QUESTION 9

1. A major recommendation for combating sexual harassment is to

   		post any sexually-toned comments you hear on the company Web site.
   		keep a running log of incidents against you.
   		embarrass anyone who tells a sexually-oriented joke by posting his or her photo and the comment on a blog.
   		wear a button that says, "Not me, not now."

5.00000 points (Extra Credit)   

QUESTION 10

1. A key purpose of the diversity umbrella is to

   		provide legal protection of people who have been discriminated against in the past.
   		ensure that everyone in the organization is welcome.
   		protect lower-ranking workers from harassment by managers.
   		provide legal safeguards against the organization being charged with discrimination.

5.00000 points   

QUESTION 11

1. A person with high cultural sensitivity is likely to

   		regard people from different cultures as pretty much the same.
   		be too sensitive to criticism from people from different cultures.
   		recognize nuances in customs among cultures.
   		overlook nuances in customs among cultures.

An Emerging Threat: Ransomware

The attack, expertly planned, was insidious. For six weeks or more, cybercriminals purportedly from either North Korea or Russia wormed their way into Monroe College’s computer systems, maneuvering undetected as they sought out weak points. Then, in July 2019, they pounced. Using an IT staffer’s pilfered password across platforms, hackers infected every server on Monroe’s two New York City-area campuses with a virus, effectively locking down administrative files, email, learning management systems, and website. “The college was a big house we were all locked out of,” says Marc Jerome, president of Monroe, a for-profit institution with 8,000 students. What’s more, as the campus reeled, hackers held Monroe’s tech infrastructure for ransom. They would restore it, they told the college’s leaders, in exchange for the Bitcoin equivalent of $1.6 million.
As Monroe students became instantly reacquainted with turning in assignments on paper, campus officials sprang into action, working feverishly to restore damaged systems. But without a policy for dealing with such attacks, Monroe was faced with few choices. After a couple weeks of failed attempts to use backup systems (which had also been infected) and with little hope of restoring its online presence, college officials decided to contact the college’s insurance company, as well as hire a law firm and a tech expert to negotiate with the attackers. In the end, Monroe paid them a considerably lesser sum than had been demanded in order to obtain the
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WITH SUPPORT FROM
decryption keys needed to eliminate the virus and bring the campus’s tech services back online. Monroe had been victimized by a ransomware attack — and it isn’t the only college that has had to face off with international criminal enterprises that have perpetrated such disruptions in recent years. Most attacks start with “phishing” expeditions. Cybercriminals send virus encoded emails in the hope that someone at a college — a professor, a staff member, a student — will open one and set in motion the virus or malware contained therein. The virus then replicates itself throughout a network. Some institutions have fended off ransomware incursions with security software or with the help of enhanced computer-safety training, while others have seen their systems disabled and their daily operations threatened. Some have devised policies for dealing with attacks, while others are in the process of considering them. Several institutions report that they have created policies but are not making them public. Doing so, they argue, might encourage such attacks or give cybercriminals an angle from which to start one. Such secrecy is far from rare. Many ransomware attacks are not reported. Colleges may not want the public to know that they have been successfully targeted. IT experts say such reticence leads some college officials to underestimate the threat. Because criminal enterprises, usually originating in China, Eastern Europe, North Korea, Russia, and Vietnam, typically demand payment in cryptocurrency to protect their anonymity, it has proved difficult to track them down or slow the rate of attacks. Law-enforcement agencies generally offer few answers. The onus on preventing ransomware attacks and policing tech systems falls on the institutions themselves. This, too, can prove difficult, given that colleges provide faculty members and students with wide access to their networks and content. The very openness that many institutions point to with pride can often become a security headache. While there is some question as to whether the threat of ransomware at colleges and universities is growing or flattening out, there is evidence that more higher-ed institutions are stepping up protection. More colleges now carry
insurance policies designed to pay them for the lost revenue and repairs that can result from cyberattacks. Several institutions have stepped up training of computer users and shored up security to forestall invasive tactics. And some have invited outside experts to look for potential vulnerabilities in their systems. Facing their seemingly built-in disadvantages, many colleges are devising policies that will make their campuses and systems safer, experts say, whether by preventing attacks, dissuading criminal enterprises from attempting them, or protecting themselves against loss. This Trends Snapshot outlines the latest efforts.   
The very openness that many institutions point to with pride can often become a security headache.
“No-Pay” Policies The FBI, among other law-enforcement agencies, urges colleges to refuse to pay ransoms. Many institutions, especially larger ones, have heeded the advice, devising a “just say no” strategy to deter criminals and make themselves less of a target. At the University of California at San Diego, two recent ransomware incidents did some temporary damage. But the university refused to cave in to demands for cash. Three years ago, the university lost access to its data during an attack, but because it had backed up both its data and its systems, it was able to recover them on its own within a week. About 18 months ago, a targeted breach centered on the work of one research faculty member. The researcher lost some data, though the loss wasn’t considered catastrophic. San Diego has since made strong efforts to persuade its research faculty members to back up their data in a safe place. The university created a website with instructions on how to do that. It also started a separate datamanagement plan for researchers to follow. Still, officials at some institutions who
an emerging threat : ransomware 3
have promised never to pay criminals admit that there may be some circumstances in which that stance becomes less absolute, such as when students’ medical information has been stolen and a threat has been made to publish it online. Even among institutions that have pledged never to give in to demands, there is a belief that there might, one day, be a particular case that offers a reason to pay out, especially if a college lacks insurance against ransomware attacks.
Many colleges have gotten the word out that, no matter how far down in the tech hierarchy staff members or students might be, they should be on the lookout for nefarious online schemes.
Training and Communications At several colleges, IT staffers run tabletop exercises for academic department members and students as well as administrators. The goal is to learn how much they know about the threat of ransomware, and to test their reactions to simulated ransomware-borne denial-of-service attacks. The websites of the University of Michigan and Pennsylvania State University offer examples of phishing expeditions, so that students know what to look for and how to respond. The Penn State site also includes videos of what people on campus can do to avoid allowing ransomware hackers to enter a system. Many colleges have gotten the word out that, no matter how far down in the tech hierarchy staff members or students might be, they should be on the lookout for nefarious online schemes. A chain of communication following an attack is also important, and has become a part of many institutions’ hacker-response strategies. Some colleges maintain an “escalation policy” that lays out in detail which campus officials should be contacting others, who receives certain kinds of messages, and in what order. Colleges
have also made contingency plans for when their email is down, such as using automated phonecalling, text alerts, and social-media blasts to reach staff members and students when a campus system is held hostage by ransomware.
Improving Security Several institutions report working harder to make their IT systems safe from attacks. At the University of California at Berkeley, a virtual private network was created with several safeguards. To remotely access it, Berkeley users must authenticate their credentials to get through several firewalls. Such measures, the university hopes, will make it much tougher for attackers to get through. Other colleges are doing something similar by expanding requirements that people on campus use multifactor authentication to gain access to networks. Larger universities frequently employ system patches, antivirus software, and common decryption keys that can free a system from ransomware. Others are beefing up their backup systems so they can replicate their main systems if ransomware takes them down. Many institutions report that they regularly test their systems against attacks. And some have taken the step of removing their campus directories, or at least parts of them, from webpages to make it harder for ransomware attackers to send infected emails en masse. Still, IT experts warn that many colleges, particularly smaller ones, aren’t availing themselves of modern cybersecurity solutions. Tech offices at institutions with budget trouble are especially vulnerable — something that could intensify as Covid-19 forces colleges to cut costs further, including by eliminating some security personnel.
Insurance While not protecting institutions against attacks, insurance policies typically can offer institutions a way back after one. After a college uses money from an insurance claim to pay off ransom demands, attackers usually remove the virus, freeing up an institution’s network. By law, if an insurance policy covers damage by
an emerging threat : ransomware 4
ransomware, insurers must respond to a college’s claim, even if that means paying it for damages. Cyber insurance companies have mushroomed in the past decade, according to one IT expert, who adds that more than $2 billion has been paid out in ransomware claims of all types (including colleges) in recent years. Purchasing a cyber insurance policy is the most common way colleges deal with possible ransomware, according to a survey of chief information officers and chief information security officers conducted by the Leadership Board of CIOs (LBCIO). The survey also found that 76 percent of higher-ed institutions now carry insurance against ransomware disruptions, up from 63 percent in 2018. Though such policies can offer a way out of danger, some experts worry that they also bring some peril. Cyberattackers who learn that an institution is insured might see it as a better opportunity. Buying insurance presents other caveats as well. For one, there is no guarantee that paying a ransom will result in the full return of an IT system. Colleges that negotiate with criminal enterprises are relying on them to be honest about the delivery of decryption keys, or the extent to which such keys will actually restore control of their original systems.
Outside Audits While most colleges rely on their chief
information officers and chief information security officers to make the technical calls to fend off ransomware attacks, some have opted to invite outside experts to assess their systems or provide continuing oversight. While on-campus professionals can develop plans and policies that make it harder for cybercriminals to commandeer a college’s computing and data systems, issues of campus culture can prevent those officials from creating and enforcing rules on how faculty and staff members and students should behave online. Some CIOs are regularly frustrated by faculty members who download unsafe software or who don’t report such actions to the IT office. Having an outside check on the system can lead to stronger, more enforceable policies, some college leaders believe. Outside experts can feel freer to monitor weak points in a system and make suggestions as to how to keep stakeholders in line with IT-security goals. In the past decade, the proportion of college-IT officials who have contracted with outside tech auditors has grown from 55 percent to 71 percent, according to the LBCIO survey. Among those institutions now planning to make third-party IT audits a regular part of their security regimen is Monroe College, which will soon retain an outside vendor in the hope that it can avoid the embarrassment and expense it suffered one year ago.

1. You are a consultant in charge of creating a Business Continuity Plan (BCP) for UALR. Based on the article what will be your focus, given the prevalent of cyber-attacks at institutions of education. Identify an area that you will focus on to prevent ransomware attacks and devise a plan so that when it happens you have a strategy to recover. Explain the reason for focusing in this area/ Explain why that area is important to institutions of education such as UALR (30 points)

2. Using paper and pen technology to store records and document process poses threats to Personally Identifiable Information (PII) . Identify 2 examples of PII and use the template below to perform a risk assessment of Personal Identifying Information (PII) stored by institutions of education, such as UALR. Using the template provided evaluate, and assess threats, vulnerabilities, risks, and Maximum Tolerable Downtime (when these PII will be inaccessible) (40 Points)
Threats : What an organization is defending itself against, e.g. a natural disaster, man-made disasters.
Vulnerabilities : The gaps or weaknesses in the IT infrastructure that undermine an organization’s IT security efforts, e.g. a firewall flaws that lets hackers into a network. Lack of employee training, ineffective BCP, flawed processes etc.
Risks : Calculated assessment of potential threats to an organization’s security and disruption of operations and the vulnerabilities within its information systems infrastructure.




Risk Assessment Template

Type of PII Threats Vulnerabilities Risks MTD

3. Based on your risk assessment and recommended Maximum Tolerable Downtime (MTD), make recommendation for Recovery Time Objective (RTO) and Alternate Processing Sites ( Cold, Hot, Warm, Mobile) to achieve the RTO . Explain why you selected that alternate processing site

We are a new Cell Phone Service Company from Argentina. We have done well there, because we help out locally and charitably. We are going to expand worldwide. We will be able to offer free cell phones to everyone who buys our service. Our Cell Service will be 50% cheaper than all of the top brands like Verizon and AT&T. We cannot get a contract with Apple so we will not be able to offer the Iphone. Create a SWOT analysis on our company and the idea of moving forward in this market.

a] Using information on the drivers for international business, and by researching information from the Internet, present examples of three Canadian companies that are entering or expanding their role in international business.

b] For each, identify: Who is the company? Is it a large, medium, or small enterprise? What is the primary good or service it markets? Where does it do business?

c] Conduct a preliminary analysis of these three companies’ international business entry modes, identify advantages they may be enjoying, and evaluate which globalization forces may be supporting their success. Defend your statements with evidence company reports, or other literature.

During the current year, Skylark Company had operating profit of $150,000. In addition, Skylark had a long-term capital loss of $10,000. Toby is the sole owner of Skylark Company. Please answer the following. Be sure to label each answer with the identifying number of the question. You can separate each answer with a comma. Type the word none is the amount is zero. Do not enter the number 0 or you will be marked wrong! Scenario 1: Skylark is a single-member LLC reporting on Schedule C, and Toby does not withdraw any funds from the company during the year. Enter None if the answer is 0. a. Toby will show how much ordinary income on his 1040 Schedule C? __________ b. Toby will deduct how much capital loss on his 1040 assuming he has no other capital gain and losses? ______ Scenario 2: Skylark is a regular (C) corporation, and Toby does not withdraw any funds from the company during the year. Enter None if the answer is 0. c. What is the total amount Toby will show on his 1040

the year from Skylark? ________ Scenario 3: Skylark is a regular (C) corporation, and Skylark makes a cash distribution of $100,000 to Toby during the year. Enter None if the answer is 0. d. Toby will report how much income on his 1040 for the year from Skylark?______ e. Skylark Corporation will report taxable income of how much for the year on their 1120? ______ Scenario 4: Skylark is a regular (C) corporation, and Skylark pays a salary of $100,000 to Toby during the year. Show the income reported by Toby on his individual income tax return from Skylark Company. Enter None if the answer is 0. f. Toby will report how much income on his 1040 for the year from Skylark?______ g. Skylark Corporation will report taxable income of how much for the year on their 1120? ______

1. An industrial area has several companies that use similar chemicals. Groundwater in this area has been found to be contaminated, and several companies are disputing who is responsible. (The responsible party must pay for remediation.) Two of the chemicals used by several companies are TCE and dioxane, but the companies often use different ratios of these chemicals. One company uses 3.6 times more TCE than dioxane, and the standard deviation of the TCE:dioxane ratio in its supply drums was 0.3. This company claims it isn’t responsible for remediation, because the ratio of TCE:dioxane in water samples is different from what the company uses. Samples of groundwater from 12 wells in the area yielded the following TCE:dioxane ratios:

3.1       2.6       4.5       6.2       4.2       3.3       1.2       3.6       5.9       2.7       3.7       3.8      

Can the company “prove” that there is less than a 5% chance that they contributed to the groundwater contamination?   Explain your answer using statistical justification.

imagine you are a network engineer who has been hired to design a network for a small company consisting of a headquarters office in Indianapolis, Indiana, and a branch office in Minneapolis, Minnesota. The company has hired you to design and build the network infrastructure from the ground up.

Following is a brief summary of the business structure: Indianapolis, IN This office is the headquarters for the company. It has 61 employees divided across the following three departments:
• Administration: 19
• Research and Development: 25
• Accounting: 17 Minneapolis,

MN This branch office has 34 employees in the following three departments:
• Administration: 9
• Research and Development: 12
• Advertising: 13
: Following are the design instructions/requirements: • The company locations should be connected to each other via a WAN that supports ALL types of traffic generated at each office. • An IP-based physical security solution should be in place, with all physical security traffic logically separated from all other traffic

The following stem and leaf diagram show the number of days in a year a team of thirty technicians were absent from their work on medical grounds. Stem and Leaf Diagram of Number of Days Absent from Work Stem (tens) Leaf (ones) 01 1 23 2 017 3 1358 4 23678889 5 01345778 6 0123 a. Calculate the median number of days of absenteeism in the company. b. Calculate the interquartile range of the number of days of absenteeism in the company. c. You are presenting the dispersion of absenteeism rates to your manager who is not trained in statistics. Would you consider using quartiles to present dispersion information or the variance? Explain. d. The human resources manager of the company mentions that the company has always used median to present the absenteeism level of its workers. Based on the stem and leaf diagram, is his choice of measure of central tendency/location justified? Explain.

Carilion Clinic

Case History/Background

Nestled in the Commonwealth of Virginia between Salem and Vinton is the city of Roanoke, whose population was approximately 98,000 in 2010. The metropolitan area population was about 309,000. Bisected by the Roanoke River and circled by the Blue Ridge Mountain Parkway, Roanoke is the commercial and cultural hub of western Virginia and southern West Virginia.

The community that became Roanoke was established in 1852. Early economic development of Roanoke resulted from its importance as the junction point for the Shenandoah Valley Railroad and the Norfolk and Western Railway. These railroads were essential for transporting coal from western Virginia and West Virginia. Roanoke’s service area includes a regional report, shopping malls, a regional hub for United Parcel Service, and manufacturing plants for General Electric, Yokohama tires, and Dynax, a maker of friction-based automobile parts.

Carilion Clinic

Carilion Clinic employs almost 12% of Roanoke’s population. The clinic includes 9 freestanding hospitals, 7 urgent care centers, and 220 (and increasing) practice centers, and it employs over 650 physicians in more than 70 specialties. The clinic has 1,026 licensed beds, not including 60 neonatal intensive care unit beds. The clinic had 48,659 admissions in fiscal year 2014-15.

The clinic’s joint ventures and related companies include the following:

Carilion Clinic Physicians, LLC (real estate holding company)

Carilion Emergency Services, Inc.

Carilion Behavioral Health, Inc.

In March 2010, the same month and year the Affordable Care Act became law, the clinic was ordered by the Federal Trade Commission to divest itself of an outpatient surgical center and an imaging center. Both had been acquired as it sought to re-create “The Mayo Clinic” medical delivery model.

Led by Edward G. Murphy, M.D., from 1998 to 2011, Carilion Health System became Carilion Clinic, a vertically integrated health-care system. During Murphy’s tenure the system expanded to include graduate and undergraduate medical education programs, a school of medicine (through a partnership with Virginia Polytechnic Institute and State University Virginia Tech), and, perhaps most impressively, Carilion established an accountable care organization in partnership with Aetna insurance company.

Dr. Murphy’s total compensation was almost $2.3 million in 2007. Nancy Agee, the clinic’s chief operating officer at the time, earned the next highest salary of about $800,000. When Murphy resigned in 2011, Ms. Agee was promoted to president and CEO. In fiscal 2014, Carilion Clinic net revenue was $1.5 million. Agee’s salary was $1.9 million.

CONTROVERSY IN ROANOKE

Despite its philanthropic mission and positive effect on Roanoke, Carilion Clinic has not always enjoyed a good relationship with its community.

   In May 1988, the U.S. Justice Department’s Antitrust Division sought to prevent the merger of Roanoke’s two hospitals: Memorial Roanoke Hospital and Community Hospital of Roanoke Valley. The lawsuit sought to block the merger because of the monopoly it alleged would result. Less than one year after the suit was filed, the Fourth Circuit U.S. Court of Appeals found for defendants Memorial Roanoke Hospital and Community Hospital of Roanoke Valley.

   The merger between defendant hospitals would not constitute an unreasonable restraint of trade under the Sherman Act $1. The merger would strengthen the competition between the hospitals in the area because defendant hospitals could offer more competitive prices and services.

In the two appeals that followed, courts found for defendant hospitals, which then merged and were named Carilion Health System. The decision provided legal basis for what is now the Carilion Clinic.

IN A MARKET: WHAT CONSTITUTES A MONOPOLY?

A monopoly occurs when one or more persons or a company dominate an economic market. This market domination results in the potential to exploit or suppresses those in the market or those trying to enter it (supplier, provider, or consumer).

   During the 19th century, the U.S. government began prosecuting monopolies under the common law as “market interference offenses” to block suppliers from raising prices. At the time, companies sometimes sought to but all supplies of a certain material or product in an area, a practice known as “cornering the market”.

   In 1887, Congress passed the Interstate Commerce Act in response to railway companies’ monopolistic practices in small, local markets. This legislation protected small farmers who were being charged excessive rates to transport their products. Congress addressed monopolistic practices further by passing the Sherman Antitrust Act of 1890, which limited anticompetitive practices of businesses. The act blocked transfer of stock shares to trustees in exchange for a certificate entitling them to some of the earnings. The Sherman Act was the basis for the Clayton Antitrust Act of 1914, the Federal Trade Commission Act of 1914, and the Robinson-Patman Act of 1936, which replaced the Clayton Act.

   Antitrust or competition laws address three main issues:

Prohibit agreements or practices that restrict free trade and competition among business entities.

Ban abusive behavior by a firm dominating a marker, or anticompetitive practices that tend to lead to such a dominant position.

Supervise the mergers and acquisitions of large corporations, including some joint ventures.

The Herfindahl-Hirschman Index (HHI)helps implement these laws by providing a mathematical method to determine market “density”, or the concentration of the market. Antitrust laws and methods of calculating market density, such as HHI, are imperfect and can leave gaps that may be exploited.

   Since its establishment, the mission of the Federal Trade Commission has remained largely unchanged. Laws affecting private enterprise and government agencies have not. It is possible this mal juxtaposition underlies many of the difficulties in the healthcare industry.

VERTICAL INTEGRATION: THE MAYO CLINIC MODEL

The Mayo Clinic is the leading example of vertical integration in the delivery of healthcare in the United States. Founded in Rochester, Minnesota, in 1863, the Mayo Clinic began as the medical practice of William Worrall Mayo and his two sons, who were also physicians. It grew to include a comprehensive array of specialties. Mayo developed different levels of care across the health services continuum. The result was a vertically integrated health system. Mayo physicians are salaried at market levels, and they control the management structure.

   Mayo Clinic is headquartered in Rochester, Minnesota; it has satellite clinics elsewhere in the United States. In addition, Mayo and various medical centers worldwide have consulting and referral relationships. Mayo provides excellence and dedication in delivery of services with a constant, and self-admittedly stubborn, commitment to core values, which include that the needs of the patient come first, the integration of teamwork, efficiency, and mission over profit.

   Mayo has been long recognized for high performance, research and innovation. It has ranked at or near the top of “Honor Roll” hospitals through the history of U.S. News and World Report’s best-hospital rankings. In 2015 - 2016, Mayo clinic had more number one rankings than any U.S. hospital or system. Eight specialties ranked number one: diabetes and endocrinology, gastroenterology and gastrointestinal surgery, geriatrics, gynecology, nephrology, neurology and neurosurgery, pulmonology, and urology.

FORESHADOWING A MAYO CLINIC CLONE

Even before Murphy took the helm in 2001, Carilion Health System actions had stirred significant, but manageable, controversy in the community. Much of the controversy resulted from the antitrust case in 1988. After the court ruled that the merger did not violate federal law because it posted no threat of monopoly, the hospital continued its previous work in the community.

   After becoming CEO, Murphy began to vertically integrate the Carilion Health System. His formal plan was presented in fall 2006. Part of evolving to a Mayo-style organization included acquiring physician practices in the community; some were closed after acquisition.

WHO IS EDWARD G. MURPHY, M.D.?

Edward. G. Murphy earned his BS from the University of Albany, New York, and his medical degree (with honors) from Harvard University Medical School. Although he never practiced medicine. Murphy was a clinical professor at the University of Albany School of Public Health and an adjunct assistant professor at Rensselaer Polytechnic Institute School of Management. Before leaving New York state he was also a member of the New York State Hospital Review and Planning Council, and he served on its executive committee as the vice chair of the fiscal policy council.

   From 1989 to 1991, Murphy served as the vice president of clinical services at Leonard Hospital, a 143-bed facility north of Albany, New York. In 1991, he was promoted to president and CEO of Leonard Hospital until it merged with St. Mary Hospital fo form Seton Health system in 1994. Murphy became president and CEO of that new health system and stayed with Seton until 1998, when he relocated to Roanoke to head Carilion Health System.

   During his tenure at Carilion Clinic, Murphy managed the growth of that two-hospital health system into a vertically integrated model of healthcare delivery anchored by a 500-physician specialty group practice that included nine not-for-profit hospitals, undergraduate medical programs, an array of tertiary referral services, and a multistate laboratory service. In 2007, Murphy announced plans for the Virginia Tech Carilion School of Medicine, which opened in 2010. In 2010, Murphy was paid $2.27 million ($1.37 million in salary and $900,000 in benefits).

Murphy’s other roles in the Roanoke community included memberships on the boards of Healthcare Professionals Insurance Company and Trust; Luna Innovations, Inc; and Hometown Bank. He is past chair of the Art Museum of Western Virginia. He also served in an influential position with the council on Virginia’s Future, which works to frame the growth and progress of the state, including businesses, people, and the health of the population.

   Murphy left Carilion to become chairman of Sound Physicians, a national provider of Intensivist and hospitalist services. In 2012, he became the operating officer of Radius Ventures, a venture capital firm that invests in health-related companies.

VERTICAL INTEGRATION: BECOMING A “CLINIC”

Murphy was always clear about his plans for Carilion Health System. In an August 2006 interview, “Right now...our core business is hospital services. In the new model, the core business will be physician services; the hospital will become ancillary. In a 2007 interview for Health Leaders Magazine, Murphy explained, “I’ve been enamored of this model of healthcare delivery for a long time.”

   In Fall 2006, Murphy, his staff, and the leadership board of Carilion Health System announced their plan to create a new model for Carilion management characterized by teamwork and salaried physicians and other caregivers focused on patients across the spectrum of care. Murphy explained:

   The essence of the clinic model is that hospitals stop becoming independent businesses and start becoming ancillary services to the physician practice….If hospitals eventually want to provide better and more cost-effective healthcare, it’s a necessary shift.

The transformation was planned for seven years with an 18-month phase -in of its new name, Carilion clinic. Plans for Carilion Clinic included a 50-50 partnership with Virginia Tech University in Blacksburg, Virginia, to establish a private, not-for-profit clinical research institute and a new medical school. Further, from 2007 to 2012 Carilion clinic would add four or five fellowships for physicians to support its mission.

Ground was broken for the much-anticipated university in early 2008. On July 20, 2009, the Virginia State Council for Higher Education approved the Virginia Tech Carilion School of Medicine as a postsecondary institution. It’s first class matriculated in fall 2010.

THE WALL STREET JOURNAL EXPOSE

Usually, an organization is pleased if the Wall street Journal publishes an article about it. That is, of course, unless the story ignites a firestorm that leads to separate citizen and physician coalitions working against the organization and raises the specter of a word from Carilion Clinic’s prehistory: monopoly.

“Nonprofit Hospitals Flex Pricing Power. In Roanoke, Va., Carilion’s Fees Exceed Those of Competitors: The $4,727 Colonoscopy” was published on the front page of the Wall Street Journal August 28, 2008. The author, John Carreyrou, explored Carilion’s history, including the 1989 antitrust case, its expanding”market clout,” and the strides toward its goal of vertical integration. The article suggested that some of the means used were questionable.

   Carreyrou asserted that skyrocketing healthcare costs in Roanoke were partially caused by, or possibly even led by, Carilion Clinic.

   In a press release, Carilion Clinic denied monopolistic practices or exploitative pricing and claimed it faced robust competition from Lewis-Gale Medical Center located in nearby Salem, Virginia. Carilion Clinic defended its pricing practices by noting it must cross-subsidize emergency departments and care for the uninsured.

   Unsettling to some, however, was Carilion’s practice of suing patients for unpaid medical bills. After Carilion obtains a court judgement, a lien is placed against the patient’s home. A lien on real property puts a “cloud” on the title, which prevents the owner from conveying the property with a clear title until the lien has been satisfied. Responding in the Wall street Journal, Murphy stated,

   Carilion only sues patients and places liens on their homes if it believes they have the ability to pay … If you’re asking me if it’s right in a right-and-wrong sense, it’s not...But Carilion cannot be blamed for the country’s “broken” healthcare system.

Murphy asserted that Carilion efforts to protect its financial interests meet legal requirements, but may be morally flawed. This position appears inconsistent with Carilion’s mission that ‘Patient Care Comes First.”

WHERE WERE THE LOCAL MEDIA?

As reported by Carreyrou, Carilion Clinic complained several times to editors of the Roanoke Times regarding reporter Jeff Sturgeon’s coverage of the system. Shortly after the complaints, and mainly in response to a May 2008 article by Sturgeon, Carilion greatly reduced advertising in the Roanoke Times. About the same time, Sturgeon, the paper’s longtime health issues writer, was reassigned.

Even after Sturgeon’s reassignment, Carilion continued to be frontpage news in the Roanoke Times. Reporter Sarah Bruyn Jones covered community reaction to the Wall Street Journal article and the impetus it gave to local coalitions. Her articles included the following: “Carilion Critics Draw Hundreds to Meeting” (September 2008); “Fed Agency Looks into Carilion Purchase” (September 2008); “Carilion Footprint Expands in Deal” (August 2008); and “Carilion to Buy Cardiology Practice” (August 2008). Jone’s reporting put Carilion practices at the forefront for Roanoke’s citizens, but, as noted by Carreyrou, Carilion growth seemed unstoppable.

THE BACKLASH

The August 2008 Wall Street Journal article resulted in a community uproar and fueled physician's’ efforts to air their concerns about Carilion, including its anti competitive actions and unfair pricing, and their desire to have open referrals for patients from outside Carilion’s health network. Citizen and physician coalitions met in hotel conference rooms and community centers to discuss the “unfair practices and behaviors” ifof Carilion Clinic. One, the citizens Coalition for Responsible Healthcare, sponsored a petition that read as follows:

   To Dr. Murphy and the Carilion Health System Board of Directors:

   Please reconsider your Carilion Clinic plans. I want to keep my right to choose my doctor, even if he or she is an independent physician. Please rethink spending $100 million of my community’s money on a Clinic model that could ruin our hospitals! Monopolies are never good for healthcare.

The Coalition’s website offered copies of the Wall Street Journal article, video recordings of their meetings, information about a new forum program, and membership form for those who wished to join their efforts.

   The citizen coalitions stated they intended to focus on the negative impact of Carilion’s transformation to a physician-led clinic that they asserted will increase costs and drive out many local physicians. Murphy’s plan was to bring into Carilion as many physicians as possible; all of whom will be salaried. The concerns of citizen coalitions stemmed from the scope of the effort, which resulted in closure or sale of many physician practices. Unaffiliated physicians asserted they could not compete. Further, Carilion’s system of internal referrals, added to the purchase of existing practices, gave many specialists no choice but to leave, or stay and fight.

   Despite the controversy, Carilion has shown no signs of slowing: it has stayed the course outlined in Fall 2006.

CARILION’S RESPONSE

On August 28, 2008, less than 24 hours after publication of Carreyrou’s Wall Street Journal article, Carilion responded. Statements published in newspapers and posted on Carilion’s website, as well as press releases, stated the allegations and conclusions drawn from them were misleading and misinformed.

   In response, Carilion directed readers’ attention to the Virginia Hospital and Health care Association PricePoint Website. It showed that Carilion’s prices are comparable to surrounding hospitals and are generally lower than its closest competitor, Lewis-Gale Medical center in neighboring Salem, Virginia. To support their position on pricing,Carilion stated “Medical care in hospitals is more expensive … having staff and technology at the ready has its costs. Also mentioned was Carilion’s Lifeguard helicopter, which is subsidized service. Carilion provided $42 million in charity care in 2007 and an additional $25 million in free care (bad debt written off), thus illustrating its dedication and support of its service area. Carilion supports research and education substantial resource commitments that add major costs to the organization and provide subsidize services tiot the community.

   In explaining the policy to sue patients, Carilion stated that efforts are made to qualify patients for public programs, as needed. Further, Carilion said only “a small fraction of the nearly 2 million” patient billings each year go to court.

   Court filings are a final resort, and we try to be flexible. If the judgement includes a lien on an individual’s property, we do not foreclose on the lien. The lien is satisfied if and when the property is sold.

In response to concerns about its internal referral practice, Carilion stated that referrals are sent from physician to physician in the system with the intention of sending patients to better, more-qualified physicians who have earned the referral. The “earn, not force” mentality contributes to the goal of well-coordinated care and service, which is the first choice of patients.

Carilion’s press release closed by describing a wasteful and poorly organized U.S. healthcare system that is hoped to improve with the vertically integrated clinic model of providing care. The hope is that comprehensive, high quality, and cost-effective care will put the patient first. The reader of the press release is reminded that what happened at Mayo could be replicated at Carilion.

CURRENT SITUATION IN ROANOKE

As noted, Carilion Clinic has a medical school partnership, an expanding physician practice with a robust specialty list, and its own accountable care organization, which continues to show progress and increased membership.

Three decades after the hospital merger controversy began in Roanoke, Virginia, the economic and healthcare environments have changed, the population is increasing, and healthcare costs are rising. When the antitrust case was brought in 1988, Roanoke had among the lowest health insurance premiums in Virginia; now, they are among the highest.

Discussion questions to be answered

1) Identify the problems Carilion Clinic faces as it seeks to become a comprehensive, vertically integrated healthcare provider.

2) Briefly explain the summary of the case

3) Identify the most important factors/facts of the Case study

4) Explain the critical issues that is the most important health administration problem/issue to be solved and if applicable, identified secondary problems.

5) Identify the recommended solution of the case. At least three realistic alternative solutions.

6) Identify the relevant concepts and tools for example, methods, techniques, principles,theories, and or models.

Carilion Clinic

Case History/Background

Nestled in the Commonwealth of Virginia between Salem and Vinton is the city of Roanoke, whose population was approximately 98,000 in 2010. The metropolitan area population was about 309,000. Bisected by the Roanoke River and circled by the Blue Ridge Mountain Parkway, Roanoke is the commercial and cultural hub of western Virginia and southern West Virginia.

The community that became Roanoke was established in 1852. Early economic development of Roanoke resulted from its importance as the junction point for the Shenandoah Valley Railroad and the Norfolk and Western Railway. These railroads were essential for transporting coal from western Virginia and West Virginia. Roanoke’s service area includes a regional report, shopping malls, a regional hub for United Parcel Service, and manufacturing plants for General Electric, Yokohama tires, and Dynax, a maker of friction-based automobile parts.

Carilion Clinic

Carilion Clinic employs almost 12% of Roanoke’s population. The clinic includes 9 freestanding hospitals, 7 urgent care centers, and 220 (and increasing) practice centers, and it employs over 650 physicians in more than 70 specialties. The clinic has 1,026 licensed beds, not including 60 neonatal intensive care unit beds. The clinic had 48,659 admissions in fiscal year 2014-15.

The clinic’s joint ventures and related companies include the following:

Carilion Clinic Physicians, LLC (real estate holding company)

Carilion Emergency Services, Inc.

Carilion Behavioral Health, Inc.

In March 2010, the same month and year the Affordable Care Act became law, the clinic was ordered by the Federal Trade Commission to divest itself of an outpatient surgical center and an imaging center. Both had been acquired as it sought to re-create “The Mayo Clinic” medical delivery model.

Led by Edward G. Murphy, M.D., from 1998 to 2011, Carilion Health System became Carilion Clinic, a vertically integrated health-care system. During Murphy’s tenure the system expanded to include graduate and undergraduate medical education programs, a school of medicine (through a partnership with Virginia Polytechnic Institute and State University Virginia Tech), and, perhaps most impressively, Carilion established an accountable care organization in partnership with Aetna insurance company.

Dr. Murphy’s total compensation was almost $2.3 million in 2007. Nancy Agee, the clinic’s chief operating officer at the time, earned the next highest salary of about $800,000. When Murphy resigned in 2011, Ms. Agee was promoted to president and CEO. In fiscal 2014, Carilion Clinic net revenue was $1.5 million. Agee’s salary was $1.9 million.

CONTROVERSY IN ROANOKE

Despite its philanthropic mission and positive effect on Roanoke, Carilion Clinic has not always enjoyed a good relationship with its community.

   In May 1988, the U.S. Justice Department’s Antitrust Division sought to prevent the merger of Roanoke’s two hospitals: Memorial Roanoke Hospital and Community Hospital of Roanoke Valley. The lawsuit sought to block the merger because of the monopoly it alleged would result. Less than one year after the suit was filed, the Fourth Circuit U.S. Court of Appeals found for defendants Memorial Roanoke Hospital and Community Hospital of Roanoke Valley.

   The merger between defendant hospitals would not constitute an unreasonable restraint of trade under the Sherman Act $1. The merger would strengthen the competition between the hospitals in the area because defendant hospitals could offer more competitive prices and services.

In the two appeals that followed, courts found for defendant hospitals, which then merged and were named Carilion Health System. The decision provided legal basis for what is now the Carilion Clinic.

IN A MARKET: WHAT CONSTITUTES A MONOPOLY?

A monopoly occurs when one or more persons or a company dominate an economic market. This market domination results in the potential to exploit or suppresses those in the market or those trying to enter it (supplier, provider, or consumer).

   During the 19th century, the U.S. government began prosecuting monopolies under the common law as “market interference offenses” to block suppliers from raising prices. At the time, companies sometimes sought to but all supplies of a certain material or product in an area, a practice known as “cornering the market”.

   In 1887, Congress passed the Interstate Commerce Act in response to railway companies’ monopolistic practices in small, local markets. This legislation protected small farmers who were being charged excessive rates to transport their products. Congress addressed monopolistic practices further by passing the Sherman Antitrust Act of 1890, which limited anticompetitive practices of businesses. The act blocked transfer of stock shares to trustees in exchange for a certificate entitling them to some of the earnings. The Sherman Act was the basis for the Clayton Antitrust Act of 1914, the Federal Trade Commission Act of 1914, and the Robinson-Patman Act of 1936, which replaced the Clayton Act.

   Antitrust or competition laws address three main issues:

Prohibit agreements or practices that restrict free trade and competition among business entities.

Ban abusive behavior by a firm dominating a marker, or anticompetitive practices that tend to lead to such a dominant position.

Supervise the mergers and acquisitions of large corporations, including some joint ventures.

The Herfindahl-Hirschman Index (HHI)helps implement these laws by providing a mathematical method to determine market “density”, or the concentration of the market. Antitrust laws and methods of calculating market density, such as HHI, are imperfect and can leave gaps that may be exploited.

   Since its establishment, the mission of the Federal Trade Commission has remained largely unchanged. Laws affecting private enterprise and government agencies have not. It is possible this mal juxtaposition underlies many of the difficulties in the healthcare industry.

VERTICAL INTEGRATION: THE MAYO CLINIC MODEL

The Mayo Clinic is the leading example of vertical integration in the delivery of healthcare in the United States. Founded in Rochester, Minnesota, in 1863, the Mayo Clinic began as the medical practice of William Worrall Mayo and his two sons, who were also physicians. It grew to include a comprehensive array of specialties. Mayo developed different levels of care across the health services continuum. The result was a vertically integrated health system. Mayo physicians are salaried at market levels, and they control the management structure.

   Mayo Clinic is headquartered in Rochester, Minnesota; it has satellite clinics elsewhere in the United States. In addition, Mayo and various medical centers worldwide have consulting and referral relationships. Mayo provides excellence and dedication in delivery of services with a constant, and self-admittedly stubborn, commitment to core values, which include that the needs of the patient come first, the integration of teamwork, efficiency, and mission over profit.

   Mayo has been long recognized for high performance, research and innovation. It has ranked at or near the top of “Honor Roll” hospitals through the history of U.S. News and World Report’s best-hospital rankings. In 2015 - 2016, Mayo clinic had more number one rankings than any U.S. hospital or system. Eight specialties ranked number one: diabetes and endocrinology, gastroenterology and gastrointestinal surgery, geriatrics, gynecology, nephrology, neurology and neurosurgery, pulmonology, and urology.

FORESHADOWING A MAYO CLINIC CLONE

Even before Murphy took the helm in 2001, Carilion Health System actions had stirred significant, but manageable, controversy in the community. Much of the controversy resulted from the antitrust case in 1988. After the court ruled that the merger did not violate federal law because it posted no threat of monopoly, the hospital continued its previous work in the community.

   After becoming CEO, Murphy began to vertically integrate the Carilion Health System. His formal plan was presented in fall 2006. Part of evolving to a Mayo-style organization included acquiring physician practices in the community; some were closed after acquisition.

WHO IS EDWARD G. MURPHY, M.D.?

Edward. G. Murphy earned his BS from the University of Albany, New York, and his medical degree (with honors) from Harvard University Medical School. Although he never practiced medicine. Murphy was a clinical professor at the University of Albany School of Public Health and an adjunct assistant professor at Rensselaer Polytechnic Institute School of Management. Before leaving New York state he was also a member of the New York State Hospital Review and Planning Council, and he served on its executive committee as the vice chair of the fiscal policy council.

   From 1989 to 1991, Murphy served as the vice president of clinical services at Leonard Hospital, a 143-bed facility north of Albany, New York. In 1991, he was promoted to president and CEO of Leonard Hospital until it merged with St. Mary Hospital fo form Seton Health system in 1994. Murphy became president and CEO of that new health system and stayed with Seton until 1998, when he relocated to Roanoke to head Carilion Health System.

   During his tenure at Carilion Clinic, Murphy managed the growth of that two-hospital health system into a vertically integrated model of healthcare delivery anchored by a 500-physician specialty group practice that included nine not-for-profit hospitals, undergraduate medical programs, an array of tertiary referral services, and a multistate laboratory service. In 2007, Murphy announced plans for the Virginia Tech Carilion School of Medicine, which opened in 2010. In 2010, Murphy was paid $2.27 million ($1.37 million in salary and $900,000 in benefits).

Murphy’s other roles in the Roanoke community included memberships on the boards of Healthcare Professionals Insurance Company and Trust; Luna Innovations, Inc; and Hometown Bank. He is past chair of the Art Museum of Western Virginia. He also served in an influential position with the council on Virginia’s Future, which works to frame the growth and progress of the state, including businesses, people, and the health of the population.

   Murphy left Carilion to become chairman of Sound Physicians, a national provider of Intensivist and hospitalist services. In 2012, he became the operating officer of Radius Ventures, a venture capital firm that invests in health-related companies.

VERTICAL INTEGRATION: BECOMING A “CLINIC”

Murphy was always clear about his plans for Carilion Health System. In an August 2006 interview, “Right now...our core business is hospital services. In the new model, the core business will be physician services; the hospital will become ancillary. In a 2007 interview for Health Leaders Magazine, Murphy explained, “I’ve been enamored of this model of healthcare delivery for a long time.”

   In Fall 2006, Murphy, his staff, and the leadership board of Carilion Health System announced their plan to create a new model for Carilion management characterized by teamwork and salaried physicians and other caregivers focused on patients across the spectrum of care. Murphy explained:

   The essence of the clinic model is that hospitals stop becoming independent businesses and start becoming ancillary services to the physician practice….If hospitals eventually want to provide better and more cost-effective healthcare, it’s a necessary shift.

The transformation was planned for seven years with an 18-month phase -in of its new name, Carilion clinic. Plans for Carilion Clinic included a 50-50 partnership with Virginia Tech University in Blacksburg, Virginia, to establish a private, not-for-profit clinical research institute and a new medical school. Further, from 2007 to 2012 Carilion clinic would add four or five fellowships for physicians to support its mission.

Ground was broken for the much-anticipated university in early 2008. On July 20, 2009, the Virginia State Council for Higher Education approved the Virginia Tech Carilion School of Medicine as a postsecondary institution. It’s first class matriculated in fall 2010.

THE WALL STREET JOURNAL EXPOSE

Usually, an organization is pleased if the Wall street Journal publishes an article about it. That is, of course, unless the story ignites a firestorm that leads to separate citizen and physician coalitions working against the organization and raises the specter of a word from Carilion Clinic’s prehistory: monopoly.

“Nonprofit Hospitals Flex Pricing Power. In Roanoke, Va., Carilion’s Fees Exceed Those of Competitors: The $4,727 Colonoscopy” was published on the front page of the Wall Street Journal August 28, 2008. The author, John Carreyrou, explored Carilion’s history, including the 1989 antitrust case, its expanding”market clout,” and the strides toward its goal of vertical integration. The article suggested that some of the means used were questionable.

   Carreyrou asserted that skyrocketing healthcare costs in Roanoke were partially caused by, or possibly even led by, Carilion Clinic.

   In a press release, Carilion Clinic denied monopolistic practices or exploitative pricing and claimed it faced robust competition from Lewis-Gale Medical Center located in nearby Salem, Virginia. Carilion Clinic defended its pricing practices by noting it must cross-subsidize emergency departments and care for the uninsured.

   Unsettling to some, however, was Carilion’s practice of suing patients for unpaid medical bills. After Carilion obtains a court judgement, a lien is placed against the patient’s home. A lien on real property puts a “cloud” on the title, which prevents the owner from conveying the property with a clear title until the lien has been satisfied. Responding in the Wall street Journal, Murphy stated,

   Carilion only sues patients and places liens on their homes if it believes they have the ability to pay … If you’re asking me if it’s right in a right-and-wrong sense, it’s not...But Carilion cannot be blamed for the country’s “broken” healthcare system.

Murphy asserted that Carilion efforts to protect its financial interests meet legal requirements, but may be morally flawed. This position appears inconsistent with Carilion’s mission that ‘Patient Care Comes First.”

WHERE WERE THE LOCAL MEDIA?

As reported by Carreyrou, Carilion Clinic complained several times to editors of the Roanoke Times regarding reporter Jeff Sturgeon’s coverage of the system. Shortly after the complaints, and mainly in response to a May 2008 article by Sturgeon, Carilion greatly reduced advertising in the Roanoke Times. About the same time, Sturgeon, the paper’s longtime health issues writer, was reassigned.

Even after Sturgeon’s reassignment, Carilion continued to be frontpage news in the Roanoke Times. Reporter Sarah Bruyn Jones covered community reaction to the Wall Street Journal article and the impetus it gave to local coalitions. Her articles included the following: “Carilion Critics Draw Hundreds to Meeting” (September 2008); “Fed Agency Looks into Carilion Purchase” (September 2008); “Carilion Footprint Expands in Deal” (August 2008); and “Carilion to Buy Cardiology Practice” (August 2008). Jone’s reporting put Carilion practices at the forefront for Roanoke’s citizens, but, as noted by Carreyrou, Carilion growth seemed unstoppable.

THE BACKLASH

The August 2008 Wall Street Journal article resulted in a community uproar and fueled physician's’ efforts to air their concerns about Carilion, including its anti competitive actions and unfair pricing, and their desire to have open referrals for patients from outside Carilion’s health network. Citizen and physician coalitions met in hotel conference rooms and community centers to discuss the “unfair practices and behaviors” ifof Carilion Clinic. One, the citizens Coalition for Responsible Healthcare, sponsored a petition that read as follows:

   To Dr. Murphy and the Carilion Health System Board of Directors:

   Please reconsider your Carilion Clinic plans. I want to keep my right to choose my doctor, even if he or she is an independent physician. Please rethink spending $100 million of my community’s money on a Clinic model that could ruin our hospitals! Monopolies are never good for healthcare.

The Coalition’s website offered copies of the Wall Street Journal article, video recordings of their meetings, information about a new forum program, and membership form for those who wished to join their efforts.

   The citizen coalitions stated they intended to focus on the negative impact of Carilion’s transformation to a physician-led clinic that they asserted will increase costs and drive out many local physicians. Murphy’s plan was to bring into Carilion as many physicians as possible; all of whom will be salaried. The concerns of citizen coalitions stemmed from the scope of the effort, which resulted in closure or sale of many physician practices. Unaffiliated physicians asserted they could not compete. Further, Carilion’s system of internal referrals, added to the purchase of existing practices, gave many specialists no choice but to leave, or stay and fight.

   Despite the controversy, Carilion has shown no signs of slowing: it has stayed the course outlined in Fall 2006.

CARILION’S RESPONSE

On August 28, 2008, less than 24 hours after publication of Carreyrou’s Wall Street Journal article, Carilion responded. Statements published in newspapers and posted on Carilion’s website, as well as press releases, stated the allegations and conclusions drawn from them were misleading and misinformed.

   In response, Carilion directed readers’ attention to the Virginia Hospital and Health care Association PricePoint Website. It showed that Carilion’s prices are comparable to surrounding hospitals and are generally lower than its closest competitor, Lewis-Gale Medical center in neighboring Salem, Virginia. To support their position on pricing,Carilion stated “Medical care in hospitals is more expensive … having staff and technology at the ready has its costs. Also mentioned was Carilion’s Lifeguard helicopter, which is subsidized service. Carilion provided $42 million in charity care in 2007 and an additional $25 million in free care (bad debt written off), thus illustrating its dedication and support of its service area. Carilion supports research and education substantial resource commitments that add major costs to the organization and provide subsidize services tiot the community.

   In explaining the policy to sue patients, Carilion stated that efforts are made to qualify patients for public programs, as needed. Further, Carilion said only “a small fraction of the nearly 2 million” patient billings each year go to court.

   Court filings are a final resort, and we try to be flexible. If the judgement includes a lien on an individual’s property, we do not foreclose on the lien. The lien is satisfied if and when the property is sold.

In response to concerns about its internal referral practice, Carilion stated that referrals are sent from physician to physician in the system with the intention of sending patients to better, more-qualified physicians who have earned the referral. The “earn, not force” mentality contributes to the goal of well-coordinated care and service, which is the first choice of patients.

Carilion’s press release closed by describing a wasteful and poorly organized U.S. healthcare system that is hoped to improve with the vertically integrated clinic model of providing care. The hope is that comprehensive, high quality, and cost-effective care will put the patient first. The reader of the press release is reminded that what happened at Mayo could be replicated at Carilion.

CURRENT SITUATION IN ROANOKE

As noted, Carilion Clinic has a medical school partnership, an expanding physician practice with a robust specialty list, and its own accountable care organization, which continues to show progress and increased membership.

Three decades after the hospital merger controversy began in Roanoke, Virginia, the economic and healthcare environments have changed, the population is increasing, and healthcare costs are rising. When the antitrust case was brought in 1988, Roanoke had among the lowest health insurance premiums in Virginia; now, they are among the highest.

Discussion questions to be answered

1) Identify the problems Carilion Clinic faces as it seeks to become a comprehensive, vertically integrated healthcare provider.

2) Briefly explain the summary of the case

3) Identify the most important factors/facts of the Case study

4) Explain the critical issues that is the most important health administration problem/issue to be solved and if applicable, identified secondary problems.

5) Identify the recommended solution of the case. At least three realistic alternative solutions.

6) Identify the relevant concepts and tools for example, methods, techniques, principles,theories, and or models.