“Assume the production of a particular good is characterized by significant economies of scale. In addition, three different versions of the good can be produced, and large segments of the population prefer different versions of the good. In this case, the preferred market structure for this good would be:Choose one answer.

a. perfect competition.

b. monopolistic competition.

c. monopoly.

d. oligopoly.

The kinked demand curve model best reflects. Choose one answer.

a. mutual interdependence among sellers.

b. price rigidities in oligopolistic markets.

c. a game theory approach to price-output decisions.

d. All of the above

Assume at the firm’s profit-maximizing level of output P = AVC. In this case, the firm will be:Choose one answer.

a. earning a positive economic profit.

b. earning economic profit = 0.

c. breaking even.

d. incurring an economic loss.

A successful and stable cartel can be established if there are.Choose one answer.

a. a few firms producing a storable product.

b. many firms producing a perishable product.

c. many firms producing a storable product.

d. a few firms producing a perishable product.

A perfectly competitive firm will maximize profits (or minimize losses) so long as price (marginal revenue) is: Choose one answer.

a. greater than marginal cost.

b. greater than average total cost.

c. greater than average fixed cost.

d. greater than average variable cost.

In the Baumol model, the total quantity sold will usually be larger than. Choose one answer.

a. if companies were interdependent.

b. if perfect competition prevailed.

c. if total costs were minimized.

d. if profit were maximized.

An industry characterized by a small number of dominant firms that face downward-sloping demand curves is best described as:Choose one answer.

a. monopolistically competitive.

b. an oligopoly.

c. a monopoly.

d. perfectly competitive.

Which of the following distinctions helps to explain the difference between relevant and irrelevant cost?Choose one answer.

a. historical cost vs. replacement cost

b. sunk cost vs. fixed cost

c. variable cost vs. incremental cost

d. accounting cost vs. direct cost

Simulation analysis choose one answer.

a. does not permit the calculation of expected value and standard deviation.

b. permits the calculation of expected value and standard deviation.

c. does not consider probabilities.

d. is too complex to ever be used in actual business situations.

Which of the following is the best example of a monopolistically competitive market?Choose one answer.

a. The wheat market.

b. The restaurant market.

c. The electricity market.

d. The market for automobiles.

A perfectly competitive firm has the cost function: TC = 1000 + 2Q + 0.1 Q2What is the lowest price at which this firm can break even?Other things being equal, the higher the cost of capitalChoose one answer.

a. the lower the NPV of the project.

b. the higher the IRR of the project.

c. the higher the NPV of a project.

d. The cost of capital has no effect on the NPV of the project.

A real option can present management with the opportunity to. Choose one answer.

a. postpone a project.

b. abandon a project.

c. vary output.

d. All of the above.

An industry characterized by a small number of dominant firms that face downward-sloping demand curves is best described as: Choose one answer.

a. an oligopoly.

b. monopolistically competitive.

c. perfectly competitive.

d. a monopoly.

Assume the firms in a monopolistically competitive industry initially are earning positive economic profits. Which of the following will not occur over time?Choose one answer.

a. The number of substitutes available in the industry will increase.

b. New firms will enter.

c. Demand for the existing firms’ output will become more inelastic.

d. The firms’ economic profits will be reduced.The following are possible examples of price discrimination except choose one answer.

a. prices in export markets are lower than for identical products in the domestic market.

b. subscription prices for a professional journal are higher when bought by a library than when bought by an individual.

c. a product sells at a higher price at location A than at location B, because transportationcosts are higher from the factory to A.

d. senior citizens pay lower fares on public transportation than younger people at the same time.

Assume that as the firms in a perfectly competitive industry expand output, the prices of productive inputs increase. All else constant, this would cause the individual firms’ marginal cost curves to ________ and the market supply curve to become ________.Choose one answer.

a. shift up; steeper

b. shift up; flatter

c. shift down; steeper

d. shift down; flatter

In order that price discrimination can existChoose one answer.

a. different demand price elasticities must exist in different markets.

b. markets must be interdependent.

c. markets must be capable of being separated.

d. demand price elasticities must be identical in all markets.

e. Both A and C

Suppose the firms in a monopolistically competitive market are incurring economic losses. What will happen to move the market to its long-run equilibrium?Choose one answer.

a. Firms will continue to exit the market until economic losses are equal to zero.

b. The demand functions of all the firms remaining in the market will become relatively more elastic.

c. More close substitutes will appear in the market until economic profits are zero.

d. The firms that dropped out of the market will reenter once the level of economic losses is zero.

A proposed project should be accepted if the net present value isChoose one answer.

a. larger than the internal rate of return.

b. negative.

c. smaller than the internal rate of return.

d. positive.

 
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Question 1

The immediate cause for the Texan Americans’ declaration of independence on March 2, 1836 was that… the Texan "war party" sabotaged the efforts of Stephen F. Austin and other "peace party" leaders who were then negotiating with the Mexican government for greater autonomy. the new president, General Antonio Lopez de Santa Ana, cut short Stephen F. Austin’s negotiations with the Mexican government and appointed a military commandant for Texas. Mexican troops commanded by General Antonio Lopez de Santa Ana destroyed the American garrison defending the Alamo. Texans prisoners at Goliad were massacred by Mexican troops commanded by General Antonio Lopez de Santa Ana. ________________________________________

Question 2  Which of the following does not help to explain the diminishing effectiveness of Reconstruction in the South? Northerners tired of the expense and violence that supporting Reconstruction engendered. Racism among moderate Republicans led them to ascribe Republican defeats in the South to the incompetence of black politicians. A severe depression in 1873 distracted Northerners from the social and racial issues of Reconstruction. The expanded presence of federal troops and officials from 1875 to 1877 brought about an escalation in southern terrorist retaliation. _______________________________________Question 3 (Multiple Choice Worth 2 points) Which of the following statements most accurately characterizes one effect of Enlightenment on America. American thinkers agreed with John Locke’s idea that political authority was divinely ordained. Cotton Mather and the Boston physician Nicholas Boyleston fought against smallpox inoculation. Some ministers combined Lockean political principles with Calvinist theology in order to attack the role of bishops and vest power in the laity. European Enlightenment ideas had little impact on Americans until 1750. _______________________________________

Question 4 (Multiple Choice Worth 2 points) In the election of 1864, Lincoln… won by a slim margin, thanks to the votes of Union soldiers. was swept to victory by Sherman’s victory at Atlanta. won despite the fact that three out of every four Union soldiers voted against him. lost the popular vote to McClellan, but won the electoral vote. ________________________________________

Question 5 (Multiple Choice Worth 2 points) The Compromise of 1850 did not include which of the following? Abolition of the slave trade in the District of Columbia. Adoption of a strong fugitive slave law. The organization of the New Mexico and Utah territories on the basis of popular sovereignty. Abolition of slavery in the Oregon Territory. ________________________________________

Question 6 (Multiple Choice Worth 2 points) The Puritans in late sixteenth-century England… denied the concept that everyone had a callingâ from God. incorporated into their religion many of the traditional Roman Catholic practices, such as burning incense and praying to dead saints. championed literacy so that everyone could read and interpret the Bible. gave final authority over religious doctrine to bishops and synods. ________________________________________

Question 7 (Multiple Choice Worth 2 points) In early nineteenth-century America… the rise in political status of ordinary white men was accompanied by a decline in the political rights of women and free blacks. most newly organized free states granted the right to vote to adult black men who owned specified amounts of freehold property. Pennsylvania and New York allowed all free adult black males to vote. women were granted the right to vote only in New Jersey in 1807. ________________________________________

Question 8 (Multiple Choice Worth 2 points) The First Continental Congress… was summoned by Patriot leaders to protest the Coercive Acts in 1774. united representatives from all the British colonies of North America for the first time. failed to enact a declaration of independence drafted by John Adams but accepted Joseph Galloway’s more moderate Plan of Union. failed to pass a declaration of rights and grievances because it was judged too mild. ________________________________________

Question 9 (Multiple Choice Worth 2 points) Between 1800 and 1860 white planters moved to the lower South to… transform the West into a free labor society. recreate the conditions of slavery. invest in agricultural development. flee antislavery laws in the upper South. ________________________________________

Question 10 (Multiple Choice Worth 2 points) Which of the following statements most accurately characterizes immigration during the 1840s and 1850s? Most immigrants settled in the South to take advantage of jobs in industry and agriculture. Most of the Irish who arrived were poverty-stricken peasants. The largest group of immigrants came from eastern and southern Europe. The poorest immigrants came from Wales and Scotland. ________________________________________

Question 11 (Multiple Choice Worth 2 points) The Mayflower Compact… was the first âconstitutionâ adopted in North America. was the Pilgrims’ declaration of independence from England. proclaimed the Pilgrims’ new religious denomination, known as the Separatist Church. pledged the settlers of the Plymouth Colony to create a democratic form of government. ________________________________________

Question 12 (Multiple Choice Worth 2 points) In their petitions to Congress in the 1830s, abolitionists frequently called for… appropriating funds to compensate slave owners for emancipating their slaves. abolishing slavery in the District of Columbia. ending the Atlantic slave trade. impeaching any president who condoned slavery and barring slave owners from serving in Congress. ________________________________________

Question 13 (Multiple Choice Worth 2 points) Before becoming president, Thomas Jefferson viewed the westward migration of Americans with… apprehension because he believed the country was growing too large to be governed as a single republic. disapproval because he sympathized with the plight of the Indians who would be displaced by white settlement of the West. disdain because, as a cultured aristocrat, he considered the settlers to be uncouth rabble who would only cause trouble with the Indians and destroy the West’s natural environment. unqualified approval because he celebrated the pioneer farmer and hoped to see the West developed by independent yeomen. ________________________________________

Question 14 (Multiple Choice Worth 2 points) The three-day Battle of Gettysburg resulted in… a decline in northern popular support for the war. Democratic victories in state and local elections in Ohio, New York, and Pennsylvania. Lee’s loss of over half his Army of Northern Virginia. the Confederate elections of 1863 to turn sharply against supporters of Jefferson Davis. ________________________________________

Question 15 (Multiple Choice Worth 2 points) The Whiskey Rebellion was significant for all of the following reasons except… the Whiskey rebels were acting in the tradition of the Patriots of 1765 and the Shaysites of 1786, only now they also waved banners proclaiming the French Revolutionary slogan âLiberty, Equality, Fraternity.â Washington used force to put down the first strong challenge to the federal government’s authority in order to make and enforce a law. by suppressing the revolt, Washington deterred secessionist movements on the frontier. when he learned that Thomas Jefferson covertly supported the insurgents, Washington publicly broke with him, precipitating open party conflict. ________________________________________

Question 16 (Multiple Choice Worth 2 points) On the eve of European colonization of the Americas, most Western Europeans lived in… small, relatively isolated, rural communities. booming new cities and towns. the older cathedral cities. the castles that dotted the countryside. ________________________________________

Question 17 (Multiple Choice Worth 2 points) The plantation elite were characterized by all of the following criteria except… roughly three thousand families comprised of the plantation elite category. plantation elites owned more than 1,000 slaves. plantation elites owned huge tracts of fertile land. plantation elites were both traditional aristocrats from the Old South and market entrepreneurs of the New South. ________________________________________

Question 18 (Multiple Choice Worth 2 points) Which of the following statements most accurately characterizes the American party system by the early 1840s? As the 1840 election demonstrated, the Whigs held the edge in party discipline and mass loyalty. The two parties offered virtually the same social and economic platform but employed differing campaign styles to attract voters. the practice of Americans voting for a particular party along ethnic and religious lines began to emerge. The Democrats had a major advantage in their wealth and the cohesiveness of their leadership and support. ________________________________________

Question 19 (Multiple Choice Worth 2 points) The Glorious Revolution in England and America… had little impact on either England or North America apart from deposing the Stuarts and barring Roman Catholics from the English throne. contributed significantly to the creation of a new empire based on commerce, with a curb on royal monopolies, encouragement of enterprising merchants, and development of the American colonies as a source of wealth. created democratic governments in Massachusetts, New York, and Maryland, but not in England. represented a major step toward democracy in both England and the North American colonies. ________________________________________

Question 20 (Multiple Choice Worth 2 points) One social change resulting from the Industrial Revolution in early nineteenth century America was that members of the upper class… came to hold the same cultural and religious values as wage earners in contrast to the elitism that in the eighteenth century had kept the gentry and the "common people" apart. openly distanced themselves by values and lifestyle from wage earners in contrast to the shared cultural and religious values that had united the gentry and ordinary folk in the eighteenth century. became more hypocritical, pretending to share cultural and religious values with wage earners, but actually behaving very differently. tended to claim that they had risen "from rags to riches" and to flaunt their crude taste and rough manners in contrast to "gentlemanly" values of the eighteenth-century elites. ________________________________________

Question 21 (Multiple Choice Worth 2 points) The ancestors of the Native American peoples… always lived in the Western Hemisphere. migrated by sea from Polynesia. migrated by sea from China. migrated by land from northeastern Asia. ________________________________________

Question 22 (Multiple Choice Worth 2 points) Which of the following statements most accurately characterizes the British colonial frontier before 1750? Hundreds of British colonists moved into the area west of the Appalachians. The Iroquois covenant chain broke down, and the confederacy’s power diminished. A lack of natural transportation routes kept the British east of the Appalachians. The French abandoned their fur-trading forts in the Ohio region. ________________________________________

Question 23 (Multiple Choice Worth 2 points) The Northwest Ordinance of 1787… prohibited slavery in the Northwest Territory. funded an exploratory party to locate the Northwest Passage. provided for the eventual creation of eight to ten new states in the Northwest Territory. required compulsory elementary education in each new township in the Northwest Territory. ________________________________________

Question 24 (Multiple Choice Worth 2 points) The Stamp Act Congress held in New York in 1765… was a failure because the nine colonies represented could not agree on a unified policy. protested loss of American rights and liberties and declared that only elected representatives could impose taxes on colonists. formulated a set of resolves that threatened rebellion against Britain. accepted the constitutionality of the Sugar Act but not the Stamp Act. ________________________________________

Question 25 (Multiple Choice Worth 2 points) At the same time that Parliament imposed the Stamp Act, it also passed the Quartering Act, which required… Americans to vacate their houses or take in British troops on the demand of any commander. colonial governments to provide barracks and food for British troops. that Americans convicted of treason be hanged and âquarteredâ; that is, cut into four pieces by the hangman. that collectors of the stamp tax receive a commission of one-quarter of the revenue they took in. ________________________________________

Question 26 (Multiple Choice Worth 2 points) The Treaty of Guadalupe Hidalgo… was rejected by the US Senate. prohibited slavery in all territories ceded by Mexico, including Texas. ceded Alta, California; New Mexico; and Texas north of the Nueces River to the United States, in addition to requiring Mexico to pay reparations of more than $50 million. purchased more than one-third of Mexico’s territory for $15 million. ________________________________________

Question 27 (Multiple Choice Worth 2 points) Most colonists’ reaction to the Navigation Acts was to… comply with its laws out of fear of reprisals. welcome these measures as a way of strengthening the bonds of empire, which would protect them from the French and Spanish. bribe customs officials to ignore the regulations. resent and resist the trade restrictions. ________________________________________

Question 28 (Multiple Choice Worth 2 points) The Fifteenth Amendment… prohibited state governments from using property requirements to disqualify blacks from voting. gave the full vote to all adult African Americans. prohibited state governments from using literacy tests and poll taxes to prevent blacks from voting. forbade states from denying any citizen the right to vote on the grounds of race, color, or previous condition as a slave. ________________________________________

Question 29 (Multiple Choice Worth 2 points) The movement toward secession in the winter of 1860-1861 was most rapid in… the Upper South. South Carolina. Virginia. Georgia. ________________________________________

Question 30 (Multiple Choice Worth 2 points) Benjamin Franklin… received an unusually thorough education in England, which put him in touch with Enlightenment ideas unknown to most Americans. was a fervent advocate of the Enlightenment but claimed to be equally influenced by the Bible. was the son of a devout Philadelphia Quaker. founded a club of mutual improvement in Philadelphia to discuss moral and political questions. ________________________________________

Question 31 (Multiple Choice Worth 2 points) All of the following are rights guaranteed by the first ten amendments to the Constitution except… the right to a jury trial. the right to vote. the right to bear arms. freedom of speech. ________________________________________

Question 32 (Multiple Choice Worth 2 points) A peace treaty was not signed until nearly two years after the surrender at Yorktown because… the American negotiators sought delays so that state governments could coordinate their demands. France and Spain stalled, hoping for some major naval victory or territorial conquest. members of Parliament could not reach agreement on the concessions that they were willing to make. the usual delays in transatlantic communications prolonged the process. ________________________________________

Question 33 (Multiple Choice Worth 2 points) The Spanish Franciscan missionaries… tried to impose cultural assimilation and forced labor along with religious conversion of indigenous peoples. became large landowners who collected tribute from the Indians. outlawed slavery in the Spanish colonies. adapted to native culture almost completely. ________________________________________

Question 34 (Multiple Choice Worth 2 points) Which of the following statements most accurately characterizes the relationship between church and state in post-revolutionary America? Most citizens accepted the principle of separation of church and state. The Baptist Church led the campaign for state protection and funding of all Christian denominations. Most religious denominations served their links to the states. By 1787, the Anglican Church of Virginia was the only example of an established church in any state. ________________________________________

Question 35 (Multiple Choice Worth 2 points) Mob violence against abolitionists… was confined to border and southern cities such as Baltimore, St. Louis, New Orleans, and Nashville. was sometimes led by well-to-do "gentlemen of property and standing." targeted only the free black communities and the homes of prominent abolitionist spokespersons. never resulted in the death of an abolitionist spokesperson or free black. ________________________________________

Question 36 (Multiple Choice Worth 2 points) By 1840 the South was on the cutting edge of the Market Revolution because… it produced and exported 1.5 million bales of raw cotton, over two-thirds of the world supply. planters were using European immigrants as industrial workers. planters were building factories to process cotton. southern society was dominated by free labor. ________________________________________

Question 37 (Multiple Choice Worth 2 points) The Missouri Compromise of 1820… resulted from the conciliatory efforts of Congressman James Tallmadge of New York. provided for Maine to enter the Union as a free state in 1820, and Missouri to enter as a slave state the following year. prohibited slavery in the Louisiana Territory south of latitude 36°30´. convinced the aged and retired Thomas Jefferson that the peaceful extinction of slavery by mutual agreement was now in sight. ________________________________________

Question 38 (Multiple Choice Worth 2 points) The abolitionist William Lloyd Garrison… attacked the US Constitution because it condoned slavery. was a minister who came to his antislavery convictions through the evangelical crusades of the 1820s. demanded the immediate abolition of slavery, with federally funded compensation for former slaveholders. criticized the colonizationists for moving too slowly in their efforts to emancipate slaves. ________________________________________

Question 39 (Multiple Choice Worth 2 points) Martin Van Buren’s most significant contribution to American political history in the 1820s was his… pioneering work in making party discipline an effective tool for governing in a democracy. behind-the-scenes efforts to settle the confused election of 1824 by putting John Quincy Adams in the White House and making Henry Clay secretary of state. development of the techniques of mass electioneering that brought about Andrew Jackson’s election in 1828. 1827 book Democracy in America, which showed how democracy could work in American society. ________________________________________

Question 40 (Multiple Choice Worth 2 points) During their first couple of years in the Jamestown colony, the English migrants… doubled the size of their population. produced an agricultural surplus–enough to trade with the Native Americans. lived remarkably disease-free. suffered from famine and diseases that killed more than half the population. ________________________________________

Question 41 (Multiple Choice Worth 2 points) George Washington’s success as a general is most accurately explained by… his political astuteness and ability to act decisively. his strong personality, which enabled him to override the decisions of Congress. a lack of any competitors among the other Patriot officers. his willingness to overlook the actions of discontented soldiers, which endeared him to his troops. ________________________________________

Question 42 (Multiple Choice Worth 2 points) In the aftermath of the nullification crisis, President Jackson responded to southern concerns about the tariff by… insisting that high protective tariffs were in the national interest. attempting unsuccessfully to have Congress repeal the Tariff of 1832. persuading Congress to pass new legislation enacting a compromise tariff to gradually reduce duties. ignoring the issue. ________________________________________

Question 43 (Multiple Choice Worth 2 points) A successful, full-scale revolt was nearly impossible for colonial-era slaves to achieve primarily because… even the Indians would refuse to help them if they escaped. whites were armed and, except in coastal South Carolina, outnumbered slaves. whites enlisted Native Americans to track down rebellious slaves. revolt would endanger the slaves’ communities and families. ________________________________________

Question 44 (Multiple Choice Worth 2 points) A famous Native American who wanted to unite the tribes east of the Mississippi into a confederation during the late 1700s, and was killed in the War of 1812, was: Sitting Bull Tecumseh Geronimo

 
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  • Describe the potential social, economic, and cultural implications associated with the Baby-Friendly Hospital Initiative.
  • Describe how the registered nurse can overcome the obstacles to make the Baby-Friendly Initiative a success.

It is well-documented that breast milk is the best choice for newborns and infants, providing protection against many common causes of infant morbidity. Exclusively breastfed newborns and infants have lower rates of otitis media, respiratory infection, gastroenteritis, urinary tract infection, conjunctivitis, and thrush than those who receive only partial or no breastfeeding.1, 2 Breastfeeding has also been found to reduce the risk of type 1 and type 2 diabetes, childhood leukemia, overweight and obesity, and necrotizing enterocolitis.3-5 There is also evidence that breastfeeding is positively and significantly associated with a child’s intelligence (as measured by IQ score) at all ages, even when birth weight and such parental factors as intelligence, educational level, social class, and age are statistically controlled for.6 Although obstacles to long-term follow-up have hindered efforts to document the maternal benefits of breastfeeding, there is evidence that breastfeeding for one year or more reduces the mother’s risks of breast and ovarian cancers, cardiovascular disease, and type 2 diabetes.4 An analysis of data from the National Institute of Child Health and Human Development ABSTRACT: The Baby-Friendly Hospital Initiative (BFHI) is a program developed by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to promote breastfeeding in hospitals and birthing facilities worldwide. Since the program was launched in 1991, breastfeeding initiation, duration, and exclusivity have increased globally, a trend largely attributed to changes in hospital policies and practices brought about by the BFHI. This article provides an overview of these practices and policies, the institutional benefits of achieving BFHI certification, and the process through which health care facilities can do so. All nurses—whether they work in maternity care or another nursing specialty in a hospital, ambulatory, or community setting—can play a role in promoting societal health through their support of long-term breastfeeding as recommended by the WHO and UNICEF. Keywords: Baby-Friendly certification, Baby-Friendly Hospital Initiative, breastfeeding, breastfeeding policy Nurses can support public health through promotion of long-term breastfeeding. Beyond Maternity Nursing: The BabyFriendly Hospital Initiative AJN ▼ August 2017 ▼ Vol. 117, No. 8 37 Centers for Disease Control and Prevention (CDC), and 2007 dollars to estimate the potential health and financial benefits of breastfeeding. The analysts concluded that if the proportion of U.S. mothers who followed the medical recommendation of exclusively breastfeeding their infants for at least six months after birth were to rise from 12.3% to 90%, it would prevent more than 900 deaths per year and save the United States approximately $13 billion in annual health care expenditures.12 Despite evidence of the pediatric and maternal benefits of breastfeeding, however, many countries, including the United States, have low levels of breastfeeding, with the CDC reporting that only 22.3% of U.S. mothers were exclusively breastfeeding through six months in 2016.13 This article describes the Baby-Friendly Hospital Initiative (BFHI) developed by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) to promote breastfeeding throughout the world. It discusses the hospital policies the BFHI advocates and factors that contribute to breastfeeding success. It explains the BFHI certification process (in which hospitals that complete the process are designated as “Baby-Friendly”), institutional benefits associated with certification, and the practices through By Regina Cardaci, PhD, RN, NP, CNM on more than 1,300 families found an association between breastfeeding and positive changes over time in “maternal sensitivity,” or heightened responsiveness to infant cues.7 Likewise, exclusive breastfeeding is inversely associated with postpartum depression.4, 8, 9 While depression during the third trimester (as measured by the Edinburgh Postpartum Depression Scale) is associated with lower rates of breastfeeding, exclusive breastfeeding at three months postpartum is associated with significantly decreased depression scores.8 Such findings, which suggest that breastfeeding may reduce depressive symptoms, underscore the importance of recognizing prenatal depression as a risk factor for early breastfeeding cessation and of offering extensive breastfeeding support to new mothers who show signs of depression. Achieving breastfeeding self-efficacy within the first week postpartum is positively correlated with both breastfeeding exclusivity and duration through six months postpartum.10, 11 Taken together, the benefits of breastfeeding are enormous. A 2010 cost analysis used pediatric disease data collected by the Agency for Healthcare Research and Quality, 2005 breastfeeding rates (the most recent available at that time) calculated by the Photo by Montgomery Martin / Alamy Stock Photo. 38 AJN ▼ August 2017 ▼ Vol. 117, No. 8 ajnonline.com which all nurses can support long-term breastfeeding and associated societal health. THE INTERNATIONAL BFHI Launched in 1991 by UNICEF and the WHO to increase support for breastfeeding in facilities that provide maternity care, the BFHI is the global standard for hospital support of breastfeeding. Mothers who deliver at institutions that follow BFHI practices are more likely to initiate breastfeeding and continue breastfeeding their infants for at least six weeks postpartum than mothers who deliver at institutions that do not.14-17 The BFHI was founded on 10 evidencebased practices for promoting breastfeeding (see The Ten Steps to Successful Breastfeeding). Institutional factors can promote or impede breastfeeding. Perrine and colleagues analyzed data from the Infant Feeding Practices Study II, which surveyed 1,457 women who had given birth to a single healthy child in a U.S. hospital between 2005 and 2007 and intended to exclusively breastfeed for periods ranging from less than one month to more than seven months.18 The women answered survey questions during their third trimester and approximately every month after giving birth for about 10 months. Initially, more than 85% of the women surveyed planned to breastfeed exclusively for three months or longer, but only 32.4% of the women met their intended breastfeeding goal, and 15% had stopped exclusively breastfeeding before hospital discharge. When the researchers investigated hospital practices, they found that the percentage of women who breastfed for as long as they intended rose with the number of BFHI practices the hospital followed. When hospitals followed none or only one of the Ten Steps to Successful Breastfeeding (Ten Steps), only 23.4% of the women met their intended breastfeeding goal, compared with 46.9% of the women whose hospital followed six of the Ten Steps. Successful breastfeeding was nonsignificantly associated with breastfeeding within one hour of giving birth, not giving the infant a pacifier, and rooming-in (mothers and infants remaining together throughout the hospital stay), and cessation or disruption of breastfeeding was significantly associated with administering formula to healthy breastfeeding infants.18 Similarly, a Hong Kong study found that policies prohibiting hospitals from accepting free formula from manufacturers reduced in-hospital formula supplementation and increased both in-hospital exclusive breastfeeding and breastfeeding duration.19 Unfortunately, institutional adherence to BFHI guidelines is not optimal even among hospitals that have achieved BFHI certification. In a study of 915 mothers who gave birth at four BFHI-accredited birthing facilities in Maine, only 34.6% of the mothers reported that their hospital followed all seven of the BFHI practices the researchers investigated, and 28.4% reported receiving a gift pack containing formula—a practice prohibited by the BFHI because of its association with breastfeeding cessation.15 In a study from the United Kingdom that included 1,130 mothers, fewer than 18% were happy with the breastfeeding information they received during pregnancy from health care professionals, fewer than 50% reported receiving adequate information on how to find breastfeeding support after birth, and more than 92% of those who stopped breastfeeding by six weeks postpartum said they would have liked to have continued beyond that point.20 THE BREASTFEEDING REPORT CARD National breastfeeding data are collected by the CDC and documented in the Breastfeeding Report Card, which provides information on breastfeeding practices in all states, the District of Columbia, and Puerto Rico. This report card is published every two years, most recently in 2016 ( pdf/2016breastfeedingreportcard.pdf).13 The report card indicators are based on the breastfeeding goals outlined in the U.S. Department of Health and Human Services (DHHS) Healthy People 2020 initiative. For health care facilities, the aims are to reduce the proportion of newborns who receive formula in the first two days of life and to increase the proportion of live births that occur in facilities that provide The Ten Steps to Successful Breastfeeding Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in the skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within a half-hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming-in—allow mothers and infants to remain together—24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic. From the World Health Organization, Division of Child Health and Development. Evidence for the Ten Steps to Successful Breastfeeding. Geneva, Switzerland; 1998. AJN ▼ August 2017 ▼ Vol. 117, No. 8 39 recommended care for lactating mothers and their infants. The results of the last report card are positive, showing that U.S. breastfeeding levels continue to rise incrementally, with 2013 rates exceeding those of 2011 for the proportion of newborn infants who started to breastfeed (more than 81% versus 79%), were breastfeeding at six months (nearly 52% versus 49%), and were breastfeeding at one year (nearly 31% versus 27%).13, 21 But despite these improvements, Healthy People 2020 targets for breastfeeding duration and exclusivity are not yet being met (see Table 1). In 2013, the Healthy People 2020 targets of at least 60.6% of infants still breastfeeding and at least 25.5% of infants still exclusively breastfeeding at six months were met in only 12 and 16 states, respectively.13 In addition to breastfeeding rates, the report card includes data on such “breastfeeding support indicators” as the percentage of live births that occur in institutions receiving Baby-Friendly designation, the number of international board-certified lactation consultants per 1,000 live births, and the number of La Leche League leaders per 1,000 live births. In 2015, the CDC reported that policies and practices of maternity units had improved nationally since 2007, but that more work was needed to ensure that all women receive breastfeeding support and education during their hospitalization.22 According to this report, the percentage of U.S. hospitals that incorporate the majority of practices recommended in the Ten Steps increased from 29% in 2007 to 54% in 2013, but of the 3,300 maternity hospitals in the United States, only 289 had been certified as Baby-Friendly.22 BABY-FRIENDLY CERTIFICATION When institutions achieve Baby-Friendly status, not only does it help them meet Healthy People 2020 targets and improve national health outcomes, but the certification process can strengthen the organizations’ leadership and increase staff competence. When a hospital commits to the work involved in achieving this designation, it can stimulate new ways of thinking among all nursing staff, the maternity team, and the facility’s administration. In addition, with BabyFriendly certification, a facility meets the Joint Commission’s maternity care standards for exclusive breastfeeding.23 Baby-Friendly certification is awarded when a facility has successfully implemented the Ten Steps and the International Code of Marketing of Breast-Milk Substitutes.17 The 13-page BFHI Self-Appraisal Tool, which a facility uses to appraise its current practices as part of the certification process, breaks down each of the Ten Steps into several substeps in the form of yes-no questions. For example, step 1—”Have a written breastfeeding policy that is routinely communicated to all health care staff”—is followed by 11 substeps, such as, “1.1 Does the facility have a written breastfeeding/infant feeding policy that establishes breastfeeding as the standard for infant feeding and addresses all Ten Steps to Successful Breastfeeding in maternity services?” (The BFHI Self-Appraisal Tool is available online at It is important to note that these policies should take effect on pediatric units, EDs, medical-surgical units, ambulatory surgical units, outpatient units, and any others in which a mother or infant may be admitted for care.17 Training of maternity nursing staff is formal, consisting of 20 hours of instruction, including 15 sessions required by UNICEF and the WHO and five hours of supervised clinical experience to ensure clinical competence.24 Other health care providers (physicians, midwives, physician assistants, and advanced practice RNs) involved in labor, delivery, maternity, or newborn care require at least three hours of breastfeeding management education and should thoroughly understand the benefits of exclusive breastfeeding, the physiology of lactation, and which medications are safe Objective 2020 Target, % Current Rate, %a Increase the proportion of infants who are breastfed • Ever • At six months • At one year • Exclusively through three months • Exclusively through six months 81.9 60.6 34.1 46.2 25.5 81.1 51.8 30.7 44.4 22.3 Increase the proportion of employers that have worksite lactation support programs 38 Not available Reduce the proportion of breastfed newborns who receive formula supplementation within the first two days of life 14.2 17.1 Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies 8.1 18.3b a Current rates represent infants born in 2013, per the National Immunization Survey 2014-15, except where noted. b Current rate represents infants born in hospitals designated as of June 2016 as Baby-Friendly. As of June 9, 2017, the Baby-Friendly USA website had updated the rate of annual births that occur in facilities designated as Baby-Friendly to 21.5. Adapted from the Centers for Disease Control and Prevention. Breastfeeding report card, progressing toward national breastfeeding goals: United States, 2016. Atlanta; 2016. Table 1. Healthy People 2020 Breastfeeding Targets and Current Rates 40 AJN ▼ August 2017 ▼ Vol. 117, No. 8 ajnonline.com to use while breastfeeding. Health care providers who are unable to describe or demonstrate breastfeeding skills are expected to provide mothers with appropriate referrals to others who can.24 To practice in accordance with the International Code of Marketing of Breast-Milk Substitutes, institutions must not accept free or reduced-cost supplies of breast milk substitutes and feeding supplies. In addition, any educational material given to mothers must be free of commercial identifiers, such as logos. Staff members are forbidden to receive gifts in the form of nonscientific material, equipment, money, or meals from producers of breast milk substitutes or artificial nipples and bottles.24 A prospective cohort study of 2,560 mother-infant pairs in public hospitals in Hong Kong investigated the effects of the BFHI guidelines on breastfeeding rates for 12 months following birth or until the cessation of breastfeeding.19 A total of 1,320 mothers delivered before and 1,240 delivered after the hospitals had implemented the guidelines. Investigators found that the proportion of mothers exclusively breastfeeding during hospitalization rose from 17.7% before guideline implementation to 41.3% afterward, and median duration of breastfeeding increased from eight to 12.5 weeks. Increased formula supplementation was associated with higher rates of breastfeeding cessation. THE ROAD TO BABY-FRIENDLY STATUS In the United States, implementation of the BFHI occurs in four phases, called the “4-D Process.” The four phases are as follows25: • The Discovery Phase is the first phase, in which staff learn what BFHI practices include and all that they entail. In this phase, the facility or institution must register with Baby-Friendly USA (BFUSA) and submit a completed BFHI Self-Appraisal Tool, a letter of support from its chief executive officer, and a completed facility data sheet (a sample of which is included in the online BFHI Self-Appraisal Tool). It should be noted that all forms must be completed online by one of two facility personnel authorized to use the BFUSA portal. • The Development Phase is the planning phase, in which the facility plans how to implement and sustain the Ten Steps. In this phase a committee is formed to oversee the process, including policy development and staff training. There are specific time frames associated with each task in this phase and, starting at this point, phase fees are required. (A fee schedule is available at org/get-started/fee-schedule.) • The Dissemination Phase is when all facility staff members who may be affected by this policy receive an orientation. Facilities must establish a breastfeeding education program for pregnant women and new mothers and begin collecting breastfeeding data from patient medical records and audits of maternity care practices. • The Designation Phase occurs after the facility submits a “Request to Move Letter” to BFUSA. This must include data demonstrating that the facility has met the specific guidelines. According to the BFUSA website, as of June 9, 2017, 440 U.S. hospitals and birthing centers had been designated as Baby-Friendly (for a regularly updated list, see In 2007, only 2.9% of U.S. births occurred in facilities with the Baby-Friendly designation, and this figure has grown to about 21.5%, exceeding the Healthy People 2020 target of 8.1%. Bumps in the road. The process for achieving BabyFriendly status may seem simple, but implementation can be difficult. A qualitative study that included 31 participants, representing midwifery, medical, nursing, and ancillary staff from six Australian maternity hospitals, found that the understanding and personal views of staff, as well as a “bottle-feeding culture,” were often at odds with BFHI objectives.26 Unpaid education time further impeded the goals and stressed staffing levels. A San Francisco hospital found it took eight years to achieve Baby-Friendly status, with challenges including health care providers with limited breastfeeding knowledge, hospital practices that did not support rooming-in or skin-to-skin contact between mother and infant, and little breastfeeding education overall.27 Hospital policies and lack of breastfeeding education on the part of staff are not the only impediments to achieving Baby-Friendly status and improving breastfeeding rates. Population characteristics such as language barriers, homelessness, substance abuse, and poverty can present challenges as well.27 ACHIEVING SUCCESS The Guided Infant Feeding Technique (GIFT), an educational program based on the Ten Steps, was introduced to 1,086 participants from 35 Louisiana hospitals between November 2008 and February 2012.28 Within 30 months, the number of hospitals that had achieved GIFT certification rose from nine to 24. Subsequently, Louisiana’s breastfeeding rates, as documented in the CDC’s Breastfeeding Report Card, increased from 50.7% ever breastfed in 2007 (the year before the program was introduced) to 60.9% ever breastfed in 2016, though this rate is still well below the Healthy People 2020 target of 81.9%.13, 29 Similarly, among mothers giving birth in a large multicenter medical institution in Chicago, rates of exclusive breastfeeding throughout the hospital stay rose from 38.6% to 53.5% over a four-month period after nurses completed a 20-hour BFHI education program.30 Other facilities that achieved Baby-Friendly designation noted that the following factors contributed to their success31: • involvement of all staff, not only nurses AJN ▼ August 2017 ▼ Vol. 117, No. 8 41 • financial assistance in the way of grants, which help offset educational fees • ongoing technical assistance with data collection Maintaining momentum. Once an institution has been designated as Baby-Friendly, it is important to maintain the momentum that was involved in attaining that status and to continue practicing in accordance with the BFHI. A study that included 915 women who gave birth in one of four Maine hospitals that were BFHI accredited either before or during the study period found that adherence to the Ten Steps was not optimal. Only 34.6% of the women reported that the hospital followed at least seven of the steps, with 35% of the women who gave birth at hospitals working toward Baby-Friendly status and 28% of the women who gave birth at hospitals that had already achieved Baby-Friendly status reporting that they had received gift packs containing formula upon discharge.15 As the number of BFHIaccredited hospitals grows, follow-up on practices will be an important area of continued nursing research. SUPPORT FOR BREASTFEEDING Health care facility programs. The DHHS has included the promotion of breastfeeding in its Healthy People 2020 objectives since 1990. Professional organizations, including the Association of Women’s Health, Obstetric and Neonatal Nurses, the American College of Obstetricians and Gynecologists,32 and the American Public Health Association,33 encourage health care facilities that serve childbearing families to maintain programs that support the successful initiation and continuation of breastfeeding. One of the difficulties women and families face in continuing to breastfeed after hospital discharge is lack of support, and it has been shown that support after discharge can increase continued breastfeeding rates. For example, in one study, 27 first-time mothers received weekly telephone calls from a lactation consultant for three months after discharge, and then once monthly for the next three months or until the infant was weaned. At six months postpartum, 73% of the women were still breastfeeding exclusively, compared with the hospital’s baseline breastfeeding rate of 38%.34 In a larger study conducted in Italy, 114 first-time mothers were randomized into two groups: an intervention group receiving weekly structured telephone counseling by a midwife for the first six weeks postpartum, and a control group having routine postnatal visits with a physician at one, three, and five months postpartum. Overall breastfeeding rates in the intervention group were significantly higher than those in the control group, and postpartum rates of exclusive breastfeeding were consistently higher at one month (76.4% versus 42.4%), three months (54.5% versus 28.8%), and five months (25.5% versus 11.9%).35 Peer counseling is also effective in promoting breastfeeding, as demonstrated in a study of 990 women who were receiving services from Michigan’s Special Supplemental Nutrition Program for Women, Infants, and Children. Women who participated in a peer-counseling breastfeeding support program in addition to receiving prenatal services were significantly more likely to initiate breastfeeding and to continue it for six months than were those in a control group who received prenatal counseling but no peer counseling.36 A systematic review of 31 qualitative studies found that the mere presence of a supportive person who is available to assist with breastfeeding and with whom the mother has a trusting, sincere rapport can increase rates of continued and exclusive breastfeeding.37 To be effective, breastfeeding support must be culturally appropriate, thorough, specific, consistent, and delivered both prenatally and postpartum. In a qualitative study in Maryland, women reported that, though they were encouraged to breastfeed because of the benefits it offered, they were not given specific oral or written information.38 Only one of the 75 women interviewed reported having received consistent information and support both at the hospital and from the pediatrician after discharge. She was also the only one interviewed who, at 10 months postpartum, reported never having given her child formula. Workplace support is also essential in promoting continued breastfeeding. Although many women stop breastfeeding when they return to work, participation in a workplace lactation program is associated with exclusive breastfeeding at six months.39 Furthermore, Implications for Nursing Practice • Educate all nursing staff, not only those on obstetric units, on the importance of providing breastfeeding support to mothers in their care. • Do not provide formula to breastfeeding mothers in the immediate postpartum period unless indicated in accordance with the nursing assessment of the mother or infant. • Cease providing new mothers with gift packs that include formula or any materials that have the logo of formula companies. • Develop breastfeeding clinics for follow-up and support of breastfeeding mothers. • Consider RN home visits (to evaluate the infant for weight loss, dehydration, or other signs of danger) for breastfeeding mothers who did not establish breastfeeding prior to discharge. • Provide information about community resources for breastfeeding upon discharge. • Provide a comfortable, clean area for breastfeeding and pumping to visitors as well as staff. • Include breastfeeding education in undergraduate nursing curricula. 42 AJN ▼ August 2017 ▼ Vol. 117, No. 8 ajnonline.com Section 4207 of the Affordable Care Act amended the Fair Labor Standards Act to require employers to provide time and space for new mothers to express breast milk for their infants for up to one year after birth.40 Informing patients of this protection may substantially increase the likelihood that they will continue breastfeeding after returning to work. Public perception. Others’ negative attitudes about breastfeeding in public spaces can discourage exclusive breastfeeding. In a survey conducted by the New York City Department of Health and Mental Hygiene, more than half of the 1,979 respondents believed women should breastfeed in private only.41 Patients should be informed that breastfeeding in public is sanctioned by laws in 49 states (all except Idaho), as well as the District of Columbia and the U.S. Virgin Islands.42 For more information on state breastfeeding laws, visit the website of the National Conference of State Legislatures at breastfeeding-state-laws.aspx. CONCERNS ABOUT BFHI ENFORCEMENT While most health care providers would agree that the BFHI can help improve outcomes for mothers and infants, the initiative has faced criticism that it is, in some cases, too rigidly enforced and may even interfere with nursing judgment. Some have expressed concerns that, with strict enforcement, mothers who have had an operative delivery may not be provided adequate time to recover before being encouraged to initiate skin-to-skin contact with their infant and begin breastfeeding.43 Some nurses have expressed the belief that hospitals need to reduce rates of cesarean section before embarking on this initiative. The BFHI prohibition against pacifier use has also been questioned, because pacifiers have been associated with a reduced risk of sudden infant death syndrome.43 Finally, some articles in the popular press have suggested that new mothers are being made to feel guilty if they cannot or choose not to breastfeed, and some nurses, midwives, and physicians echo this sentiment, voicing discomfort with hospital policies that prohibit infant formula from being provided without a medical order. Whether following an operative delivery or a long labor and vaginal birth, it’s clearly important for exhausted mothers to be carefully observed during the postpartum period when engaged in skin-to-skin contact, breastfeeding, or bottle feeding.44 The BFHI does not prevail on mothers to breastfeed when it is unsafe for them to do so, and with appropriate observation, infants will be moved to a separate sleep surface if the mother is drowsy. Regarding pacifier use, since it is associated with shortened duration of both exclusive breastfeeding and any breastfeeding, the American Academy of Pediatrics recommends delaying the introduction of pacifiers to healthy infants born at term “until breastfeeding is well established,” generally at three to four weeks after birth.44 While BFHI practices support new mothers with breastfeeding, offering them the assistance of lactation consultants, midwives, and nurses, it is important that mothers who choose not to breastfeed are never made to feel guilty or uncomfortable. RECOMMENDATIONS At Jacobi Medical Center in New York City, before mothers give birth, we host “Baby Showers” for patients and their families. At these showers, we provide gifts, food, and extensive breastfeeding education. RNs and nursing students from a local university have been active participants in organizing and presenting at these events. Such experiences are invaluable. At a time when so much clinical learning occurs in simulation, this is one area in which hands-on learning is best. Upon discharge after childbirth, breastfeeding mothers receive written information that includes telephone numbers they can call for support. We also invite new mothers to participate in a breastfeeding clinic within a week of giving birth. At the clinic, the mothers are evaluated by a lactation specialist, and the infants are weighed and examined by a pediatric health care provider. The lactation counselor observes breastfeeding, offering assistance as needed. This visit incorporates a support group, led by a health educator, in which mothers are encouraged to share what has helped them with breastfeeding. In addition to educating the mothers and families, the clinic provides an opportunity for medical and nursing students to participate and learn more about breastfeeding. Both RNs and local nursing students have led some of the groups. Although the data suggest that the numbers of women breastfeeding exclusively are increasing, significant improvements must be made if we are to meet Healthy People 2020 targets. All nurses can help promote breastfeeding in their practice and in speaking with their friends and neighbors (see Implications for Nursing Practice). We must also work to include breastfeeding education in the curricula of nursing and medical education programs. ▼ Regina Cardaci is associate director of Women’s Health Services at Jacobi Medical Center, Bronx, NY. The author acknowledges Michael Zinaman, MD, chair of the Department of Obstetrics and Gynecology, North Bronx Health Network, for his support of this project. Contact author: . The author and planners have disclosed no potential conflicts of interest, financial or otherwise. REFERENCES 1. Hetzner NM, et al. Associations among feeding behaviors during infancy and child illness at two years. Matern Child Health J 2009;13(6):795-805. For one additional continuing education activity on the Baby-Friendly Hospital Initiative, go to AJN ▼ August 2017 ▼ Vol. 117, No. 8 43 2. Ladomenou F, et al. Protective effect of exclusive breastfee

 
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Judge Learned Hand, in discussing “degree of care” in connection with the standard by which a prudent person is to be held, said this: “The degree of care demanded of a person by an occasion is the result of three factors: the likelihood that his conduct will injure others, taken with the seriousness of the injury if it happens, and balanced against the interest which he must sacrifice to avoid the risk.” Discuss how Judge Hand’s statement might be applied to the responsibilities of management in establishing an internal control system and to the role of a performance auditor in assessing the control system. Please answer this question in own words. See paragraphs below to answer the question and get an idea. (If some of the paragraphs below do not relate to the question, then you can skip them.) Kindly please help me. I understand that this is a lot of paragraphs, but I really need help.

The Control Environment:

Standards for Internal Control in the Federal Government

Integrity and Ethical Values of Managers:

Operating Style and Attitude of Managers:

Organizational Structure and Methods of Assigning Authority and Responsibility:

The Way in Which Managers Exercise Control:

Competence and Reliability of the People in the Organization:

Hiring and Promoting

Rotating Employees.

Salary and Benefits Structure.

Supervision and Training.

Assessing Risk:

The Risk Assessment Process:

Qualitative Approach to Assessing Risk:

Significance of Judgment in Assessing Risk:

Managing Risk During Change:

Control Activities: Consistent with the scope of modern performance auditing, this book defines an entity’s control activities to encompass a broad range of both operating-type or safeguarding-type of activities. As noted in the GAO’s internal control standards, control activities are the “policies, procedures, techniques, and mechanisms that enforce management’s directives.” They are also the actions taken to detect and prevent identified risks. To encompass the concepts established in Canada’s Criteria of Control, we consider control activities also to cover the process by which goals and objectives are established, the strategies, action plans and criteria by which progress is measured,

and the way in which human capital is managed.

-Operating strategies and controls cover a broad spectrum of managerial activities, such as developing: program goals and objectives; reporting systems to measure achievement of objectives; policies, procedures and strategies to give reasonable assurance that objectives are accomplished efficiently and effectively; qualitative and quantitative standards of employee performance; and supervision to ensure that employees meet those standards.

-Safeguarding controls help management either prevent or detect in a timely manner the unauthorized acquisition, use or disposition of the entity’s resources. They cover such techniques as: requiring authorizations and approvals; documenting transactions, events, and decisions; securing assets from loss due to pilferage and other factors; and separating related functions.

Control activities are essential to efficient and effective operations and to accountability for resources entrusted to managers. Control activities vary from agency to agency. Variances in mission, goals and objectives, as well as differences in risk that each agency faces, will affect the nature and extent of the controls they put in place. Weak operating controls can result in a lack of direction and a failure to achieve the agency’s missions. Weak safeguarding controls can lead to a failure to prevent or to detect fraud and other improper activities in a timely manner. Some safeguarding controls, such as requiring documentation in support of certain events and requiring supervisory approval, help to prevent losses through inefficiency. As you read this discussion of controls, remember that the cost of each type of control needs to be measured against its anticipated benefit in determining the extent of its application to a particular set of circumstances. Also, care needs to be taken that the controls are not so intrusive that they stifle employee initiative. For example, for some activities, it may be more effective to tell staff what needs to be accomplished rather than how it should be done.

Establishing Program Goals and Objectives:

Developing Reporting Systems to Measure Achievement of Objectives: Establishing goals and objectives in line with an entity’s missions lies at one end of the management control process. At the other end is measuring entity performance to see the extent to which the

Establishing Policies, Procedures and Strategies to Achieve Objectives:

Managing Human Capital – General: The GAO’s internal control standards point out that effective management of an entity’s workforce is essential to achieving results and is an important part of internal control. Therefore, management needs to view human capital as an asset, rather than as a cost. Major elements of managing human capital include: obtaining and retaining a workforce that has the skills needed to achieve the organization’s goals, developing appropriate performance standards; having training programs aimed at developing the skills needed to meet changing needs, providing staff with incentives that foster effective performance, obtaining employee feedback, and ensuring effective and qualified supervision. Some of these elements are discussed in the ensuing paragraphs.

Developing Quantitative and Qualitative Standards of Employee Performance:

-Qualitative work standards generally refer to the nature of the work that employees are required to do. Qualitative standards often take the form of work programs or inspection

protocols, expressed in procedures manuals and in checklists. More complex qualitative standards might take the form of anticipated client performance such as the level of student achievement.

Quantitative and qualitative standards need to set with care. They should not be set in a manner that stifles initiative, nor can they be so loose as to be meaningless. They cannot remain static. Managers need to be alert to the potential for greater efficiency and effectiveness as a result of changing technology and better methods based on experience within the jurisdiction and in other jurisdictions. For example, the use of personal and hand-held computers has had a major impact on the efficiency of numerous operations. For another example, a large city reduced garbage collection costs significantly by using two-person, rather than three-person, sanitation trucks.

As a performance auditor, you need to determine the nature of the quantitative and qualitative work standards established by management. You also need to find out how the standards were established, and whether they are revised to take advantage of changing technology and experience.

You also need to be aware of the literature pertaining to the program you are auditing and the standards adopted by other jurisdictions. Contact with state, national or international professional associations (for example, the International Association of Chiefs of Police) applicable to the program you are auditing is often helpful. Your goal is to become as knowledgeable as you can about the activity being audited.

Supervising to Ensure that Employees Meet Performance Standards: Procedures manuals and checklists are just one element of a control system. Without supervision,

there is no assurance that employees are adhering to the established qualitative and quantitative work standards. Although supervision is needed for all activities, it is particularly important for activities such as inspection and maintenance, which take place away from the agency’s offices. Effective supervision gives top management reasonable assurance that staff employees are not “cutting corners” regarding work quality, allowing them to “goof off” or be absent without authorization. Lack of effective supervision increases the risk that poor quality work will come to management’s attention the hard way – as a result of accidents, reports of bribery, client complaint, or other incidents that reflect poorly on the entire government.

There are quantitative and qualitative aspects to supervisory performance, just as there are in staff performance. For some programs, laws or higher-level oversight agencies may establish ratios of numbers of supervisors to staff. Generally, however, agency managers are responsible for establishing the span of supervisory control. The extent of top management’s commitment to an effective control environment, discussed earlier in this chapter, contributes to the quality of an agency’s supervision. In performance auditing, you will often find a close relationship between the quality of the first line of supervision and efficient staff performance.

Control Activities for Computerized Information Systems: We referred earlier to the importance of controls regarding computer systems. Computerized information systems are the primary means by which most organizations control operations.Control activities are just as important for computerized systems as they are for manual systems. There are two generally accepted groups of controls – general controls and application controls.

General controls include security planning and management, access security, application software development and change control, system software control, segregation of duties, and contingency planning for service interruption. Application control helps ensure that all transactions processed by a software application are complete, accurate, authorized and valid.

Access security controls are intended to protect the network from inappropriate access by hackers and others. Security control activities include changes of dial-up numbers; restrictions on users allowing access only to information they need; frequent changes of passwords and deactivation of passwords used by former employees; and software and hardware “firewalls” that restrict access.

The Information Systems Audit and Control Association has issued extensive guidance on the control activities that management needs to protect the integrity of its information systems. You can get more information on this critical function at its web site: http:// and Communication:

The fourth component of internal control, information and communication, is the lifeblood of most organizations. This component fills many needs:

● Managers needs to convey the organization’s goals, objectives, policies and procedures to staff, and staff needs to convey operating problems and successes to managers.

● Managers need operating information to see if they meeting their goals and objectives, and they need financial information to see if actual performance is within budget.

● Operating units need to coordinate activities with each other.

● Management must constantly assess client needs and demonstrate accountability both to the legislature and the citizenry.

Communication must flow up, down, across and in and out of an organization. Information must be useful, timely, accurate and complete. The information and communication systems in an organization must work together to be successful in today’s environment.

Information:information, at the right time, to the right people. Networked computer systems enable people to share an incredible amount of information today. The challenge is to assure:

-Content is relevant

-Information is communicated in a timely manner

-Information is accurate and current

-Information is readily accessible

Today, managing information is a discipline receiving increasing management attention. In view of the amount of documents and other objects being sent and received for different business processes, the need for efficient administration is important. Naturally, this also applies to the environment of the users themselves, who should be able to find their way around the electronic office quickly and effortlessly. This also applies, however, to groups of users who must have joint access to certain information within the context of a specific project.

Software packages today feature multilevel folder management systems that support both the requirements of individual users and user groups:

-Private folders can be used to store information that is accessible only to the relevant user or selected persons.

-Public folders can be used to communicate important information, as well as to collect information, ideas, and expertise within an organization. Information of general interest, for example, can be posted in the form of “notice boards” to communicate information from management and other departments. Public folders can also be used to administer project-specific documentation, minutes of meetings, or planning documentation. Information in these folders is only accessible to certain departments, project groups, or

individual users.

-Access rights can be defined based on the individual person or distribution lists, which can include project groups or departments.

Electronic information systems and the use of information technology have risks that must be effectively controlled in order to avoid disruptions to business and potential losses. Controls over information systems and technology should include both general and application controls. General controls are controls over the computer system (i.e., mainframe and end-user terminals) and ensure its continued, proper operation. For example, general controls include back-up and recovery procedures, software development and acquisition policies, maintenance procedures, and access security controls.

Communication: Effective communication is needed to convey numerous matters, such as management’s goals and objectives, policies and procedures, specific performance targets, ethical values and expectations regarding dealings with the citizenry. Without effective communication, information is useless. Managers need to establish effective paths of communication in order to ensure that necessary information is reaching the appropriate people. This information relates to both the operational policies and procedures of the organization as well as information regarding the actual operational performance of the organization. Management must help the flow of information – upward, downward, across the organization and in and out of the organization. When information flows upward, management is aware of the risks and the operating performance of the organization. Information flowing down through an organization helps ensure that the mission, goals and objectives and expectations, as well as established policies and procedures, are communicated to lower level management and operations personnel. This communication is essential to achieve a unified effort by all members of the organization. Communication across the organization is necessary to ensure that information available to one unit is shared with other affected units to coordinate activities.

Auditors ask a number of questions when assessing communication systems. They include:

-Are employee duties and control responsibilities communicated effectively?

-Are there established channels for people to communicate suspected improprieties?

-Is management receptive to employee suggestions on ways to enhance productivity, quality or other improvements?

-Is there adequate communication across the organization? Is the information

communicated completely, timely and sufficiently to enable people to discharge their responsibilities effectively?

-Are there open and effective channels of communication with customers, suppliers and other external sources? Are changing customer needs communicated?

-Are employees and outside parties made aware of the entity’s ethical standards?

-Is there timely and appropriate follow-up action by management resulting from communications with others?

Monitoring:

Separate Evaluations of the Control System: Separate evaluations of the control system are needed because the ongoing agency-level managerial and supervisory activities are not sufficient to provide assurances to all those who are concerned with a governmental agency’s activities. The stream of accountability runs upward from unit managers to agency chiefs, to the chief executive officer, to the legislature, to higher level government resource providers, and ultimately to the citizenry. All individuals and groups in this accountability chain need assurances that control systems are in place and working. An agency chief may be satisfied with the internal control system, but that does not

necessarily mean that the mayor will be made aware of matters known to or overlooked by the agency head. The mayor may be satisfied with an agency’s control system, but state and federal resource providers may want to make sure the mayor’s staff is interpreting higher-level agency directives accurately and reporting honestly. Finally, as discussed in Chapter 1, legislatures may establish legislative auditors; and citizens, expressing their views through constitutional conventions, may prefer separately elected auditors. The views we express are consistent with the private sector notion that corporate boards of directors need strong audit committees exercising close supervision of corporate internal audit staffs.

Separate evaluations of control systems might occur at any point in the accountability chain. They may be made by agency internal auditors, external financial auditors, auditors appointed by the legislature or elected by the citizenry, or auditors from a higher-level government. Many larger agencies have in-house internal audit staffs or obtain separate internal control evaluations under contract with an outside entity. Because this textbook covers the techniques used in performance auditing, there is no need to discuss this aspect of the monitoring process in this chapter. We would point out, however, that a major role of the internal auditor is to evaluate the effectiveness of the monitoring accomplished through routine managerial and supervisory activities. We also note that monitoring through separate evaluations requires procedures for ensuring that the findings resulting from the separate evaluations are promptly resolved.

Routine, Ongoing Managerial and Supervisory Activities: There is no clear distinction between control activities, discussed earlier in this chapter, and monitoring done through routine managerial and supervisory functions. Control activities are the policies and procedures adopted by management to ensure that its directives are carried out. However, some types of control activities, particularly those involving review and approval by supervisors or managers, are also monitoring activities. Here is an example of how routine, ongoing managerial and supervisory monitoring activities might work in an inspection activity. Description of situation: Assume a governmental agency is responsible for inspecting nursing homes or day care centers for cleanliness and for conformance to safety and dietary standards. The inspections are made by a group of inspectors, using checklists, who must visit all facilities once a year. Deficiencies found on inspection are set forth in a complaint report. Facility owners have 30 days to correct deficiencies, and a re-inspection is made if deficiencies are considered to be serious. The checklists serve as a control to ensure nothing is overlooked. The decisions to visit all facilities once a year and to re-inspect non-compliant facilities are control or operating strategies, based on a risk assessment related to inspection frequencies needed to give agency managers reasonable assurance that facility owners conform to health and safety standards. Control through supervision: After completing an inspection, the inspectors prepare reports on deficiencies and leave the report and the completed checklist with the unit supervisor. The unit supervisors review the check lists for completeness; issue complaint reports, if necessary, to the facility owner; and sign off on the checklists to signify approval of the inspection. The unit supervisors also make spot checks of the quality of the work performed by the staff by visiting a sample of the sites inspected by each staff inspector, shortly after the inspection. The supervisors make a note on the checklist whenever they visit a site.

Monitoring activity accomplished by supervision: What are the supervisors doing in this illustration? When they review the checklists for completeness and make spot checks of the inspection quality, the supervisors are performing control activities intended to ensure the quality of the inspections. Supervisory sign-off provides evidence of the approval. These control activities are also part of the ongoing monitoring of the quality of the inspection activity. Effective supervision may lead to the conclusion that one of the other controls – employee training – needs to be upgraded or increased in frequency.

Related monitoring activities: But what if there were an insufficient number of inspectors or an insufficient number of supervisors? In that event, other types of routine managerial controls might call management’s attention to the problems. Reports on numbers of inspections performed compared with the budgeted number of inspections provides another monitoring type of activity. Complaints made by relatives of those in nursing homes or day care centers also aid in the monitoring process.

Role of the performance auditor: Where does the separate evaluation – the performance audit – fit into this picture? The performance auditor will assess such matters as: (a) whether the unit supervisors are doing what they are supposed to do (that is, reviewing the completed check lists, making spot visits, and sending out complaint reports in a timely manner); (b) whether managers get periodic reports showing numbers of completed inspections relative to plan and whether they act promptly in the event of lagging inspection performance; and (c) whether there are a sufficient number of supervisors to do the job.

Examples of Routine, Ongoing Managerial Monitoring Techniques: There are many ways in which managers and supervisors accomplish routine, ongoing monitoring of the performance of the control systems. (Remember that we defined a control as any activity intended to ensure achievement of managerial objectives.) It is important to note that several monitoring activities described in the previous paragraphs required management to establish performance standards against which the monitoring would be accomplished. Here are some of the ways in which managers and supervisors do routine, ongoing monitoring:

-Review and approval of staff actions on transactions over a certain dollar amount, to ensure that established procedures were followed in making decisions.

-Visits to a sample of work sites, to ensure quality of staff performance relative to standards, or adherence of employees to work rules.

-Review of monthly or quarterly reports showing quantity of work done compared with a budget standard, or cost of work done compared with a budget standard. This enables

prompt detection and correction of shortfalls from targeted performance.

-Review of routine or special reports showing deviations from established norms, such as supply outages, facility breakdowns, or overtime and sick leave reports. Such deviations may be indicators of problems in supervision and other controls.

-Review of accident reports and client complaints. Incidents such as these may result from weak operating practices or from insufficient consideration of risks underlying the

strategies adopted to prevent such problems.

-Follow-up on deviations uncovered during routine reconciliation processes. For example, analysis of differences between physical inventories and amounts shown in perpetual

inventory records might provide evidence of breakdowns in the accounting system, in security, or in other aspects of the control system. An inability to reconcile cash balances

with amounts shown in bank statements might lead to discovery of fraud.

-Review of asset write-offs. For example, write-offs of loans receivable might be evidence of weak processes in granting governmental loans. Write-offs of inventory might be

evidence of poor purchasing or poor storage practices. Write-downs of investment values might have been caused by a failure to adhere to investment guidelines.

-Managerial review of reports comparing performance of one facility with another, or one branch office with another.

Need for Prompt Communication of Serious Internal Control Shortcomings: Performance auditors also have a responsibility to report major problems promptly to the appropriate levels of management. As discussed in Chapter 5, performance auditors need to establish a line of continuous communication with top management at the opening audit conference. Formal procedures should also be established for reporting on actions taken by management to resolve the conditions noted in performance audit reports.

Finding the Right Controls: Auditors sometimes tend to over-emphasize the wrong control components under the premise that control activities (i.e., policies and procedures) are the most critical elements of an organization’s success. Policies and procedures are certainly important. An effective performance auditor, however, ensures not only that they exist, but also that they exist within the appropriate control environment and that they are followed by staff and not over-ridden by management. In conclusion, if auditors are to be successful in finding the real cause of the problems uncovered in an organization, it’s imperative to address all of the control components identified in COSO’s Internal Control — Integrated Framework. Auditors must understand the entity’s control environment and the information and communication systems. These components are harder to assess than the others, but are just as critical in determining the entity’s success or failure.

 
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