Because of this movement, rectal balloons are increasingly being used in prostate radiotherapy treatment as an immobilization device (Su et al., 2012). Rectal balloons significantly reduce prostate motion during treatment through immobilization. This allows for safer and smaller planning target volumes, which minimizes the high-dose of radiation to the anterior rectal wall and total rectal volume (Teh et al., 2002). Even though rectal balloons reduce prostate motion, there is still a portion of the rectum that touches the prostate gland during radiotherapy and, therefore, a device that could create

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a space between the rectum and prostate gland could reduce the radiation to the rectum.

SpaceOAR In April of 2015, Augmenix announced FDA clearance for the SpaceOAR ÂŽ System, a new treatment device for prostate cancer patients that creates space between organs at risk. SpaceOAR is a synthetic, polyethylene-glycol-base (PEG) hydrogel composed of approximately 90% water. The gel is inserted during a one-time injection into the anterior perirectal fat creating a temporary space between the rectum and prostate gland (Gysen et al., 2014). The created space has the potential to reduce rectal toxicity from radiation, which in turn, decreases proctitis treatment and potentially allows for increasing radiation doses to decrease the rate of cancer recurrence and/or reduce the number of treatments (Uhl et al., 2014). Figure 1 demonstrates the created space that is encouraging for physicians, but SpaceOAR is not designed to be an immobilization device; therefore, there is potential for prostate motion, which still leads to larger treatment volumes.

The challenge for a radiation oncologist is to determine if SpaceOAR creates enough distance between the rectum and prostate gland to warrant its use over rectal balloons. Historically, rectal balloons do a great job immobilizing the prostate. There are only a few studies demonstrating that motion of the prostate gland is very minimal using SpaceOAR. One study

by Juneja (2015), demonstrated that prostate motion was slightly higher for patients with hydrogel than without hydrogel. From a clinical standpoint, using SpaceOAR hydrogel seems reasonable to incorporate into practice.

However, not everything done in medicine is just clinical in nature.

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Facilities looking to incorporate SpaceOAR into its practice will need to evaluate the financial constraints of this procedure.

Adding a New Medical Procedure Once a medical product or procedure has been deemed medically appropriate to incorporate into practice, administrators must be agents that deem the product or procedure is fiscally reasonable to incorporate into care. Basically, administration has to decide if the organization can afford to offer a procedure. In most cases, medical procedures conducted in an outpatient setting use descriptive codes for identifying services to collect reimbursement from payers called Current Procedural Terminology (CPT) codes (Baker & Baker, 2014). When these codes are used for billing, they will trigger payment amounts from the payer. The problem with SpaceOAR Systems is the CPT code is new. It was not until October of 2015 that CPT code A4649 became available for the supply of SpaceOAR hydrogel. The new code does not have a stated Medicare reimbursement amount and there is not a physician procedural code to place the gel.

Not having an established CPT code for the gel supply and not having a physician procedural code places insurance companies and outpatient radiation therapy centers in a challenging financial position. The insurance company is in a challenging position because a new code brings further complications that lead to rejections (Thomas, 2009). In some ways, by rejecting new CPT codes, the insurance company is protecting the provider from a potential billing and coding error. However, the denial process is very common with approximately 35% of claims being denied for various reasons (Kreimer, 2014). This leaves the provider in a challenging position to either wait or not offer a procedure because of the risk of losing reimbursement.

Not only denials are increasing, but providers are waiting longer to collect unpaid claims. Some nurse practitioner (NP) practices are reporting that their percentage of claims uncollected 60 days after submission is rising (Buppert, 2011). About 45 percent of family practices are reporting the average length of account receivables are up to 69 days (Larkin, 2007). The increased length of time to collect payments places financial stress on a clinic that could have devastating consequences. In some cases, the lack of cash flow could mean freezes on staff wages (Bostock, 2013) or worse, it could lead to defaulting on financing that could lead to acquisitions or mergers.

Certainly paying staff and bills are important for a clinic, but the longer the claim stays unpaid, the likelihood to receive payment goes down.

It is common practice to send 180 day unpaid claims to collections (Spears, 2009). Unfortunately, sending patients to collections is a double edge 174

sword. The first is the perception of sending someone to collections. The word could get out that the medical facility is all about money and not patient care. It is not a process that leadership should take lightly because it could bring about a poor stigma of the clinic. The second problem is the amount of money actually collected by a collection agency is relatively small.

Nationwide, collection agencies recover only 15 to 20 percent of delinquent accounts. They then keep 33 to 50 percent of the recovered money as a collection fee (How your collection agency can work for you, 1999). The lack of receiving a benefit from a collection agency and the challenge of denials places a strain on a clinic trying to get paid for new procedures that have a high probability of being denied payment.

Also, CPT codes eliminate the chance for providers to present Medicare patients with an Advance Beneficiary Notices of Noncoverage (ABN) (DiSantostefano, 2012). An ABN is a notice that must be completed and signed prior to the delivery of services by patients with Medicare health insurance whenever care providers believe that a particular service or treatment will not be covered (Shomaker & Link, 2014). A signed ABN would allow UFHPTI to charge patients for SpaceOAR before the procedure and let the patient get reimbursed from Medicare. This would mitigate the financial risk from the provider. Since SpaceOAR has a code, the provider will have to bill the insurance company and wait for payment or wait written denial of coverage. Waiting for approval from traditional healthcare payments under Medicare might take too long or provide too little in reimbursement for the procedure to be sustainable. Legally, providers must wait to get written denial of a procedure before an ABN can be signed. Only then, can the provider begin to have patients sign the ABN. The downfall is it will be too late for the clinic to collect funds from patients that did not sign an ABN. Managed Care Outpatient radiation oncology centers typically operate under the Fee-for-Service (FFS) managed care platform. Managed care is a very global health care topic that describes a system and arrangement for planning, managing, delivering and evaluating care (Linsley & Morton, 2014). The key players involved in managed care are customers, third-party payers, providers, and consumers of health care (Finkelman, 2001). All of these key players contribute a significant role to improve health care, but managed care is also viewed as one alternative to tackle healthcare expenditures (Rischatsch & Zweifel, 2013). One way to tackle healthcare expenditures is through reimbursement systems such as Fee-for-Service, case-based care, and capitation. Since most outpatient radiation oncology

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centers bill under the FFS managed care model, it is imperative to understand how FFS affects a clinic.

Fee-for-Service.

Medical practices need to be paid for the services it provides.

There are multiple ways for procedures to be paid, but FFS is the traditional method used for payment of health care services (Finkelman, 2001). In 2011, approximately three fourths of Medicare beneficiaries received health care through the traditional Medicare FFS program (Song, 2014). This means the individual items of care are reimbursed retrospectively (Britton, 2015), and the reimbursement is based on three factors: (1) indemnity fee schedules/predetermined payments per procedure or services, (2) usual, customary and reasonable fee schedule, and (3) relative value units (Marrelli, 1997).

Since SpaceOAR is so new, Medicare does not recognize the CPT code under a fee schedule. In addition, there is not a CPT code to prove the relative value units for the physicianâ&#x20AC;&#x2122;s time and expertise for the procedure. Title XVIII of the Social Security Act states, â&#x20AC;&#x153;No payment may be made for any expenses incurred for items and services that are not reasonable and necessary for the diagnosis or treatment of illness or injuryâ&#x20AC;?

(Garber, 2001, p. 64). The onus is on the provider to prove that new procedures are reasonable and necessary, but insurance companies ultimately determine what is reasonable and necessary. For instance, Medicare has allowed individual Medicare administrative contractors (MACs) to process Medicare claims to interpret the guidelines as determine whether the documentation justifies the payments (Buppert, 2010). As a result, physicians who rely on the nationally recognized guidelines are at risk of being denied payment (Hughes, 2010). This could leave providers in a sticky situation to choose between performing procedures that could be beneficial to patients verses receiving reimbursement from insurance companies.

Cost of Time Even when payers reimburse procedures under the FFS model, administrators still need to evaluate the time physicians will spend performing those procedures. The good news is relative-value units (RVUs) account for physicians work effort and clinic expenses (Stecker & Schroeder, 2013). This payment structure assures administrators that physicians should receive proper reimbursement for procedures. However, RVUs do not account for the opportunities lost by physicians spending time on procedures. Time is an equally distributed commodity among 176

practitioners. Adding new procedures for physicians, such as implanting SpaceOAR hydrogel, will require a change in their time management, but it will also impact clinical flow and potentially patient volumes. The time spent on procedures will vary from clinician to clinician. The longer the procedure, the longer resources will be devoted to the physician, and the more challenging the clinical day will become to examine the addition patients with scheduled appointments.

Simply making patients wait is not really an option. Patients do not want to hear that it will take weeks to be seen by their doctor, or worse wait for hours in a lobby or exam room to have a physician rush in and out in five minutes. In the same fashion, physicians became physicians to take care of people. Providers do not want to be so busy that they cannot meet the needs of their patients. Frustration can take place on both sides when physicians are bound to the care of just a few patients while others wait. In addition, physicians might be feeling the pressure from administration to keep the same patient volumes as before the new procedure. Physicians just might believe they are too busy to accept new patients.

Not accepting new patients because of added procedures is not the answer. Dr. William Manard warned, â&#x20AC;&#x153;Once a physician decides to turn the faucet off, turning it back on when the situation changes may be a challenge if word gets around the community that the provider is not accepting new patientsâ&#x20AC;? (Crane, 2013, p. 52). This is extremely true for prostate cancer treatments. The potential reimbursement amount of inserting SpaceOAR hydrogel pales in comparison to full reimbursement of radiotherapy for prostate cancer. The median Medicare reimbursement for intensitymodulated radiation therapy (IMRT) is $18,575 and it is $32,428 for proton therapy (Orenstein, 2015). Administration must keep a close eye on patient volume. If physicians are spending too much time inserting SpaceOAR, it is possible that patient volumes could drop, which will contribute to loss revenue. The potential combination of denied claims of the gel supply and no RVUs built into the procedure could mean that SpaceOAR will cost more than the purchase price of the gel. It also means that physicians will have less time to see patients.

Project Design The project is designed to use a quantitative research study method to evaluate the financial impact the University of Florida Health Proton Therapy Institute experienced when it switched from using rectal balloons to SpaceOAR hydrogel. The three dependent variables are: (1) reimbursement revenue from SpaceOAR and rectal balloons, (2) availability of new patient consultation appointments, and (3) physicianâ&#x20AC;&#x2122;s time spent in

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SpaceOAR cases. This project was conducted at the University of Florida Health Proton Therapy Institute.

Sample In 2010, it was estimated 219,000 men in the United States were diagnosed with prostate cancer making it one of the most commonly diagnosed cancers in the nation (Perlroth, Bhattacharya, Goldman, & Garber, 2012). These patients received different treatments around the world. One possible treatment for prostate cancer is to receive proton therapy from the University of Florida Health Proton Therapy Institute (UFHPTI). Part of the treatment requires minimizing the radiation dose to the rectum. SpaceOAR hydrogel and rectal balloons are two separate methods that can reduce the radiation dose to the rectum while prostate cancer patients undergo proton therapy. In this study, the sample population is prostate cancer patients treated at UFHPTI. The sample size is a smaller volume of patients from UFHPTIâ&#x20AC;&#x2122;s sample population.

Sample Size The sample size for patient information including reimbursement and length of physician time was collected retroactively from data during a two month period, February â&#x20AC;&#x201C; March of 2016, from all prostate cancer patients treated at UFHPTI. During the sample period, a total of 51 prostate cancer patients started their workup for prostate cancer treatments.

Of that group, 29 patients received SpaceOAR and 22 patients received rectal balloons. Ideally, each patient would have been randomly selected to appropriately represent the study population and remove selection bias (Kumar, 2014). However, to allow enough time to obtain reimbursement information, all 51 prostate patients were evaluated. The 29 SpaceOAR patients were the first patients to receive SpaceOAR at UFHPTI. Collecting Sample Data.

All data was collected retrospectively by evaluating various billing, scheduling, and clinical documents. To evaluate the impact SpaceOAR had on revenue compared to rectal balloons, the first 29 SpaceOAR cases were used. The reimbursement amounts were recorded for each patient and then averaged. Table 3 demonstrates different payers that UFHPTI billed.

Medicare was the most common insurer, 20 (69%), while all the others were less than 10 percent of payers.

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Physicians time spent with patients using SpaceOAR hydrogel impacts both revenue and resources. It is valuable to determine how much more time physicians will spend in clinic with SpaceOAR patients compared to rectal balloon patients. To analyze the amount of time physicians spent with SpaceOAR patients, the study used information from the clinical document SpaceOAR/Fiducial Marker Procedure form (appendix 2). Specifically, the difference between the nurses recorded lidocaine injection time and the recorded finish time was used. The recorded time represents the approximate amount of time a physician spent inside an exam room with one SpaceOAR case. The time will be in stark contrast of using rectal balloons. The use of rectal balloons does not require any physician time and therefore, only SpaceOAR cases will take away time from a physician schedule.

Clinical revenue can be impacted if SpaceOAR injections reduce the number of available new patient consultations. To determine the correlation of SpaceOAR to new consultation appointments, historical data of rectal balloon patients was compared to the study period. To obtain a broader picture, the capture period was extended to include the month of 179

April; therefore,, data was gathered from February through April 2015 and 2016. This should be acceptable because all prostate cancer patients treated in 2015 received rectal balloons. That data was compared to the number of new prostate cancer patient appointments available during the sample period of 2016.

Ethical Issues Participant privacy and safety are of the utmost importance in research. The medical field has a strong layer of patient privacy protection through the Health Insurance Portability and Accountability Act of 1996 (HIPAA). For all practical purposes, HIPAA set a national standard for privacy of individually identifiable health information (HHS, 2003).

Participants need to understand that their medical information will be safe in research studies. This is why the first component of HIPAA was implemented by covered entities focusing on protecting private health information (Erlen, 2005). However, there are times when patient information needs to be shared. The Department of Health and Human Services (HHS) has listed six categories when personal health information can be released without an individual’s authorization: (1) To the individual, (2) treatment, payment, and health care operations, (3) opportunity to agree or object, (4) incident to an otherwise permitted use and disclosure, (5) public interest and benefit activities, and some (6) limited data set for the purposes of research, public health or health care operations (HHS, 2003, p.

4) There are more subcategories that can be found in the six categories of the Permitted Uses and Disclosure section of HIPAA. In addition, institutional review boards (IRBs) serve as another layer of oversight protecting privacy rights by keeping information confidential and rendering subjects anonymous (Erlen, 2005).

Privacy is the primary function of HIPAA but not of the IRB. The IRB’s goal is to protect human subjects (Ozdemir, 2009). The IRB is concerned with ethical issues related to research. Research ethics rose to prominence in the second half of the twentieth century as a response to the crimes against human subjects in medical research; such as the Nuremberg case (Ozdemir, 2009). In many of these crimes, participants did not know to the full extent the research that was being conduct on them. Therefore, research on human subject must obtain IRB approval (Shafer, 2011) and informed consent (Quazi & Rafiquddin, 2006). The IRB does not want to see people taken advantage of for research purposes.

This quantitative research project is subject to IRB approval because human subject are involved. To obtain this approval, the University of Florida’s IRB wanted to know how human subjects will be involved.

According the UFHPTI’s director of research, Amanda Prince, she stated, 180

“If the organization had to change normal activities, it would require the project to obtain a separate IRB approval to investigate patient information.” The retrospective information gathered for this project was not new information. Instead, the information analyzed was normally and customarily conducted for patient care.

Since the retrospective information was not specifically captured apart from normal daily practices, this project was able to use a preestablished IRB protocol. In 2013, the local IRB approved PRX21 as a guideline of appropriate data collection sets to monitor and report outcomes for prostate cancer patients treated with proton therapy (appendix 1). This approval allows for research on a number of data sets including medical record numbers, treatment information, and pretreatment work-up information. All prostate cancer patients sign the informed consent for outcome tracking. If patients do not sign this consent, their charts are electronically flagged with a pop-up prompt stating, “Not approved for outcome tracking protocol.” In this study, all participants signed PRX21.

Results The results for this project confirmed some of the hypotheses while disproving others. Hypothesis one (H1) was confirmed; treating patients with SpaceOAR hydrogel will have a negative correlation to revenue compared to rectal balloons. Hypothesis two (H2) was confirmed; treating patients with SpaceOAR hydrogel will require more than 20 minutes of a physician’s time. Hypothesis three part A and B (H3a and H3b) were not confirmed; treating patients with SpaceOAR hydrogel will have a negative correlation to the number of available new patient consultation appointments, and treating patients with rectal balloons will have a positive correlation to the number of available new patient consultations appointments.

Reimbursement Results The results revealed that UFHPTI does not bill for any of the rectal balloons during the course of treatment. This means that the average prostate cancer patient will have 40 rectal balloons used during the course of treatment without any reimbursement. The average selling price per rectal balloon is $100. However, it was discovered that with UFHPTI’s bulk order discount, the organization was spending $45 per balloon or on average $1,800 per patient for the course of radiotherapy. According to Nanotechnology Industries Association and Magellan Health Services (2015), radiation oncology facilities can use CPT code 77334 to bill a rectal 181

balloon one time as a complex treatment device. Rectal balloons would not be reimbursed for the other 39 treatments. According to the American Society for Radiation Oncologyâ&#x20AC;&#x2122;s (ASTRO) Chief Executive Officer Laura Thevenot (2015), the CPT code 77334 should have an average reimbursement rate of $297.70. This one-time reimbursement would offset the cost of the other 39 balloons. However, leadership at UFHPTI has chosen not to charge for a rectal balloon because the medical billing company that UFHPTI uses suggested that it was not a proper billing practice.

The reimbursement results for the SpaceOAR procedures were mixed. No insurance company paid for the SpaceOAR gel under supply code A4649 or physician placement under code 45999. Of the 29 cases, five private insurance companies responded with denials by claiming the procedure was not covered or payment was included under the Correct Coding Initiative (CCI), which is, charges are bundled or covered under other procedures (Painter, 2002). The median length of time for those five insurers to respond was 12.4 days. Of the remaining 24 pending cases, four were private insurance companies and 20 were Medicare claims. All of those claims were still pending at the end of April 2016. The length of time for the pending claims from private insurers ranged from 15 to 38 days with the median time of 25 days. Of the 20 pending Medicare claims, the range was 9-38 days with a median time of 23 days.

A total of 192 charges were billed for the SpaceOAR procedures, of which, 45 charges have been reimbursed and 30 charges have been denied or classified under CCI. The other 117 charges are pending.

Interestingly, the first 18 of 19 patients had some claims reimbursed that were associated with the SpaceOAR procedure. All 10 patients that went through a SpaceOAR procedure after March 15, 2016 did not have any claims reimbursed. The clinic has received $6,498.70 in reimbursements which equates to an average of $361.04 per patient for the first 18 patients that insurers made a reimbursement. Table 4 illustrates the reimbursement profile for each charge associated with the SpaceOAR procedure.

The ultrasound for needle placement, CPT code 76942, was the most commonly reimbursed procedure. Only one private insurer denied the procedure, while the other 23 charges were pending. The first 10 patients were not charged for the transrectal ultrasound, CPT code 76872, due to the lack of capturing an image for documentation. For the nine that were charged, eight cases were paid. Peripheral nerve blocks, CPT code 64450, were reimbursed for three patients while seven charges were denied under the CCI. The other 19 cases were pending responses. Only four insurersâ&#x20AC;&#x2122; reimbursed fiducial markers, CPT code A4648, and three completely denied the coverage. The other 22 cases were pending response. The second most common code reimbursed associated with the SpaceOAR procedure was 182

the fiducial placement, CPT code 55876. Thirteen of eighteen cases were reimbursed. Two of the five claims not reimbursed referenced CCI and the other three were not able to be processed. The other 11 cases were still pending.

Ultimately, rectal balloons cost UFHPTI $1,800 per patient, while SpaceOAR costs $2,901 per procedure. After review of the reimbursement profiles, each of the first 18 patients had an average reimbursement amount of $361.04 per patient. Factoring in this payment brings the total cost per SpaceOAR procedure to $2,539.96. The difference in cost between rectal balloons and SpaceOAR is $739.96 per prostate cancer patient. It is also possible that the most likely reimbursement amount could be determined by evaluating the eight cases that included reimbursement from the transrectal ultrasound charge. Just evaluating those eight cases,,, reimbursement would have averaged $446.66.

Physician Time Results When this program began, the physicians stated goal was to conduct the SpaceOAR procedures in 20 minutes. Hypothesis 2, treating patients with SpaceOAR hydrogel will require more than 20 minutes of a physicianâ&#x20AC;&#x2122;s time, was confirmed. Three radiation oncologists were assigned to conduct SpaceOAR hydrogel placement. It is important to note that during the exam for the first 14 patients UFHPTI physicians were being taught how to insert the gel by a SpaceOAR employee and physician specialist in the exam room. Certainly, during this training period, procedure time would take longer. In addition, this evaluation did not focus on an independent physician. Instead, all 29 SpaceOAR cases were evaluated based on the recorded length of time a physician spent in the exam room to complete a SpaceOAR case.

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The time was calculated from the written notes by the nurse or medical assistant on the SpaceOAR/Fiducial Marker Placement form (appendix 2). The beginning of the procedure used the recorded physician lidocaine injection time, while the end of the procedure time was specifically marked as “end of procedure.” All of these procedures required the physician to inject lidociane, implant fiducial markers, and inject the SpaceOAR hydrogel. The range of time to complete the procedure varied between 25-65 minutes with the average length of 42.9 minutes. Since these were the first 29 patients to receive the SpaceOAR, they were evaluated in their procedure order. For instance, figure 2 demonstrates the length of time each procedure took. The first patient’s procedure was 60 minutes, while patient 29’s procedure was 43 minutes. The trend line in figure 2 demonstrates that with more experience, the length of time physicians spent conducting the procedure slightly decreased.

Consultation Appointments Results Available and filled appointments were evaluated from February through April 2015 and compared to available and filled appointments from February through April 2016. SpaceOAR injections were not available in 2015, but the clinic did start them in February of 2016. There was no statistical significance in the difference of available physician appointments

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when SpaceOAR procedures were offered compared to when they were not offered. Therefore, hypothesis 3a and 3b were not confirmed.

In the 2015 timeframe, 112 of 188 available consultation appointments were filled, which converted to a 59% filled appointment schedule. The average weekly available consultation appointments were 14 of which nine per week were filled. In the same timeframe of 2016, 104 of 165 available consultation appointments were filled, which converted to a 63% filled appointment schedule. The average weekly available consultation appointments were 13 of which eight were filled. Figure 3 displays the comparison of appointment available and filled per week during the discovery period. The maximum amount of appointments available was 19 in the first week of February 2015. That same year, the fourth week in March only had three consultation appointments available. According to the scheduling practice that UFHPTI follows, the most common reason there were lower appointment times available was due to physicians being out of the office. The most common reasons physicians were out of the office was for vacation and academic travel.

Discussion & Recommendations Reimbursement Recommendations Approximately 250 prostate cancer patients will be treated annually at UFHPTI. If the center only utilized rectal balloons, it would spend $450,000. If half of the patients received SpaceOAR, it would cost UFHPTI an additional $92,495 to the tune of losing $542,495 for all 185

prostate cancer patients treated at UFHPTI. To offset some of this cost, UFHPTI can immediately submit a one-time charge for rectal balloons.

According to the American Society for Radiation Oncology’s (ASTRO) Chief Executive Officer Laura Thevenot (2015), the CPT code 77334 should have an average reimbursement rate of $297.70. That would safe UFHPTI approximately $30,000 annually.

The lack of reimbursement of $2,565 for the SpaceOAR gel is most concerning. In the long run, it is not conceivable that spending the extra money is sustainable. However, in the big picture, UFHPTI should continue to offer the procedure to stay competitive because other proton and radiation oncology facilities are offering the gel. According to Oncology Business Week (2015), many leading radiotherapy centers across the country are using SpaceOAR. The most responsible action is to offer the gel to a smaller group of patients, so that, UFHPTI can market the procedure, but minimize the out of pocket costs associated with SpaceOAR. A comprehensive reimbursement review should be completed monthly to obtain a better understanding of the reimbursement trends and to identify any new or updated codes associated with SpaceOAR. In addition, UFHPTI’s billing department should work with Augmenix to develop an appeal package for CPT code A4649. Finally, if Medicare denies the procedure, UFHPTI’s billing team needs to have an Advance Beneficiary Notice for patients to sign. This will be the only way that UFHPTI can collect from patients with Medicare.

Physician Time Recommendations The physicians’ goal was to be in the exam room for 20 minutes to complete a SpaceOAR case. Instead it took double that amount of time, 43 minutes. It was to be expected take longer to complete the first patient procedures, but as physicians began to gain more experience, there should have been marked improvements in efficiency. According to Figure 2, the time spent on the cases was decreasing; however, it was not at a consistent rate. The times look more like the stock market than a decreasing downward slope of efficient improvements. Anticipating only 20 minutes created a large gulf of time between expectations and reality. With the first 29 SpaceOAR cases, physicians, nurses, and medical assistants spent at least an extra 667 minutes or 11 hours to complete these cases. Over the course of a year, that time could exceed 60 additional hours of patient care, and it will impact other areas of a clinic.

It did not seem the extra time spent in these cases impacted consultation appointments, but the fact that these cases took longer impacted not only the physician’s time but other resources. The first impact of a physician taking longer to complete the procedure required 186

other medical team members to devote more time in the exam. Primarily, nursing had to be with patients to properly position them on the surgical table, assist the physician during the procedures, and then complete the procedures with each patient. All of these duties take time away from nurses or nurse teams have to deal with other responsibilities. For nurses, time is both an enemy and friend (Hemsley, Balandin, & Worrall, 2012).

When nursing is stretched thin, they cannot complete other tasks, or they have to make up time in other areas. Frequently, to make up lost time, nurses will limit the amount of time spent communicating with patients or change the type of communication from verbal to electronic (Hemsley, Balandin, & Worrall, 2012). The potential for UFHPTI nurses to minimize patient communication needs to be evaluated. Nurses are not communicating simple medical procedures such as blood pressures or lab work, they are trying to explain, confirm, and reassure very technical oncology terminology during a life and death situation. Time devoted to all aspects of patient care cannot be an area that the clinical team at UFHPTI can simply overlook.

In the future, UFHPTI should revaluate the length of time physicians are spending on SpaceOAR cases. Primarily speaking, the clinical supervising nurse must manage and evaluate job satisfaction, burnout, and quality patient care (Cross, Moore, & Ockerby, 2010). If it is determined that physicians cannot complete a procedure in 20 minutes, UFHPTI should revaluate the resources devoted to each case. Currently, a physician, nurse, and medical assistant are in the exam room. If patient care is not compromised, a nurse and physician could conduct the entire procedure.

This would free up time for medical assistants to complete other tasks so that nurses will still have time to communicate with patients.

Consultation Appointments Recommendations SpaceOAR cases did not have an impact on new patient consultation appointments. However, the findings of this project demonstrated that 40 percent of available consultation appointments are not filled. It is possible that UFHPTI offers more consultations than needed, but perhaps this void of appointments directly impacts the daily patient treatment volumes. It raises the question if UFHPTI physicians are maximizing their patient volumes.

First and foremost, physicians need to carry a caseload of patients that he/she can reasonably handle to provide optimal patient care.

However, it is important to evaluate if physicians are meeting evidence based benchmarks for patient volumes. The American College of Radiology (ACR) is an independent accrediting body for radiation oncology centers.

According to the ACR practice accreditation guidelines, academic cancer 187

centers like UFHPTI should not exceed 163 new patients per year per radiation oncologist (American College of Radiology, 2015). For the six physicians that care for prostate cancer patients, UFHPTI could treat 978 prostate cancer patients per year. If consultation appointments stay consistent for the remainder of 2016, UFHPTI would offer 660 appointments of which 416 appointments would be filled. If UFHPTI had a 2-1 conversion ratio, it could anticipate treating approximately 200 prostate cancer patients.

The UF Health Proton Therapy Institute’s exam room capacity could not sustain 978 prostate cancer consolations. However, each physician has time to see more patients. There are two potential solutions for this problem. The first, UFHPTI could simply minimize the volume of available appointments, so that physicians would have better control of their daily obligations. The second option is to take advantage of the physician accessibility and offer telemedicine appointments.

Minimizing patient appointments is not ideal. Having a robust option of consultation appointments allows UFHPTI to be flexible in meeting the needs of their patients. However, that still leaves a large void of unfilled appointments. To fill these appointments, UFHPTI should begin to offer telemedicine consultations. Since most of UFHPTI’s patients travel from out of town, telemedicine fits the center’s medical tourism model and can create an identification of UFHPTI as a leader in second opinions.

Telemedicine in oncology is commonly referred to as teleoncology.

The primary purpose of teleoncology was created to enhance access and quality to clinical cancer care for rural, low and middle-income patients (Hazin & Qaddoumi, 2010). It seems to be working. In India, teleoncology has been able to reduce the number of emergency visits to the hospital, avoid unnecessary admissions, and enhance routine follow-up (Sudhamony, Nandakumar, Binu, & Niwas, 2008). In the U.S., telemedicine has been used in hospice care since the 1990s (Whitten, Holtz, Meyer, & Nazione, 2009). Finally, Royal Children’s Hospital (RCH) has been using telemedicine for post-acute burn care of children in Queensland. The hospital researched the difference of patient satisfaction between face-toface and videoconferencing appointments. Royal Children’s Hospital found that there was no impact to patient satisfaction (Smith, et. al, 2004).

Even though telemedicine has been successfully implemented at other places, the financial impact should be evaluated for this recommendation. According to Whitacre (2011), two different hospitals were able reduce their radiologist and psychiatrist hours from one full-time equivalent (FTE) to 0.2 FTE. This is a perfect example for radiation oncologists because much of their role during a consultation is a cross between a radiologist and psychiatrist with the addition of oncology 188

knowledge. If telemedicine can truly reduce staff, UFHPTI radiation oncologists would have more time to see more patients.

There are two major hurdles with telemedicine; cost of infrastructure and reimbursement (Lewis, 2015). Traditionally, private insurers have not reimbursed providers for telemedicine services, and Medicare was restrictive how it viewed telehealth (Geyer, 2015; Lewis, 2015). The good news is the technological cost is coming down, and UFHPTI has much of the infrastructure with teleconference capabilities.

Also, if the Medicare Telehealth Parity Act of 2015 is passed, it would open the door to more telehealth procedures. The act seems to have good traction based on some published consumer documents. According to the nationâ&#x20AC;&#x2122;s largest telehealth company, Teladoc, has 11.5 million members and expects to deliver more than 500,000 virtual visits in 2015 with a typical consultation price of $49 (Grube, Kaufman, Clarin, & O'Riordan, 2016). In addition, Kaiser Permanente has made telehealth a centerpiece of its efforts to improve service access and deliver high-quality care while keeping costs competitive for its 3.4 million members in Northern California (Grube et al., 2016). Giving all of this information, UFHPTI should seriously consider the opportunity telemedicine has to offer the organization.

Limitations and Future Investigation Overall, this study demonstrates some of the challenges related of adding a new procedure in a clinic. Specifically, there was a minimal amount of SpaceOAR reimbursement information. It is possible that there could be more denials, but possibly some insurers will pay. It would be helpful to determine the full length of time it took to receive a final answer of payment or denials from all insurers. Therefore, future investigations into the reimbursement of the SpaceOAR gel would require both a larger sample and a longer investigational period.

This study only evaluated the first 29 patients that received SpaceOAR. Because these were the first patients, it is possible that the results cannot be interpreted as future results. For instance, the length of time it took physicians to complete a SpaceOAR case was trending down.

The likelihood is with more practice physicians will reduce their time performing the procedure. Therefore, investigating a similar sample size one year from this study might be beneficial to evaluate if the learning curve helped physicians become more proficient injecting SpaceOAR. In addition, physicians were evaluated as a whole and not independently. Of the three physicians injecting SpaceOAR, some of them could have improved quicker than others. Future investigations should evaluate the length of time the procedures took for each physician instead of the entire group.

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Lastly, the study tried to evaluate the impact implanting SpaceOAR hydrogel had on the availability of new patient consultations. Like the other limitations, it would have been beneficial to expand the look back period to include yearâ&#x20AC;&#x2122;s 2010-2014. This robust data could demonstrate patterns in consultation appointments. Particularly, the data could reveal the most common months or weekâ&#x20AC;&#x2122;s physicians take time off for conferences and vacations. In addition, instead of just mining data, conducting a qualitative study about the way physicians feel about balancing their time with the addition of SpaceOAR could reveal valuable information to help leadership at UFHPTI build physician schedules to prevent burnout.

Conclusion The overall findings of this research project give a somewhat sobering picture of the state of using SpaceOAR hydrogel compared to rectal balloons for patients undergoing proton therapy at the University of Florida Health Proton Therapy Institute. Both public and private health insurance companies have not paid for the gel and only a few ancillary procedures have been reimbursed. In no way, the amount of reimbursement paid is sustainable for the foreseeable future. However, SpaceOAR is a new product with a new CPT code. Frequently, insurers deny coverage of new CPT Codes. Sometimes that is done to protect the provider from false claims and other times it is to protect the insurance company from paying unreasonable charges. Either way, UFHPTI should still review and submit SpaceOAR claims. Because SpaceOAR is being adopted by many academic cancer centers, it is likely insurers will begin to recognize the procedure and provide reimbursement for the hydrogel.

Quite often, money is the bottom line for decision making.

However, SpaceOAR is a new product with procedures that can impact the clinic. This project also reviewed how much time physicians spent on the procedure, and the impact SpaceOAR had on consultations. SpaceOAR had some negative impact to the amount of time physicians spent conducting the procedure. As the procedure becomes more common, physician expertise should increase and correlate to reduce procedure times.

Only consultations were not impacted by conducting SpaceOAR procedures. It is possible that physicians will still have time to see more patients to compensate for the lost revenue of SpaceOAR cases.

REFERENCES American College of Radiology. (January 12, 2015). Radiation oncology practice accreditation program requirements, 1-18.

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Augmenix Inc. (2015). Augmenix announces FDA clearance of spaceoar ÂŽ system. FDA Law Weekly, 64.

Baker, J. J., & Baker, R. W. (2014). Health care finance: Basic tools for nonfinancial manager (4th ed.). Dallas, TX: Jones and Bartlett Learning.

Beasley, M., Driver, D., & Dobbs, H. J. (2005). Complications of radiotherapy: Improving the therapeutic index. Cancer Imaging, 5(1), 78-84.

Bostock, N. (2013). Exclusive: Cash flow problems hit partners' income. GP, 8.

Britton, J. R. (2015). Healthcare reimbursement and quality improvement: Integration using the electronic medical record comment on "feefor-service payment--an evil practice that must be stamped out?" International Journal of Health Policy and Management, 4(8), 549551. doi:10.15171/ijhpm.2015.93 Buppert, C. (2010). Medicare contractors step up educational efforts and audits. Dermatology Nursing, 22(1), 1-3.

Buppert, C. (2011). How to avoid reimbursement denials. The Journal for Nurse Practitioners, 7(4), 321-322.

Crane, M. (2013). Are you too busy to accept new patients? Medical Economics, 90(24), 51-54.

Cross, W., Moore, A., & Ockerby, S. (2010). Clinical supervision of general nurses in a busy medical ward of a teaching hospital. Contemporary Nurse: A Journal for the Australian Nursing Profession, 35(2), 245-53.

DiSantostefano, J. (2012). Updated advance beneficiary notice instructions. The Journal for Nurse Practitioners, 8(9), 749-750.

Erlen, J. A. (2005). HIPAA-implications for research. Orthopedic Nursing, 24(2), 139-42.

Finkelman, A. W., (2001). Managed care: A nursing perspective. Saddle River, NJ: Pearson Custom Publishing Garber, A. M., (2001). Evidence-based coverage policy. Health Affairs, 20(5), 62-82 191

GabcanovĂĄ, I. (2012). Human resources key performance indicators. Journal of Competitiveness, 4(1), 117-128.

Geyer, S. (2015). Telemedicine barriers. Managed Healthcare Executive, 25(10), 37-37, 43.

Grube, M. E., Kaufman, K., Clarin, D., & O'Riordan, J. (2016). Health care on demand: Four telehealth priorities for 2016. Healthcare Financial Management, 70(1), 42-51.

Gysen, K., Kneebone, A., Alfieri, F., Guo, L., & Eade, T. (2014). Feasibility of and rectal dosimetry improvement with the use of SpaceOARÂŽ hydrogel for dose-escalated prostate cancer radiotherapy. Journal of Medical Imaging and Radiation Oncology, 58(4), 511-516. doi:10.1111/1754-9485.12152 Hazin, R., & Qaddoumi, I. (2010). Teleoncology: Current and future applications for improving cancer care globally. Lancet Oncology, 11(2), 204-10.

Hemsley, B., Balandin, S., & Worrall, L. (2012). Nursing the patient with complex communication needs: time as a barrier and a facilitator to successful communication in hospital. Journal of Advanced Nursing, 68(1), 116-126 HHS. (2003, May). OCR privacy rule summary: Summary of the HIPAA privacy rule. Retrieved from United States Department of Health and Human Services: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary /privacysummary.pdf Hoppe, B. S, Flampouri, S., Lynch, J., Slayton, W., Zaiden, R., Li, Z., & Mendenhall, N. P., (2012). Improving the therapeutic ratio in hodgkin lymphoma through the use of proton therapy.

Oncology, 26(5), 456-9, 462-5.

How your collection agency can work for you. (1999). Journal of the American Chiropractic Association, 36(7), 28.

Hughes, C. (2010). Is your Medicare payer playing by the rules? Family Practice Management, 17(4), 27-32.

192

Jha, S., Noori, H., & Michela, J. L. (1996). The dynamics of continuous improvement: Aligning organizational attributes and activities for quality and productivity. The International Journal of Quality Science, 1(1), 19-47.

Juneja, P., Kneebone, A., Booth, J. T., Thwaites, D. I., Kaur, R., Colvill, E. â&#x20AC;Ś Eade, T. (2015). Prostate motion during radiotherapy of prostate cancer patients with and without application of a hydrogel spacer: A comparative study. Radiation Oncology (London, England), 10(1), 215. doi:10.1186/s13014-015-0526-1 Kreimer, S. (2014). 15 ways to fight claim denials. Optometry Times, 6(7), 2627.

Larkin, H. (2007). Cut your A/R cycle? Try this option. Contemporary OB/GYN, 52(6), 82-86 3p.

Lewis, C. B. (2015). Private payer parity in telemedicine reimbursement: How state mandated coverage can be the catalyst for telemedicine expansion. The University of Memphis Law Review, 46(2), 471-502.

Lewis, J. D., & Asch, D. A. (1999). Barriers to office-based screening sigmoidoscopy: Does reimbursement cover costs? Annals of Internal Medicine, 130(6), 525-530.

Linsley, P., & Morton, S. (2014). Managed care: a structured approach. Nursing Standard, 28(19), 37-42.

Marrelli, T. (1997). The nursing managerâ&#x20AC;&#x2122;s survival guide. (2nd ed.). St. Louis, MO: Mosby-Year Book, Inc. NIA Radiation Oncology Coding Standard (2015, January). Treatment devices.

Retrieved from http://www1.radmd.com/media/239860/treatment-devicescoding-standard-77332-77333-77334-77338-eff-010115.pdf Oncology Business Week (Nov., 2015). Augmenix, inc.; augmenix' SpaceOAR(R) system experiences rapid U.S. adoption. 227.

Orenstein, B. (2015, February). Proton therapy and cost. Radiology Today, 16(2), 22.

193

Ozdemir, V. (2009). What to do when the risk environment is rapidly shifting and heterogeneous? Anticipatory governance and real-time assessment of social risks in multiply marginalized populations can prevent IRB mission creep, ethical inflation or underestimation of risks. American Journal of Bioethics, 9(11), 65-68. doi:10.1080/15265160903197671 Painter, R. (2002). Medicare carriers must use correct coding initiative. Urology Times, 30(8), 39.

Perlroth, D. J., Bhattacharya, J., Goldman, D. P., & Garber, A. M. (2012).

An economic analysis of conservative management versus active treatment for men with localized prostate cancer. Journal of the National Cancer Institute Monographs, (45), 250-257.

Quazi, T. I., & Rafiquddin, A. (2006). Ethical issues in medical research & publications. Journal of Medicine, 7(2), 42.

Rischatsch, M., & Zweifel, P. (2013). What do physicians dislike about managed care? Evidence from a choice experiment. The European Journal of Health Economics: HEPAC, 14(4), 601-13.

Schaum, K. (2000). Steps to reimbursement success for 2000 step 3: Write orders to justify medical necessity. Advances in Skin & Wound Care, 13(4), 150.

Shafer, S. L. (2011, March). Anesthesia & Analgesia policy on Institutional Review Board approval and informed consent for research. Anaesthesia. 157-158. doi:10.1111/j.13652044.2010.06605.x.

Shomaker, D. K., & Link, L. R. (2014). Medicare's advanced beneficiary notice: An ethical analysis. Clinical Practice, 11(4), 403-407.

Smith, A. C., Kimble, R., Mill, J., â&#x20AC;ŚBailey, D. (2004). Diagnostic accuracy of and patient satisfaction with telemedicine for the follow-up of pediatric burns patients. Journal of Telemedicine and Telecare, 10(4), 193-8.

Spears, T. L. (2009). Ways to maximize effective collections. The Journal of Medical Practice Management : MPM, 24(6), 384-6.

194

Sudhamony, S., Nandakumar, K., Binu, P. J., & Niwas, S. I. (2008).

Telemedicine and tele-health services for cancer-care delivery in India. IET Communications, 2(2), 231-236. doi:10.1049/ietcom:20060701 Stecker, E. C., & Schroeder, S. A., (2013). Adding value to relative-value units. The New England Journal of Medicine, 369(23), 2176-9.

Song, Y., (2014). Varied differences in the health status between medicare advantage and fee-for-service enrollees. Inquiry - Excellus Health Plan, 51, 1-12.

Su, Z., Zhao, T., Li, Z., Hoppe, B., Henderson, R., Mendenhall, W., â&#x20AC;Ś Mendenhall, N. (2012). Reduction of prostate intrafraction motion using gas-release rectal balloons. Medical Physics, 39(10), 5869-5873. doi:10.1118/1.4749932 Swartz, M. J., & Petereit, D. G. (2010). The role of radiation therapy in the management of lung, prostate and colorectal cancer in South Dakota. South Dakota Medicine: The Journal of the South Dakota State Medical Association, Spec No. 60-66.

Teh, B. S., McGary, J. E., Dong, L., Mai, W., Carpenter, L. S., Lu, H. H., . . .

Butler, E. B. (2002). The use of rectal balloon during the delivery of intensity modulated radiotherapy (IMRT) for prostate cancer: More than just a prostate gland immobilization device? The Cancer Journal, 8(6), 476-83.

Thevenot, Laura I. "Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center." Letter to Andy Slavitt.

31 Aug. 2015. ASTRO. N.p., n.d. Web. 19 Apr. 2016. <https://www.astro.org/uploadedFiles/Main_Site/Practice_Mana gement/Reimbursement/Medicare/News/2015/OppsComments. pdf>.

Thomas, J. R. (2009). Managing CPT code rejects. Journal of AHIMA, 80(5), 70-71.

Uhl, M., Herfarth, K., Eble, M. J., Pinkawa, M., van Triest, B., Kalisvaart, R., . . . DeWeese, T. L. (2014). Absorbable hydrogel spacer use in men undergoing prostate cancer radiotherapy: 12 month toxicity and proctoscopy results of a prospective multicenter phase II trial.

Radiation Oncology, 9, 96.

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Whitacre, B. E. (2011). Estimating the economic impact of telemedicine in a rural community. Agricultural and Resource Economics Review, 40(2), 172-183.

Whitten, P., Holtz, B., Meyer, E., & Nazione, S. (2009). Telehospice: reasons for slow adoption in home hospice care. Journal of Telemedicine and Telecare, 15(4), 187-190. doi:10.1258/jtt.2009.080911 For Robbertâ&#x20AC;&#x2122;s Appendices, please see the individual link on the Bellwether webpage, accessing the document from Library archives.

-an

BRADLEE ROBBERT is a proud father of two beautiful daughters and is married to a wonderful woman that inspires him to be better at work, play, and life. Their combined inspiration led him back to school where he completed his graduate program for Healthcare Administration in the summer of 2016. Since then, he has been active in the American College of Healthcare Executives and the National Association of Proton Therapy.

Both of these professional organizations provide opportunities for collaboration and education to enhance the healthcare field. When he is not working, he loves spending time with those three ladies in my life: dressing up, drinking tea, and being showered with cards.

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AMIRAM ZEIGER

Cognitive Behavioral Therapy Versus Adlerian Therapy Abstract Cognitive behavioral and Adlerian therapy are two of the most common theories applied by therapists today. This paper will examine the basic concepts and techniques of both theories and how their therapeutic processes operate in the context of real-life scenarios. As each theory will be applied to distinctly different clients, a detailed analysis of each theory, along with the appropriate methods of implementation, will follow. As the advantages, limitations, and cultural applications of each theory will be explored, the author will share his personal opinion and comfort level regarding each one.

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Theory Application Paper: Cognitive Behavioral Therapy Versus Adlerian Therapy As clients relate their personal story, the competent counselor will carefully observe and measure various case details in order to determine the suitable mode of therapy. Although a therapist may have a personal style of preference, it is crucial to maintain a healthy balance of several methodologies in order to remain flexible and relevant for each client's specific needs. This paper will focus on cognitive behavioral and Adlerian therapies in an attempt to allow the reader to gain a proper appreciation of their strengths and weaknesses and to learn their appropriate applicability and implementation.

Cognitive Behavior Therapy Aaron Beck developed cognitive therapy (CT) as an evidencedbased therapy for depression. While sharing many similarities with other forms of therapy (developed around the same time), such as Albert Ellis' rational emotive behavior therapy (REBT), CT set itself apart due to its heavy reliance on empirical research rather than philosophical doctrine (Corey, 2017, p. 281). Although Beck coined the term cognitive therapy to reflect the great emphasis that he placed on thinking, the concept of cognitive behavioral therapy (CBT) eventually emerged, signifying the addition of certain behavioral techniques. As CT itself is predicated on the connection between changing one's thinking and the creation of new behaviors (Beck & Haigh, 2014), the evolution of CBT was simply a natural merger between two already heavily connected ideas.

Dr. Beck's research led him to the conclusion that the interpretations of depressed people were distorted, thereby making them more likely to make cognitive errors, such as catastrophizing, overgeneralizing, and magnifying problems. He noted that these thoughts came spontaneously, and as such, the afflicted people accepted them as absolute truth and were unaware of their ability to challenge them.

However, he found that once these thoughts were identified and corrected, the ensuing emotions and behaviors followed suit in a positive pattern.

While other forms of psychotherapy involve exploring a client's past in order to understand emotions, Beck mainly focused on currently held thoughts and beliefs. He taught his clients to identify their thoughts, thereby allowing them to challenge whether the thoughts were factually accurate or simply based on error. Although unpublished personal correspondence suggests that Beck continued to think somewhat psychoanalytically even after he broke with psychoanalysis, his techniques unquestionably reflected a heavy shift from the traditional psychodynamic approach of Freud, Jung, and Adler (Rosner, 2012).

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An excellent example of the behavioral element of CBT can be seen in prolonged exposure therapy (PE). Developed by Edna B. Foa, PE is a form of cognitive behavioral therapy designed to treat post-traumatic stress disorder (PTSD), which is characterized by the re-experiencing of traumatic events. As most PTSD clients attempt to avoid trauma reminders, even when not inherently dangerous, the PE therapist applies both imaginal exposure (i.e., recounting and processing the experience) and in vivo exposure (i.e., confrontation with objects that cause distress but are not inherently dangerous) to reduce the distress and avoidances evoked by the trauma reminders (Reger et al., 2016). However, the cognitive component of PE must also not be overlooked, as the ultimate goal is to help the client recognize that the safety behaviors and catastrophizing thoughts reflect cognitive distortions triggered by the traumatic event.

Finally, it is noteworthy that CBT has been shown to be effective for a wide variety of maladaptive behaviors and conditions, such as substance use disorder, schizophrenia, eating disorders, anger and aggression, criminal behaviors, chronic pain (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012), and even insomnia (Shaughnessy, 2016).

Adlerian Therapy Alfred Adler (1927), a contemporary of Freud, developed Adlerian theory. Adler's psychodynamic approach was quite different from the classic psychoanalytical style, as he disagreed with Freud on several issues.

For example, Adler placed less emphasis than Freud on concepts such as instinctual determination, accessing the unconscious and the unresolved issues of early childhood stages. Instead, Adler's theory highlighted a positive viewpoint of human nature and revolved around man's ability to search for meaning, take responsibility, and attain a life goal. In addition, rather than dividing man into different parts, Adler took a more holistic stance, placing heavy consideration in the social context as it pertains to the understanding and counseling of individuals (Mosak & Maniacci, 2011).

According to Schultz and Schultz (2013; as cited in Corey, 2017), even though Adler and Freud grew up in the same city and were educated at the same university, their very different early experiences were critical factors in shaping their distinctly different views of human nature.

Adler (1927) maintained that the innate desire to grow results in the development of a life goal, which molds one's beliefs and assumptions regarding himself and society and unifies his personality into fulfilling that life goal. His theory adopted a radical stance in regards to the naturenurture debate by viewing the developing individual as creating a unified self-identity and personality in response to the (oftentimes conflicting) demands of nature and nurture, albeit not absolutely determined by them (Adler, 1927). Finally, Adler believed that feelings of inferiority could be the very impetus for one to strive for mastery and completion, as one can 199

overcome feelings of insecurity by redirecting the pursuit for significance into more socially beneficial directions (Corey, 2017).

The role of the Adlerian therapist is to help the client better understand himself and ultimately, self-create an improved life story. One of the methods to accomplish this is through the examination of family constellation, which includes early interactions with parents and siblings, as well as issues related to birth order and self-perception of one's life role.

This affords the therapist with somewhat of a picture of the client's early social world and the influences that proved crucial in formulating his assumed role in society. In addition, a therapist may use early recollections (primarily before the age of 10) to understand certain goals and motivations, as well as assess the client's overall life story. After examining the occurrences that the client claims to have happened and the accompanying thoughts and feelings, the therapist can better identify the sources for his current style of life and subsequently provide a point of departure and targets for therapy. As Adler and his followers emphasized the effect that oneâ&#x20AC;&#x2122;s perceived childhood experiences has on adult life, it is interesting to note that Adlerian play therapy has been recently developed as a way to integrate Adlerian philosophy with play therapy skills and concepts (Meany-Walen, Kottman, Bullis, & Dillman, 2015). Such therapy is predicated on Adlerian concepts and is designed to preempt the need for such therapy later in life.

The first three phases of Adlerian therapy involve the therapist establishing the relationship, assessing psychological dynamics, and encouraging self-understanding. Afterwards, the therapist begins the phase of reorientation, which is designed to put the insights gleaned from previous stages into practice. During this phase, the client is reeducated and reoriented to find a more functional and useful perspective on life, rather than wallow in self-pity and declare himself a victim of fate. The client is encouraged to develop a sense of being valued and expand himself to experience genuine interest in the lives of others people. Furthermore, the client is taught to accept imperfection and develop the sense of humor and positive outlook necessary to break out of certain guiding self-ideals.

Finally, the client is taught how many of his inferiority feelings can be harnessed as the very source for the creation of a new self. As the client is challenged to find the inner strength and courage to take risks and implement change, the therapist provides great encouragement, while accentuating the client's natural strengths and inner resources.

Similarities and Differences Between CBT and Adlerian Therapy Before comparing CBT and Adlerian therapy, it is noteworthy that Albert Ellis (the founder of REBT, which has heavily contributed to contemporary CBT) made no attempt to hide the great influence that Alfred Adler had on his theoretical approach. For example, the concept of 200

the "tyranny of shoulds" (Corey, 2017, p. 271) is present in both CBT and Adlerian therapy, albeit manifested differently, as will be explained later. In addition, the concept of a strong client-counselor relationship is heavily emphasized in both models, as collaboration and mutual trust are the basis through which client problems are analyzed and addressed. Although Adlerian therapy actually promotes an egalitarian therapeutic alliance (Corey, 2017), CBT is not far behind, as indicated by its emphasis on the client's role in self-discovery. Finally, Corey (2017) notes that modern CBT has been greatly expanded by Padesky and Mooney's (2012) strengths-based model, in which client and therapist collaborate to address the problem by cleverly feeding off of the resiliency that the client displays in other areas of life. As this approach undoubtedly finds its source in the therapeutic encouragement practiced by Adlerian therapists, it is indicative of the mutual respect that the counselor seeks to engender in both forms of therapy.

While CBT and Adlerian therapy share certain external similarities, the essence of these two approaches is quite different, both in terms of their view of pathology and their vision of therapeutic healing. The first notable distinction pertains to their approach in understanding the root of the client's struggles. While the CBT therapist perceives psychological issues as an exaggeration of responses which are the result of cognitive distortions (Corey, 2017), the Adlerian therapist takes a broader approach by exploring the client's perception regarding self and others, as well as his inferiority feelings that follow. Indeed, Adlerian therapy rests on the very premise that the individual is embedded in society and the whole of humanity, and as such, cannot be properly appreciated outside of his social context. In addition Adlerian therapy requires that the counselor gain some level of psychoanalytic insight, as demonstrated by its exploration of birth order and other early dynamics. While cognitive therapy has indeed incorporated some aspects of the unconscious in terms of implicit and tacit knowledge, it staunchly asserts that dysfunctional schemas are not buried deeply in the unconscious mind (Beck & Weishaar, 2011).

The second important contrast between the above therapies can be seen by simply observing the actual therapeutic process. CBT places heavy emphasis on pinpointing the specific erroneous beliefs, or "shoulds" (Corey, 2017, p. 272) that have triggered the maladaptive emotions and behaviors. Only after such thoughts are identified can the client begin the process of modifying his underlying errors, thereby leading to positive change in behaviors and emotions. Adlerian therapy, on the other hand, focuses on the overall holistic state of the client, maintaining that the process of recreation and healing will naturally occur, provided that one correct general self-misconceptions within his social context.

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Finally, CBT's great emphasis on thinking, deciding, and doing is what truly sets it apart from its Adlerian counterpart. As the client is actively engaged in the heavily structured goals organized in the sessions, there is simply insufficient time for any lengthy psychodynamic analysis.

The interconnectedness between cognitive processes, emotions, and behaviors is truly the main focus of the sessions (Corey, 2017), along with the ensuing homework that the client is expected to complete before the next session. Adlerian therapy, on the other hand, allows the client to take a step back and take a more introspective approach for understanding his problems, before embarking on the ultimate goal of healing.

Application of CBT and Adlerian Therapy as Applied to Case Studies As a beginning counselor, I remain particularly open-minded toward theories and therapy modes to which I have not yet become acclimated or with which I have not yet grown comfortable. As I evaluate the needs of a diverse clientele, I begin to recognize the importance of viewing each patient as a world unto himself, as per the Talmudic dictum (1835, p. 37a), which states: "One who upholds one soul... it is as if he upheld the entire world." For example, I have recently begun therapy with two new clients, Maroli and Markieff. My initial two encounters with them demonstrate the above concept in marked fashion, as I learn about their strikingly different backgrounds, needs, and ultimate goals.

Maroli is a young immigrant mother of two who escaped an African country to avoid persecution. As she is tormented by nightmares and flashbacks of family and friends being raped and tortured, she has considered taking her life, if not for her motherly concern for her children.

Markieff, on the other hand, is a young man who had deep aspirations to play basketball professionally, but whose dreams have recently been broken due to a serious car accident. As the oldest of six children in a singlemother household, he is shattered by the reality that his dream of helping his family financially is no longer possible. As he endures the pain of the injury, along with his limited mobility, fleeting thoughts of self-harm have crossed his mind, but he says that he would never act on them because of his religion. As later this week I will be seeing both of these clients for the third time, I must reflect on the therapy model that I will initially implement.

Maroli is clearly displaying post-traumatic symptoms and, as such, the CBT model would seem appropriate, since research has shown it to be most effective for post-traumatic syndrome disorder (PTSD). As Maroli's thoughts about her trauma increase her stress (and cyclically make her symptoms worse), I will work with her to identify the thoughts about the world and herself that make her feel afraid or upset. For example, it is quite possible that she lives with the shame and guilt of having forsaken her friends and family, both during the actual horrific events and by leaving and 202

immigrating to America. As we collaborate to replace these thoughts with more accurate and less distorted thoughts, Marina will also learn specific ways through which she can cope with feelings such as anger, guilt, and fear.

As for specific modes of CBT, both cognitive processing therapy (CPT) and prolonged exposure (PE) therapy may be equally appropriate for Maroli. However, I will choose to initially implement PE, as I have been witness to its success and am indeed a believer in its model. The basic premise of PE is that people learn to fear thoughts, feelings, and situations that remind them of the past traumatic event. Therefore, by encouraging Maroli to repeatedly talk about her experience in a comfortable environment, she can learn to be in control of her thoughts and feelings about the trauma, as well as develop the courage to face her memories.

Depending on Maroli's condition, I may either desensitize her by encouraging her to discuss memories that are less upsetting before talking about worse memories or "flooding" her with many bad memories at once.

I may also teach her different relaxation and breathing techniques to help her "survive" the painful encounters with her past. At first, Maroli may find this enormously difficult and strange that I am encouraging her to purposely think about stressful thoughts. However, over time, I expect her to become desensitized to her fears and replace her distorted associations with healthy thoughts.

In the case of Markieff, I will employ a significantly different mode of therapy. While Maroli is plagued by deep traumatic experiences, Markieff seems unphased by the mere memory of his accident. Rather, he suffers from deep confusion as to his life role, both from a personal and social perspective. His confusion is compounded by the fact that the expectations for his athletic success were so high, yet now he must look deeply inward to find alternate talents. As he struggles academically, he begins to challenge his self-worth, as he must discover previously hidden strengths.

Based on the above analysis, I feel that the Adlerian model will suit Markieff's needs, as it allows Markieff to explore his own situation from the perspective of his social world. In addition, considering Markieff's current feelings of inadequacy and self-doubt, the Adlerian assertion that feelings of inferiority can be the very impetus for self-creation may provide him with the glimmer of hope that he so sorely yearns.

Although Markieff may view me as the counselor with all the answers, I will insist that he approach counseling as a relationship between equals. I can accomplish this by helping him explore his feelings of inferiority, and explain to him that the goals of counseling must be developed mutually. Next, I will prepare a lifestyle assessment based on a questionnaire that collects information about Markieff's early relationships with his family and friends. This assessment will include a determination of 203

whether he indeed poses a danger to himself, as he did mention self-harm.

As we explore early memories as a way of understanding his goals and values, I will aim at having him recognize the consistency between his past and present. Based on these early recollections, we will collaborate in order to gain an understanding of his self-perception, and we will summarize and interpret this information.

I would expect that the above assessment would bring out certain self-defeating perceptions and faulty conclusions that Markieff has internalized. For example, due to his enormous promise as a child, it is quite possible that he has unconsciously decided that his role in life is to serve as the supportive fatherly figure that his siblings never had. The mere ability to articulate such fictional finalism is indeed Markieff's first step in recreating his life-goalâ&#x20AC;&#x201D;in light of his new handicap. Another inaccuracy in Markieff's private logic may simply be an assertion that he can never make it in the academic world. In fact, the combination of his physical prowess coupled with his ostensible academic ineptness may have indeed reinforced such an assertion. However, I will guide him in discovering that this belief may reflect the simple fact that he has never felt the need to pursue academic success, as until now, everything he ever wanted was achieved within the framework of his athleticism.

My goal is to use the Adlerian method as a means for Markieff to come to the realization that he need not be locked into past patterns; rather, it is always within his power to improve his lot in life. I will emphasize that change will not occur merely as a result of the insights that he has gained unless he actually makes use of these insights by carrying out an actionoriented plan. Finally, I will encourage Markieff as he embarks in his new journey, all the while reminding him that many of the lessons that he learned during his short athletic career (e.g., teamwork, loyalty, sportsmanship, work ethic, etc.) can be transferred into the new life-path that he creates.

Challenges Facing the Therapist in the Above Case Studies Although I am fairly confident that each model is reasonably appropriate for its case study, I have several concerns regarding each application. In Maroli's situation, I would be quite cautious to remain sensitive to certain cultural nuances that may affect her reaction to the process of desensitization to fears. Although it is fair to assume that she should react well to the challenges that I pose to her trauma-induced distortions, I may not be sufficiently in tune to the degree in which she needs to rehash and relive her horrific past. As she now feels disconnected from her husband and children, she may very well need to also focus on the present, thereby finding solace and comfort through the fulfillment of current relationships.

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In the case of Markieff, my main concern is that he may simply not be ready to thoroughly explore his early childhood experiences and memories. Unlike most of my other clients, Markieff's crisis is quite recent and he may need to sort out his feelings and belief system. In fact, as Markieff is a religious person, a healthy dose of existential intervention may also be in order, as this may allow him to identify and clarify his assumptions about the world in general.

However, after analyzing the above two concerns, I would say that I am a bit more comfortable with the CBT model, as its empirically-derived principles have been time-tested as a process for healing so many different mental ailments. In addition, unlike Adlerian theory's largely philosophical method, CBT's empirically tested methods create a more measurable and objective benchmark for the definition of client recovery. As such, I will be able to properly monitor Maroli's progress and assess whether other interventions (besides for CBT) are also necessary.

Personal Reflection of Therapist Experience in the Above Case Studies As I have always had a penchant toward CBT, one of the great discoveries provided to me by writing this paper was that Adlerian therapy could also be applicable to real scenarios. While my initial reaction (when first learning about Adlerian theory) was that it was largely theoretical, I have now come to realize that it can indeed serve as the primary model in cases where clients are in the midst of a crisis involving the identity of their life-role. Simplistic as it may sound, Markieff is an excellent example of a person who has no choice but to start a new beginning, both in terms of career path and from a social perspective.

Finally, I was surprised to learn of the various dynamic ways in which Adlerian therapy has been implemented. From play therapy to grief counseling, and from group therapy to family counseling, the core beliefs of Adlerian theory provide a solid and consistent foundation in an everchanging and quick-paced world. While therapy modes are constantly being updated and fine-tuned, Adler's imprint is unquestionably evident in almost all forms of contemporary therapy, including CBT. Although different from CBT in its technical delivery of theory and the way in which it creates change, it also shares many similarities, as evidenced by the collaborative nature of the therapeutic relationship and the process of change as reeducation and reorientation. As the goals of both modes of therapy are to recognize and increase understanding of self, as well as establish more positive life goals and behaviors, the competent counselor may "store away" both models, and integrate their principles in the appropriate situation.

In light of the above, I must say that I am more comfortable with the CBT model, albeit with a healthy dose of Adlerian theory. As these models have great overlap, I view such integration not as the combination

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of arbitrary techniques, but rather as a holistic and comprehensive way of meeting the complete needs of my clients.

REFERENCES Adler, A. (1927). Understanding human nature. New York, NY: Greenberg.

Beck, A. T., & Haigh, E. A. P. (2014). Advances in cognitive theory and therapy: The generic cognitive model. Annual Review of Clinical Psychology, 10, 1-24.

Beck, A. T., & Weishaar, M. E. (2011). Cognitive therapy. In Corsini, R. J., & Wedding, D. (Eds.), Current psychotherapies (9th ed, pp. 276-309).

Belmont, CA: Brooks/Cole, Cengage Learning.

Corey, G. (2017). Theory and practice of counseling and psychotherapy (10th ed.).

Boston, MA: Cengage Learning.

Hofmann, S., Asnaani, A., Vonk, I., Sawyer, A., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses.

Cognitive Therapy & Research, 36, 427-440. doi:10.1007/s10608-0129476-1 Meany-Walen, K. K., Kottman, T., Bullis, Q., & Dillman Taylor, D. (2015).

Effects of Adlerian play therapy on children's externalizing behavior. Journal of Counseling & Development, 93, 418-428. doi:10.1002/jcad.12040 Mosak, H., & Maniacci, M. (2011). Adlerian psychotherapy. In Corsini, R. J., & Wedding, D. (Eds.), Current psychotherapies (9th ed., pp. 67-112).

Belmont, CA: Brooks/Cole, Cengage Learning.

Padesky, C. A., & Mooney, K. A. (2012). Strengths-based cognitive behavioural therapy: A four-step model to build resilience.

Clinical psychology & Psychotherapy, 19(4), 283-290.

Reger, G. M., Koenen-Woods, P., Zetocha, K., Smolenski, D. J., Holloway, K. M., Rothbaum, B. O., & ... Gahm, G. A. (2016). Randomized controlled trial of prolonged exposure using imaginal exposure vs. virtual reality exposure in active duty soldiers with deploymentrelated post-traumatic stress disorder (PTSD).

Journal of Consulting and Clinical Psychology, 84, 946-959. doi:10.1037/ccp0000134 206

Rosner, R. I. (2012). Aaron T. Beck's drawings and the psychoanalytic origin story of cognitive therapy. History of Psychology, 15(1), 1-18. doi:10.1037/a0023892 Shaughnessy, A. F. (2016). CBT effective for chronic insomnia. American Family Physician, 93(1), 60.

Talmud. (1835). Tractate sanhedrin. Vilnius, Lithuania: Romm Brothers.

AMI ZEIGER is a first year student in the Master of Science in Clinical Counseling (MSCC) program at Bellevue University. A native Philadelphian, he now resides in South Bend, Indiana where he and his wife have lived for the past eight years. They are the proud parents of two boys and nine girls, some of whom vehemently insist that cognitive behavioral therapy (CBT) should never be practiced on them by a parent. As a teacher and Rabbi in a small private high school, Ami believes that a strong background in mental health is a valuable asset in the classroom. An avid student of the Talmud, he finds great satisfaction in incorporating its teachings into his studies.

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ALEX KELLERSTRASS

Speaking the Right Language: The Importance of Communications and Soft Skills Development Executive Summary In the field of international development, the United States government contracts millions of dollars of aid to private and non-government organizations in order to carry out the full scope of deliverables tasked to the United States under the umbrella of international foreign aid.

These government contracts are contingent on the completion of very specific deliverables by the non-government organization and the detailed and specific reporting of these deliverables is a critical component to the process of completion and renewal of government contracts. The government sponsor determines if goals and expectations were met by their review of reporting done by the non-government organization.

Clear, concise, and thorough reporting is critical to the continuance of government contracted work. In many international development organizations, the reporting focus is too heavily concentrated on the technical information. The technical statistics are often reliant on additional narrative in order to successfully display the full scope of the activity accomplished. Interpersonal written and verbal communication is an essential element to successful reporting of organizational activities. The error of miscommunication of such activities can easily result in the implication of failure and loss of government funding. Technical professionals are not receiving the communication and soft skills training required to provide this interpersonal element of narrative to their reporting. This white paper will expose why this training is lacking and what educators, employers and individuals can do to improve communications skills for technical professionals.

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Speaking the Right Language: The importance of communications and softs skills development for technical professionals Agnes Mukampeta, a midwife in the Ngororero District of Rwanda, was able to save a 32-year-old mother from dying of heavy postdelivery bleeding. Agnes had recently learned the skills to stop the bleeding only a few weeks prior to the delivery during a United States Agency for International Development Maternal and Child Survival Program midwife training. By applying the skills she had learned during the training, she was able to save both the mother’s and baby’s life (Home, 2017).

This short success story is one of many that are highlighted by the Maternal Child Survival Program. The Maternal and Child Survival Program (MCSP) is an international maternal and child health systems development project funded by the United States Agency for International Development (USAID). Working specifically in the health areas of reproductive, maternal, newborn, and child health (RMNCH), MCSP runs health systems programs in 27 developing countries throughout Africa, Southeast Asia and the MidEast (Home, 2017). As with any project that is contracted by USAID, MCSP is required to provide both quarterly and annual reports that capture results and achievements related to activities stated in annual work plans that are jointly developed by MCSP and USAID and approved by USAID. These reports are a critical method of communicating progress and accomplishments to the funder (USAID) and impact the future of the project’s existence. Through these reports, as well as through case studies and success stories, MCSP must effectively communicate their accomplishments to USAID .

In many unique scenarios, charts, figures and statistics are simply not efficient in providing a comprehensive report of the full scope of a project’s activities. Because of this, it is imperative that these technical details are accompanied by narratives like success stories or case studies that display the human impact behind the numbers. It is common for technical professionals to struggle with the human impact element of reporting due to lower skill levels in the areas of interpersonal written and verbal communication and soft skills. These lower skill levels are a result of lack of communications and soft skills training in technical school programs as well as lack of professional development resources for technical professionals during their careers.

This white paper will explore the disparity between the communications skills requirements of many technical academic programs compared to the skill set expectations of many employers and hiring managers within these technical fields. What solutions best meet the need for strong communications skills for technical professionals’ 209

communications obligations like those at MCSP? This paper will highlight common fields that lack strong communications training and skills development, causes for those short-comings, and how both the academic institutions and employing organizations can implement solutions to this lack of preparedness. Finally, this paper will explore the best solutions for communications skills development for technical professionals and how businesses, organizations, schools and individuals can begin implementing these solutions in order to prevent miscommunication or failed communication that can result in misrepresentation of accomplishments.

These solutions vary in focus from education, professional development, and personal growth.

The Gap between Educational Requirements and Employer Expectations By prioritizing communications skills within fields of technical study, academic programs can more effectively prepare technical professionals with the communications and soft skills required to fulfill the full scope of the results-reporting elements of their jobs in areas like global health development. An issue in accomplishing this prioritization is the gap between the educational requirements of many technical school programs compared to the expectations of many hiring managers in today’s technical industries (Brink, 2015). Many technical academic programs do not require many or any communications-centered studies (Suvedi, 2016).

Additionally, with globalization, the scope of work for many careers are transforming. Technical professionals need to have the communications skills to go beyond the technical practice of their job descriptions. During a survey of students at Michigan State University, results showed that “increas[ed] globalization, advancement in science and technology, a surge in unemployment and layoff rates and quickly changing job markets demand that today’s graduates be more efficient and skillful than their predecessors.” (Suvedi, 2016). This means that skills in written communication, verbal communication, and interpersonal relationship building that may not have been prioritized in technical academic programs in the past, must now be prioritized as these professionals are being expected by their employers to hold these skills in order to successfully do their jobs.

A great disparity exists between the low emphasis on communications skills within technical education programs compared to the growing expectation of communications skills within technical professional fields (Balancing, 2016). For example, school programs for medical doctors may put little to no emphasis on non-technical written or verbal communication skills. Contrarily, when a patient visits a doctor there 210

is a significant expectation for that doctor to demonstrate what many refer to as a warm “bedside manner” and the ability to not only treat their patient’s physical needs, but provide a welcoming and comforting interpersonal exchange while doing so (Jackson, 2011). One of the major sources of this problem is the lack of prioritization of written communication skills, verbal communication skills, or soft skills development within the training programs for technical professions such as medicine, finance or engineering (Brink, 2015).

There exists a vast amount of research and commentary surrounding this issue of lack of soft skills and communication skills development within the technical professions. In addition to unsuccessful communication of accomplishments, or unsatisfactory customer service, there are consequences that might impact the very existence of certain projects and the continuation of funding for projects as a whole. In the case of MCSP and many other projects that rely on federal funding, the ability to effectively gather and disseminate information about accomplishments and program impact is a major determinant to whether or not the work will continue.

Recent scholarly journals for educators, school administrators and students emphasize the need for better soft skills and communications training in technical academic programs. These journals also provide guidance and suggestions for strengthening training in these skill areas that will address the current need (Jackson, 2011). One prominent source of this need stems from academic programs that do not align their curriculum requirements to meet the expectations and priorities of employers in the field of study (Brink, 2015). For example, many AACSB-Accredited business school programs do not require classes that cover many of the communications skill-based training and knowledge that today’s employers expect potential new hires to possess (Brink, 2015). By implementing stronger career center services within academic institutions, schools can better prepare students for the real-world expectations their future careers will include. By doing this, students can find ways outside of the classroom to develop those skills through internships or extracurricular activities.

Closer collaborations between schools and industry leaders within professional fields can also help bridge this gap. Schools must be more proactive in preparing students for the diverse and evolving expectations of today’s employers.

Sarpparaje’s example of today’s employer expectations provide a strong case for the need to communication and soft skills development in school programs.

“They want employees who can continue to learn and adapt, read, write and compute competently; listen and communicate effectively, think creatively, solve problems independently; manage 211

themselves at work, interact with co-workers, work in teams or groups; handle basic technology, lead effectively as well as follow supervision.”

It is clear that employers want to hire individuals with well-rounded skill sets. Technical professionals no longer have an excuse for their lack of attention to social communications and professional-level writing skills.

Resulting Challenges One challenge in executing clear communication at global health projects such as MCSP is the organizational leadership is often comprised of technical or clinical professionals like in MCSP’s case—physicians. As has been previously mentioned, communications skills are not prioritized in many clinical or technical academic programs. As a result of this, these organizational heads need to gain the communications and managerial skills needed to run an entire project. They also need to know where to employ communications professionals to meet the needs of the project in areas of work where technical professionals are better off spending their time on clinical tasks .

In some cases, statistical reporting can cover most of the scope of an activity if the basis of the activity is a concrete deliverable, but some reporting of accomplishments are not as easy to report as the number of commodities provided to a health facility or the amount of immunizations administered to children in a specific district.

The example of Agnes’ success story shared at the beginning of this paper demonstrates the life-saving impact of the MCSP training she participated in weeks before saving the laboring mother’s life. It would be irresponsible to try to report a hard number of the amount of lives saved as a result of newly acquired knowledge from a training. Although in a technical sense the number of health workers trained with the life-saving knowledge could be reported (as shown in the infographic below), the added interpersonal element of a success story telling of a mother and child being saved as a result of the training makes a much stronger case that these trainings did not only take place, but resulted in life-saving skills. In order to fully capture the scope of accomplishment in a program like MCSP, multiple forms of communication must be utilized. Graphs and statistics work best for certain accomplishments while success stories and case studies serve best to communicate less tangible kinds of success.

Below are two examples of technical results that could benefit from accompaniment of written communication like Agnes’ success story. It is all too easy for analytics and statistics to be shared within technical settings and not show the full impact of the work being done. Communications professionals know that the interpersonal communication that is done by 212

individuals who possess strong soft skills can make a more lasting impact for success (Hassan, 2016).

Another case for the need of interpersonally-based communication in reporting is evident in situations where further explanation of statistics could result in saving an activity from being deemed unsuccessful. In the following graphic used by MCSP to show family planning activities in Kenya, the chart shows a drastic decline over time.

The case for further reporting in the form of written narrative is clear because the cause for the decline in activity shown on the graphic was due to a nurse strike that was taking place in the region at that time. No nurses at the facilities were working, therefore the operations came to a complete halt (Niyitegeka, 2016). This could be easily explained through 213

thoughtful written narrative and the graphic would no longer appear as a complete failure.

In some cases, communications professionals are enlisted to carefully capture and communicate accomplishments, but this option is costly and not always obtainable by smaller projects and teams. Strong written and verbal communication skills stem from a combination of professional training and soft skills development. As Robles states in Business Communication Quarterly, “People skills are a core component of soft skills. People skills are the interpersonal attributes that characterize a person’s relationships with others.” Interpersonal relationships between colleagues are a necessary element to understanding the work that has been done by all contributors and successfully communicate those accomplishments to others. For example, if the MCSP staff are working closely and building strong relationships with their colleagues in Kenya, they will be aware of the external situations that are affecting progress and will be able to report those details to USAID before the success of the program comes into question.

As with the example of reporting requirements at MCSP, in many cases, lack of communication can reflect poorly beyond solely the communication skills themselves. Failure to communicate effectively can cause an individual’s or organization’s technical expertise to appear less effective than it actually is (Claxton, 2016).

Solutions To avoid these negative results, schools must put a stronger emphasis on building written communication skills, verbal communication skills and soft skills into technical academic programs. These programs must give communications skill development stronger emphasis oppose to portraying them as being much less important than the hard skills (technical skills) being taught within the program.

In addition to identifying the risks that accompany this problem of inadequate communication and soft skills training within many technical professional fields, there are a great deal of solutions offered for educators, employers and individuals. Examining the psychology behind soft skills development and determining what practices strengthen skills can allow employers and educators to develop the most effective programs for professionals and students (Claxton, 2016).

To address the lack of these skills in a post-graduate setting, many employers are exploring ways to implement communications skills training and soft skills strengthening through offering professional development and continued education opportunities to their employees. Researchers believe that strong soft skills lie at the core of the success of an organization 214

(Hassan, 2016). If the progress and success of an entire organization depends on the strength of the employees soft skills at that organization, shouldn’t the investment in strengthening these skills be a top priority? This question is answered by Lisa Pierson in the Orange County Business Journal article “Bridging the Soft Skills Gap.” “The risks of not making soft skills a “must have” can be severe, resulting in increased operating costs, problems with quality, loss of business to competitors, and delays in introducing new products or services. The bottom line is that soft skills matter, so employees and businesses have to look for practical ways to increase their development. After all, businesses are made up of people, so people skills will always be important.”

Some organizations have the option of investing in the continued education of their employees by providing benefits that allow employees to complete courses in communications (Claxton, 2016). There are also more affordable options involving managers and supervisors coaching employees through information and exercises that will strengthen their soft skills.

Communications professionals provide guidance and information for educators and employers to use in schools or the workplace to strengthen individual soft skills and communication skills (Duckworth, 2014).

Additionally, employers can use personal development plans that will guide them through supervising the development of their employees’ soft skills and communication skills (Jackson, 2011). The chart below is an example tool used in personal development plans. Employers can use a tool like this to help their employees identifying areas in need of development and track progress through training programs.

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Whether it be through academic programs, personal development, or professional development benefits offered by an employer, technical professionals not only have an opportunity, but an obligation to develop and possess strong communications skills in order to effectively conduct the all aspects of their jobs. In the case of MCSP, where lives are being saved every day through the health services provided in developing countries as a result of this programâ&#x20AC;&#x2122;s existence; the impact of these communications skills is truly a life or death matter. This responsibility to be clear and effective communicators is shared by students, schools, and employers. Prioritizing these skill requirements at all stages of career development is critical to continued impact and development in an endless expanse of industries.

REFERENCES Balancing soft skills with technical abilities. (2016). Journal of Accountancy, 222(6), 1-2.

Brink, K. E., & Costigan, R. D. (2015). Oral Communication Skills: Are the priorities of the workplace and AACSB-accredited business programs aligned? Academy of Management Learning & Education, 14(2), 205-221. doi:10.5465/amle.2013.0044 Claxton, G., Costa, A. L., & Kallick, B. (2016). Hard thinking about soft skills. Educational Leadership, 73(6), 60.

Duckworth, R. (2014). Hard Times for Soft Skills. Educator Update, 13-14.

Hassan, M., Laghari, S., Kathiya, A. A., & Ayub, A. (2016). Identifying determinants of organizational development as the key developers of employee soft skill. Acta Universitatis Danubius: Oeconomica, 12(5), 120-129.

Home | Maternal and Child Survival Program. (n.d.). Retrieved from http://www.mcsprogram.org/ Jain, S., & Anjuman, A. S. (2013). Facilitating the acquisition of soft skills through training. IUP Journal of Soft Skills, 7(2), 32-39.

Jackson, C., & Thurgate, C. (2011). Personal development plans and workplace learning. British Journal of Healthcare Assistants, 5(6), 292296.

Loup, C., Kornegay, J., & Morgan, J. (2017). Career Exploration AND Soft 216

Skills: Preparing Students for Success. Techniques: Connecting Education & Careers, 92(1), 14.

Mascle, D. D. (2013). Writing self-efficacy and written communication skills. Business Communication Quarterly, 76(2), 216-225. doi:10.1177/1080569913480234 Murti, A. B. (2014). Why soft skills matter. IUP Journal of Soft Skills, 8(3), 32-36.

Niyitegeka, T. (2016, December 10). Kenya: Nursesâ&#x20AC;&#x2122; union officials say strike is still on until. Retrieved from http://en.igihe.com/news/kenya-nurses-union-officials-say-strikeis-still.html Pierson, L. (2016). Bridging the soft skills gap. Orange County Business Journal, 39(49), B-46.

Robles, M. M. (2012). Executive perceptions of the top 10 soft skills needed in todayâ&#x20AC;&#x2122;s workplace. Business Communication Quarterly, 75(4), 453465. doi:10.1177/1080569912460400 Sarpparaje, M. (2016). Importance of enhancing communication skills among young graduates and how to make them career-ready & lifeready? Language in India, 16(4), 93-100.

Siriwardane, H. P., & Durden, C. H. (2014). The communication skills of accountants: what we know and the gaps in our knowledge.

Accounting Education, 23(2), 119-134. doi:10.1080/09639284.2013.847329 Suvedi, M. s., Ghimire, R. P., & Millenbah, K. F. (2016). How prepared are undergraduates for a career? NACTA Journal, 6013-20.

ALEX KELLERSTRASS completed a MA in Business and Managerial Communication with a concentration in Transnational and Cross-Cultural studies from Bellevue University in June 2017. She previously earned a B.S. in History from Bradley University and currently works in international development on a USAID-funded digital health project. Alex lives in Washington, D.C. with her husband, Jack, and dog, Bernie.

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