The Quality of Health Care Delivered to Adults in the United States
Elizabeth A. McGlynn, Ph.D., Steven M. Asch, M.D., M.P.H., John Adams, Ph.D., Joan Keesey, B.A., Jennifer Hicks, M.P.H., Ph.D., Alison DeCristofaro, M.P.H., and Eve A. Kerr, M.D., M.P.H.
N Engl J Med 2003; 348:2635-2645June 26, 2003DOI: 10.1056/NEJMsa022615
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The degree to which health care in the United States is consistent with basic quality
standards is largely unknown.1,2 Although previous studies have documented serious
quality deficits, they provide a limited perspective on the issue.3-5 Most have assessed a
single condition,6,7 a small number of indicators of quality,8,9 persons with a single type of insurance coverage,10 or persons receiving care in a small geographic area.11,12 The few national studies have been limited to specific segments of the population, such as
Medicare beneficiaries13-15 or enrollees in managed-care plans16; have focused on a
limited set of topics, such as preventive care,17 diabetes,18 or human immunodeficiency
virus19; or have assessed health outcomes without a link to specific processes involved in care.20 As a result, we have no comprehensive view of the level of quality of care given to the average person in the United States. This information gap contributes to a persistent
belief that quality is not a serious national problem.1
In this article, we report results from the Community Quality Index (CQI) study, a collateral study of the Community Tracking Study (CTS).21 The CTS, conducted by the Center for
Studying Health System Change (CSHSC), monitors changes in health care markets in the United States. The CTS obtains self-reported information from a random sample of the U.S.
population on their insurance coverage, patterns of utilization of health care services, and
health status. The CSHSC has reported on trends in health care costs,22 factors affecting the choice of employer-sponsored or public insurance,23 and changes in the structure of
managed-care plans.24 However, the CTS lacks detailed information about the
implications of these variations in health care markets for the quality of health care. By
collaborating with the CSHSC, we were able to assess the extent to which the
recommended processes of medical care — one critical dimension of quality — are
delivered to a representative sample of the U.S. population for a broad spectrum of
conditions.
METHODS
Recruitment of Participants
In 12 metropolitan areas (Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; Newark, N.J.; Orange County, Calif.; Phoenix, Ariz.; Seattle; and Syracuse, N.Y.), using random-digit-dial telephone surveys, the CTS deliberately recruited enough participants to assess how structural characteristics in each market (e.g., the penetration of managed care) affect patterns of access to and utilization of health care services. Between October 1998 and August 2000, we recontacted by telephone households that had participated in the CTS interviews. Participants were asked to complete a telephone interview regarding their health history and to provide a listing of all individual or institutional health care providers whom they had seen during the previous two years. Participants who orally agreed to provide access to their medical records were sent written consent forms to sign and return to RAND. Photocopies of the medical records of participants providing written consent were sent to RAND for central abstracting. Response Rates
Because of the complex, multistage nature of the study design, several calculations of the response rate are provided. Among the 20,028 adults in the initial sample, 2091 (10 percent) were deemed ineligible, primarily because they had left the area. Among the
17,937 eligible adults, 13,275 (74 percent) participated in the telephone interview regarding their health history, including 863 (7 percent) who had had no visits to a health care provider during the previous two years. Among the 12,412 participants who had had visits, 10,404 (84 percent) agreed orally to provide access to their medical records. We obtained written consent from 7528 (61 percent of those with visits to a provider). Participants reported having seen between 1 and 17 providers (mean, 2.6) during the study period. We obtained at least one record for 6712 (89 percent) of those who returned their consent forms. Overall, we received 84 percent of the records for which we had consent forms; we received all expected records for 4612 of the 6712 participants with consent forms and records (69 percent) and all but one record for 1547 of these participants (23 percent). Sensitivity analyses revealed few differences in results related to the completeness of records, so all participants for whom we obtained at least one record were included in the results we report (37 percent of the sample of eligible adults). Development of Indicators of Quality
The indicators of quality used in the study were derived from RAND's Quality Assessment Tools system.25 RAND staff members selected acute and chronic conditions that represented the leading causes of illness, death, and utilization of health care in each age group, as well as preventive care related to these causes. For each condition, staff physicians reviewed established national guidelines and the medical literature and proposed indicators of quality for all phases of care or medical functions (screening,
diagnosis, treatment, and follow-up). We developed indicators to assess potential problems with the overuse and underuse of key processes. We primarily chose measures of processes as indicators, because they represent the activities that clinicians control most directly, because they do not generally require risk adjustment beyond the specification of eligibility, and because they are consistent with the structure of national guidelines.5,26
Four nine-member, multispecialty expert panels were convened to assess the validity of the indicators proposed by the staff, using the RAND–UCLA modified Delphi
method.27 The members of the panels, nominated by the appropriate specialty societies, were diverse with respect to geography, practice setting, and sex. Indicators were rated on a 9-point scale (with 1 denoting not valid and 9 very valid). Only indicators with a median validity score of 7 or higher were included in the Quality Assessment Tools system. This method of selecting indicators is reliable28 and has been shown to have content, construct, and predictive validity in other applications.29-32
The criteria for the selection of conditions, reviews of the literature, the process followed by the panels, and the final indicators have been published elsewhere.33-36 (Further information on all the quality indicators used in this study is available
at https://www.doczj.com/doc/fc4521384.html,/health/mcglynn_appa.pdf or from the National Auxiliary
Publications Service [NAPS].) Table 1TABLE 1Selected Quality-of-Care Indicators and Classifications Used in the Community Quality Index Study. provides a brief description and classifications for a sample of the indicators we used. The classifications enabled us to examine quality from the perspective of what is being done (type of care), why it is being done (function), how it is being delivered (mode), and the nature of the quality problem (underuse or overuse). Results are based on 439 indicators for 30 conditions and preventive care.
Health History Interview
We obtained selective information directly from respondents to augment information in their medical records. The health history took an average of 13 minutes to complete. The data obtained in this interview were used to refine the analysis of a respondent's eligibility for inclusion in the analysis or to augment the scoring for 22 of the 439 indicators. For example, we used reports of symptoms from participants with asthma to classify those with moderate-to-severe disease. We augmented scores for influenza or pneumococcal immunizations and screening for cancer on the basis of self-reports.
Abstracting of Charts
We developed computer-assisted abstraction software on a Visual Basic platform (version 6.0, Microsoft). The software allowed the manual abstraction of charts to be tailored to the
specific record being reviewed and provided interactive checks of the quality of the data (for consistency and range), calculations (e.g., the determination of the presence of high blood pressure), and classifications (e.g., the determination of drug class) during abstraction.
Data for the study were abstracted by 20 trained registered nurses who had successfully abstracted a complex standard chart after a two-week training program. Charts were abstracted separately for each health care provider of each participant (i.e., at the dyad level). The average time required to abstract a chart for a participant–provider dyad was 50 minutes.
To assess interrater reliability, we re-abstracted charts from a randomly selected 4 percent sample of participants. Average reliability, with the use of the kappa statistic, ranged from substantial to almost perfect37 at three levels: the presence or absence of a given condition (κ=0.83), the participant's eligibility for the process represented by a given indicator (κ=0.76), and scoring of a given indicator (κ=0.80).
Statistical Analysis
We specified the combination of variables necessary to determine whether each participant was or was not eligible for the process specified by each indicator and whether each participant did or did not receive each process or some proportion of it. Each indicator was scored at one of three levels — that of the individual participant, that of the participant–provider dyad, or that of the episode — depending on the nature of the process being evaluated. The level at which an indicator was scored affected the number of times a participant was eligible for the specified process; the resulting number served as the denominator in the calculation of the aggregate score. For participant-level indicators, we gave the participant a score of ―pass‖ if at least one of his or her health care providers had delivered the indicated care (e.g., influenza vaccination). For indicators scored at the level of the participant–provider dyad (e.g., smoking status noted in the chart), we scored every dyad separately, so the number of times the participant was counted in the denominator depended on the number of providers who saw the participant and could have performed the specified process. For indicators scored at the episode level (e.g., follow-up after hospitalization for an exacerbation of asthma), we scored every event rendering the participant eligible for the specified process and involving any of the participant's providers, so the number of eligibility events depended on the number of episodes that occurred.
In order to produce aggregate scores, we divided all instances in which recommended care was delivered by the number of times participants were eligible for indicators in the category. For example, Table 1 presents information about seven of the indicators for acute care; the number of times participants were eligible for these indicators would constitute the denominator for the acute care score. The results are presented as proportions, theoretically ranging in value from 0 to 100 percent. We used the bootstrap method to estimate standard errors directly for all the aggregate scores.38
Because everyone in the initial sample for the CQI study had participated in the CTS, we had a rich set of variables for assessing nonresponse. We used logistic-regression
analysis to estimate the relations between individual characteristics (age, sex, race,
educational level, income, self-reported level of use of physicians and hospitals, insurance status, and health status) and participation in the study. In general, participants tended to be older than nonparticipants (P<0.001) and were more likely than nonparticipants to be female (P<0.001) and white (P<0.001), with higher levels of education (P<0.001) and income (P<0.001). They were also more likely to have used health care services (P<0.001) and to be in other than excellent health (P=0.03). We used the coefficients from the regression equation to adjust the scores for nonresponse, and we weighted the data for the
participants to be representative of the population from which they were drawn. RESULTS
Characteristics of the Participants
Table 2TABLE 2Characteristics of the 6712 Participants. summarizes the characteristics of the participants; these characteristics differ from population averages but parallel the profile of persons receiving medical care. For example, the average age of patients in the National Ambulatory Medical Care Survey39 is 44.7 years. Women have higher rates of visits than men (319.9 vs. 234.9 visits per 100 persons per year), and whites have higher rates of visits than blacks (293.2 vs. 210.7 visits per 100 persons per year).39 Participants were well educated. Forty-three percent had one or more of the chronic conditions we assessed, and 34 percent had one or more of the acute conditions. Preventive care was assessed for all participants; in addition, participants' care was assessed for 1.5 chronic or acute conditions, on average, for a total of 2.5 (range, 1 to 13). Participants were included in the overall denominator an average of 16 times (range, 2 to 304).
Analysis of Care Delivered
Table 3TABLE 3Adherence to Quality Indicators, Overall and According
to Type of Care and Function., Table 4TABLE 4Adherence to Quality
Indicators, According to Mode., and Table 5TABLE 5Adherence to Quality Indicators, According to Condition. show the number of indicators included in the aggregate score, the number of persons eligible for one or more processes within the category, the number of times participants in the sample were eligible for indicators, and the weighted mean proportion (and 95 percent confidence interval) of recommended processes that were delivered.
Overall, participants received 54.9 percent of recommended care (95 percent confidence interval, 54.3 to 55.5) (Table 3). This level of performance was similar in the areas of preventive care, acute care, and care for chronic conditions. The level of performance according to the particular medical function ranged from 52.2 percent (95 percent confidence interval, 51.3 to 53.2) for screening to 58.5 percent (95 percent confidence interval, 56.6 to 60.4) for follow-up care.
―Mode‖ refers to the mechanism of care delivery required for the provision of the indicated process. Analysis of performance in terms of mode may identify areas in which
system-wide interventions could offer solutions to problems of quality, such as improved methods for ordering, processing, and communicating laboratory results. We found greater variation among modes than among functions in adherence to the processes we studied (Table 4). Care requiring an encounter or other intervention (e.g., the annual visit recommended for patients with hypertension) had the highest rates of adherence (73.4 percent [95 percent confidence interval, 71.5 to 75.3]), and processes involving counseling or education (e.g., advising smokers with chronic obstructive pulmonary disease to quit smoking) had the lowest rates of adherence (18.3 percent [95 percent confidence interval, 16.7 to 20.0]). All pairwise differences were statistically significant at P<0.001 except those between the prescribing of medication and care requiring an encounter or other intervention (P=0.02), physical examination and immunization (P=0.001), surgery and immunization (P=0.004), and surgery and physical examination (P=0.05). The difference between surgery and laboratory testing or radiography was not significant (P=0.39). Problems with Quality of Care
We also classified indicators according to the problem with quality that was deemed most likely to occur, and we found greater problems with underuse (46.3 percent of participants did not receive recommended care [95 percent confidence interval, 45.8 to 46.8]) than with overuse (11.3 percent of participants received care that was not recommended and was potentially harmful [95 percent confidence interval, 10.2 to 12.4]).
Variations in Quality
Table 5 shows substantial variability in the quality-of-care scores for the 25 conditions for which at least 100 persons were eligible for analysis. Persons with senile cataracts
received 78.7 percent of the recommended care (95 percent confidence interval, 73.3 to
84.2); persons with alcohol dependence received 10.5 percent of the recommended care (95 percent confidence interval, 6.8 to 14.6). The aggregate scores for individual conditions
were generally not sensitive to the presence or absence of any single indicator of quality. DISCUSSION
Overall, participants received about half of the recommended processes involved in care. These deficits in care have important implications for the health of the American public. For example, only 24 percent of participants in our study who had diabetes received three or more glycosylated hemoglobin tests over a two-year period. This finding parallels the finding by Saaddine and colleagues that 29 percent of adults with diabetes who participated in the nationally representative Behavioral Risk Factor Surveillance System reported having their blood sugar tested during the previous year.18 This routine monitoring is essential to the assessment of the effectiveness of treatment, to ensuring appropriate responses to poor glycemic control, and to the identification of complications of the disease at an early stage so that serious consequences may be prevented. In the United Kingdom Prospective Diabetes Study, tight blood glucose control and biannual monitoring decreased the risk of microvascular complications by 25 percent.40
In our study, persons with hypertension received 64.7 percent of the recommended care (95 percent confidence interval, 62.6 to 66.7). We have previously demonstrated a link between blood-pressure control and adherence to process-related measures of quality of care for hypertension.41 Persons whose blood pressure is persistently above normal are at increased risk for heart disease, stroke, and death.42 Poor blood-pressure control contributes to more than 68,000 preventable deaths annually.43
Overall, 68.0 percent (95 percent confidence interval, 64.2 to 71.8) of the recommended care for coronary artery disease was received, but only 45 percent of persons presenting with a myocardial infarction received beta-blockers, which reduce the risk of death by 13 percent during the first week of treatment and by 23 percent over the long term.44 Only 61 percent of participants with a myocardial infarction who were appropriate candidates for aspirin therapy received aspirin, which has been shown in randomized trials to reduce the risk of death from vascular causes by 15 percent, to reduce the risk of nonfatal myocardial infarction by 30 percent, and to reduce the risk of nonfatal stroke by 40 percent.45
Deficits in processes involved in primary and secondary preventive care are also associated with preventable deaths. Among elderly participants, only 64 percent had received or been offered a pneumococcal vaccine; nearly 10,000 deaths from pneumonia could be prevented annually by appropriate vaccinations.43 About 38 percent of participants had been screened for colorectal cancer; annual fecal occult-blood tests could prevent about 9600 deaths annually.43
Nonresponse bias is a potential limitation of the study. Because the sample we analyzed included 37 percent of the eligible adults, the results are likely to be biased, but the direction of that bias is not clear. For example, because our participants were more likely to use the health care system than were eligible persons who did not participate in the study,
our results may be biased toward an underestimation of deficits in quality related to underuse.
The study relied primarily on the review of medical records to score indicators, which may lead some to conclude that we have identified problems with documentation rather than quality. This issue has been examined in studies that compared process-based quality scores using standardized patients, vignettes, and abstraction of medical records46 and studies that compared standardized patients with audiotapes of encounters.47 Overall, the process scores among the four conditions studied were 5 percentage points lower with the use of medical records than with the use of vignettes and 10 percentage points lower with the use of medical records than with the use of standardized patients. About two thirds of the disagreement between data from standardized patients and data from audiotapes was attributable to reports by standardized patients that they received care processes that were not confirmed by audiotape. A related study reported a false positive rate of 6.4 percent in medical-record documentation, with the highest false positive rates found for physical examination and elements of the diagnostic process.48 Thus, our scores might have been as much as 10 percentage points higher if we had used a different method of obtaining data. We used the interview about the participant's health history to partially offset this effect. For example, among elderly participants, only 15 percent had a note in any chart indicating that an influenza vaccination had been received, but 85 percent reported having received one. In general, the inclusion of self-reported data improved scores.
Our results indicate that, on average, Americans receive about half of recommended medical care processes. Although this point estimate of the size of the quality problem may continue to be debated, the gap between what we know works and what is actually done is substantial enough to warrant attention. These deficits, which pose serious threats to the health and well-being of the U.S. public, persist despite initiatives by both the federal government and private health care delivery systems to improve care.
What can we do to break through this impasse? Given the complexity and diversity of the health care system, there will be no simple solution. A key component of any solution, however, is the routine availability of information on performance at all levels. Making such information available will require a major overhaul of our current health information systems, with a focus on automating the entry and retrieval of key data for clinical decision making and for the measurement and reporting of quality.49 Establishing a national base line for performance makes it possible to assess the effect of policy changes and to evaluate large-scale national, regional, state, or local efforts to improve quality.
Supported by the Robert Wood Johnson Foundation and by career development awards (to Drs. Asch and Kerr) from the Veterans Affairs Health Services Research and Development program. NAPS See NAPS document no. 05610 for 50 pages of supplementary material. To order, contact NAPS, c/o Microfiche Publications, 248 Hempstead Tpke., West Hempstead, NY 11552.
We are indebted to Maureen Michael, James Knickman, and Robert Hughes at the Robert Wood Johnson Foundation for their support; to Paul Ginsburg at the Center for Studying Health System Change for his support of this collaboration; to Richard Strauss at Mathematica Policy Research for developing systems for passing the initial sample from the Community Tracking Study household
survey to RAND for this study; to RAND's Survey Research Group (Josephine Levy and Laural Hill) and the telephone interviewers for recruiting participants; to Peggy Wallace, Karen Ricci, and Belle Griffin for their assistance in the design of the data-collection tool, for hiring and training the nurse abstractors, and for overseeing the data-collection process; to Liisa Hiatt for serving as the project manager; and to Vector Research for developing the data-collection software.
SOURCE INFORMATION
From RAND, Santa Monica, Calif. (E.A.M., S.M.A., J.A., J.K., J.H., A.D.); the Veterans Affairs (VA) Greater Los Angeles Health Care System, Los Angeles (S.M.A.); the Department of Medicine, University of California Los Angeles, Los Angeles (S.M.A.); the VA Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Ann Arbor, Mich. (E.A.K.); and the Department of Medicine, University of Michigan, Ann Arbor (E.A.K.).
Address reprint requests to Dr. McGlynn at RAND, 1700 Main St., P.O. Box 2138, Santa Monica, CA 90407, or at beth_mcglynn@https://www.doczj.com/doc/fc4521384.html,.
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英语演讲稿：未来的工作 这篇《英语演讲稿范文：未来的工作》，是特地，希望对大家有所帮助！ 热门演讲推荐：竞聘演讲稿 | 国旗下演讲稿 | 英语演讲稿 | 师德师风演讲稿 | 年会主持词 | 领导致辞 everybody good afternoon:. first of all thank the teacher gave me a story in my own future ideal job. everyone has a dream job. my dream is to bee a boss, own a pany. in order to achieve my dreams, i need to find a good job, to accumulate some experience and wealth, it is the necessary things of course, in the school good achievement and rich knowledge is also very important. good achievement and rich experience can let me work to make the right choice, have more opportunities and achievements. at the same time, munication is very important, because it determines whether my pany has a good future development. so i need to exercise their municative ability. i need to use all of the free time to learn
世界经典哲学类书籍 哲学，是理论化、系统化的世界观，是自然知识、社会知识、思维知识的概括和总结,是世界观和方法论的统一。是社会意识的具体存在和表现形式，是以追求世界的本源、本质、共性或绝对、终极的形而上者为形式，以确立哲学世界观和方法论为内容的社会科学。 《性心理学》 《作为意志和表象的世界》 《理想国》 《西方哲学史》 《自然哲学的数学原理》 《权力意志》 《新工具》 《纯粹理性批判》《文明论概略》 《劝学篇》 《伦理学》 《耶稣传》 《时间简史》 《逻辑哲学论》 《精神现象学》 《物性论》 《感觉的分析》 《精神分析引论》《基督何许人也——基督抹煞论》 《科学的社会功能》《人有人的用处》《科学史》 《人类理智新论》《逻辑学》 《哲学研究》 《新系统及其说明》《道德情操论》 《实践理性批判》《美学》 《判断力批判》 《基督教的本质》《薄伽梵歌》 《伦理学中的形式主义与质料的价值伦理学》《物种起源》 《物理学》《人类的由来》 《人性论》 《人是机器》 《法哲学原理》 《狄德罗哲学选集》 《野性的思维》 《哲学史教程》 《科学与近代世界》 《人类的知识》 《精神分析引论新编》 《自然宗教对话录》 《基督教并不神秘》 《科学中华而不实的 作风》 《一年有半，续一年有 半》 《时间与自由意志》 《哲学辞典》 《历史理性批判文集》 《苏鲁支语录》 《文化科学和自然科 学》 《十六、十七世纪科 学、技术和哲学史》 《科学哲学的兴起》 《灵魂论及其他》 《斯宾诺莎书信集》 《实验心理学史》 《最后的沉思》 《纯粹现象学通论》 《近代心理学历史导 引》 《佛教逻辑》 《神圣人生论》 《逻辑与知识》 《论原因、本原与太 一》 《形而上学导论》 《诗学》 《路标》 《心的概念》 《计算机与人脑》 《十七世纪英格兰的 科学、技术与社会》 《卡布斯教诲录》 《薄伽梵歌论》 《尼各马可伦理学》 《论老年论友谊论责 任》 《实用主义》 《我的哲学的发展》 《拓扑心理学原理》 《在通向语言的途中》 《科学社会学》 《埃克哈特大师文集》 《逻辑大全》 《简论上帝、人及其心 灵健康》 《宗教的本质》 《论灵魂》 《科学的价值》 《内时间意识现象学》 《艺术即经验》 《宗教与科学》 《感觉与可感物》 《行为的结构》 《真理与方法》 《阿维斯塔》 《善的研究》 《人类知识原理》 《伦理学体系》 《科学与方法》 《第一哲学（上下卷）》 《物理学理论的目的 与结构》 《思维方式》 《发生认识论原理》 《爱因斯坦文集》 《伦理学的两个基本问题》 《数理哲学导论 《耶稣传（第一、二卷）》 《美学史》 《原始思维》 《面向思的事情》 《普通认识论》 《莱布尼茨与克拉克论战 书信集》 《对莱布尼茨哲学的批评 性解释》 《物理学和哲学》 《尼采（上下卷）》 《思想录》 《道德原则研究》 《自我的超越性》 《实验医学研究导论》 《巴曼尼得斯篇》 《人类理解论》 《笛卡尔哲学原理》 《人生的亲证》 《认识与谬误》 《哲学史讲演录》 《圣教论》 《哲学作为严格的科学》 《人类知识起源论》 《回忆苏格拉底》 《心的分析》 《任何一种能够作为科学 出现的未来形而上学导论》 《科学与假设》 《宗教经验之种种》 《声音与现象》 《苏格拉底的申辩》 《论个人在历史上的作用 问题》 《论有学识的无知》 《保卫马克思》 《艺术的起源》
八口语测试 1 口语的特点 ●交互性：口语交际是交际双方或多方的活动，通过交际各方相互交流传递信息。 ●即时性: 口语活动一般要求参与者对谈话对方的言语立即作出反应（包括回答问 题、补充、反对、赞成、延续等）。由于这种反应具有即时性，说话者来不及精心 准备话语，因此话语中多有迟疑、停顿、口误、冗余成分等。 ●副语言因素: 口语中说话者往往借助语调、重音、音量等副语言手段来增加表达效 果。 ●非语言因素: 说话者在说话时常借助手势、目光、表情等体势语来表情达意。 ●与听的不可分割性: 除了自言自语、演讲、口授等，一般场合下的口语活动是在“… 听→说→听→说…”的过程中进行的。 2 口语能力的构成 Weir & Bygate (1992) 将口语能力分为微语言技能（micro-linguistic skills）、常规技能（routine skills）和应变技能（improvisation skills）三个层次。 ●微语言技能（micro-linguistic skills） ◆Accuracy in phonology, grammar, lexis, etc. ●常规技能（routine skills） ?Information routines ◆Expository routines: narration, description, instruction, comparison, etc. （expository essay, expository writing：说明文） ◆Evaluative routines: explanations, predictions, justifications, preferences, decisions, etc. ?Interaction routines ◆Sequences of turns: telephone conversations, interviews, conversations at parties, etc. ●应变技能（improvisation skills） ?Negotiation of meaning ◆Level of explicitness: Speakers need to choose an appropriate level of explicitness, taking into account what the listener knows and can accommodate; ◆Procedures of negotiation: speakers need to be concerned about selecting an appropriate level of specificity in the light of listener response, including use of paraphrase, metaphor, choice of general of specific lexical items, conversational adjustments to contact and ensure understanding, and repetition and clarification procedures. ?Management of interaction ◆Agenda management: referring to co ntrol over the content (participants’ right to choose the topic, or introduce topics they want to talk about) and control over the development or duration of a topic; ◆Turn-taking: knowing how to signal that one wants to speak, recognizing the right moment to get a turn, how not to lose one’s turn, recognizing other people’s signals of desire to speak, knowing how to let other persons have a
关于坚持的英语演讲稿 Results are not important, but they can persist for many years as a commemoration of. Many years ago, as a result of habits and overeating formed one of obesity, as well as indicators of overall physical disorders, so that affects my work and life. In friends to encourage and supervise, the participated in the team Now considered to have been more than three years, neither the fine rain, regardless of winter heat, a day out with 5:00 time. The beginning, have been discouraged, suffering, and disappointment, but in the end of the urging of friends, to re-get up, stand on the playground. 成绩并不重要，但可以作为坚持多年晨跑的一个纪念。多年前，由于庸懒习惯和暴饮暴食，形成了一身的肥胖，以及体检指标的全盘失常，以致于影响到了我的工作和生活。在好友的鼓励和督促下，参加了晨跑队伍。现在算来，已经三年多了，无论天晴下雨，不管寒冬酷暑，每天五点准时起来出门晨跑。开始时，也曾气馁过、痛苦过、失望过，但最后都在好友们的催促下，重新爬起来，站到了操场上。 In fact, I did not build big, nor strong muscles, not a sport-born people. Over the past few years to adhere to it, because I have a team behind, the strength of a strongteam here, very grateful to our team, for a long time, we encourage each other, and with sweat, enjoying common health happy. For example, Friends of the several run in order to maintain order and unable to attend the 10，000 meters race, and they are always concerned about the brothers and promptly inform the place and time, gives us confidence and courage. At the same time, also came on their own inner desire and pursuit for a good health, who wrote many of their own log in order to refuel for their own, and inspiring. 其实我没有高大身材，也没健壮肌肉，天生不属于运动型的人。几年来能够坚持下来，因为我的背后有一个团队，有着强大团队的力量，在这里，非常感谢我们的晨跑队，长期以来，我们相互鼓励着，一起流汗，共同享受着健康带来的快
模拟试题一 个人信息介绍：(机问人答） 1. A: What’s your name, please? B: My name is ______. 2.A: Where do you study? B. I study at NO.1 senior middle school. 3.A: What subjects do you study? B: I study Chinese, Math, English, Physics, Chemistry, Biology, PE and so on. 4. A.:What subject do you like best? B: As far as i am concerned ,i like English best. 场景1：安排旅行计划(机问人答） 旅行行程单 目的地：西藏 交通工具：飞机 出发日期：5月2日 所需费用：2000元左右 所需行李：衣服、药品、照相机等 1.A: Where do you plan to go? B: I pan to go to Tibet. 2.A: How do you go there ? B: I will go there by plane.
3.A: When do you set off? B: I will set off on May 2nd. 4.A: What luggage do you need to take? B: I need to take some clothes,some medicine as well as a camera. 5.A: How much will the trip cost ? B: The trip will cost about 2000 RMB. 6.A: Which places have you been to already and where do you plan to go next? Why? B: I have been to Shanghai, Nanjing,Suzhou and so on. And i plan to go to Hainan next, for i love the sea so much. 7.A: How do you often go travelling by plane or by train? B: I often go travelling by train, as it is a cheap way to travel. 8.A: Do you think it is a good time to travel during the Spring Festival? B: I don’t think so. After all ,there will be too many people during the Spring Festival. I don’t like the crowds and noises. 场景2：去邮局寄包裹（人问机答） 包裹单 目的地： 包裹重量： 邮寄方式： 包裹内容： 付费方式：
1.How to build a business that lasts100years 0:11Imagine that you are a product designer.And you've designed a product,a new type of product,called the human immune system.You're pitching this product to a skeptical,strictly no-nonsense manager.Let's call him Bob.I think we all know at least one Bob,right?How would that go? 0:34Bob,I've got this incredible idea for a completely new type of personal health product.It's called the human immune system.I can see from your face that you're having some problems with this.Don't worry.I know it's very complicated.I don't want to take you through the gory details,I just want to tell you about some of the amazing features of this product.First of all,it cleverly uses redundancy by having millions of copies of each component--leukocytes,white blood cells--before they're actually needed,to create a massive buffer against the unexpected.And it cleverly leverages diversity by having not just leukocytes but B cells,T cells,natural killer cells,antibodies.The components don't really matter.The point is that together,this diversity of different approaches can cope with more or less anything that evolution has been able to throw up.And the design is completely modular.You have the surface barrier of the human skin,you have the very rapidly reacting innate immune system and then you have the highly targeted adaptive immune system.The point is,that if one system fails,another can take over,creating a virtually foolproof system. 1:54I can see I'm losing you,Bob,but stay with me,because here is the really killer feature.The product is completely adaptive.It's able to actually develop targeted antibodies to threats that it's never even met before.It actually also does this with incredible prudence,detecting and reacting to every tiny threat,and furthermore, remembering every previous threat,in case they are ever encountered again.What I'm pitching you today is actually not a stand-alone product.The product is embedded in the larger system of the human body,and it works in complete harmony with that system,to create this unprecedented level of biological protection.So Bob,just tell me honestly,what do you think of my product? 2:47And Bob may say something like,I sincerely appreciate the effort and passion that have gone into your presentation,blah blah blah-- 2:56(Laughter) 2:58But honestly,it's total nonsense.You seem to be saying that the key selling points of your product are that it is inefficient and complex.Didn't they teach you 80-20?And furthermore,you're saying that this product is siloed.It overreacts, makes things up as it goes along and is actually designed for somebody else's benefit. I'm sorry to break it to you,but I don't think this one is a winner.
关于工作的优秀英语演讲稿 Different people have various ambitions. Some want to be engineers or doctors in the future. Some want to be scientists or businessmen. Still some wish to be teachers or lawers when they grow up in the days to come. Unlike other people, I prefer to be a farmer. However, it is not easy to be a farmer for Iwill be looked upon by others. Anyway,what I am trying to do is to make great contributions to agriculture. It is well known that farming is the basic of the country. Above all, farming is not only a challenge but also a good opportunity for the young. We can also make a big profit by growing vegetables and food in a scientific way. Besides we can apply what we have learned in school to farming. Thus our countryside will become more and more properous. I believe that any man with knowledge can do whatever they can so long as this job can meet his or her interest. All the working position can provide him with a good chance to become a talent. 1 ————来源网络整理，仅供供参考
口语考试机考指南 机考当天，每场考试监考老师不得少于两人。一人负责计算机操作，其他监考老师负责监控学生是否有夹带或者使用手机进行作弊。一旦发现作弊，口试成绩记为0分。 1.考前准备：考生清单，格式如下表1。U盘或移动硬盘，用于拷贝学生的考试录音。考 试结束后老师们带回录音，交换听评。同时将音频文件夹以“考试时间+考试班级”命名，存在教研室电脑指定位置，之后将统一刻成光盘，作为教学资料存档。提供给学生抽签用的小纸条。建议多做一些。 2.设备检查：机考前，学生全部进入教室，落座，戴好耳机，打开话筒。教师打开语音 授课系统，依次点击学生，请他们说话确认话筒及耳机正常。如有发现有故障的座位，要求学生将耳机摘下，将所在位置的液晶显示器翻转，以表明此位置不可用于考试。（设备检查每次考试只需在考前做一次即可，不需要每考一个班都检查一次） 3.登记座位：设备检查完毕之后，学生按实际可使用的机器数，进入考场落座。教师依次 点击每个落座学生，询问姓名，座位号等信息，并相应登记入表格中。 4.抽取（随机分发）考题，同时登记每个考生所抽取的题目号。考生有1-2分钟的准备时 间。 5.点击考试-点击口语考试-1人考试-点选存储位置，新建文件夹，命名为考试班级名称， 确定，举手，示意考生考试即将开始。按下开始考试，将手放下，示意考生开始答题。 6.考生答题：考试答题时，需要在录音一开始报自己的学号，姓名，班级和抽取的题目。 而后开始正式考试。考生务必将麦打开。考试结束，摘下耳机，坐在位置上。直到老师示意可以离场。考试过程中，监考老师应及时巡视。发现有考生作弊，立即取消考试资格，口试成绩记为0分。 7.考生离场：在最后一名考生放下耳机后。监考老师按下考试结束。系统将在刚才建立的 文件夹中自动生成以座位号命名的wav格式的音频文件。监考老师可以点击阅卷，随机抽取几个考生，确保录音有效。随后示意考生将耳机挂好，离开。 8.下一场考生进场，重复步骤3-7. 9.考试结束后，将本次考试班级的所有录音资料用移动存储工具带走，交换阅卷。 以下为软件操作步骤：
尊敬的领导，老师，亲爱的同学们， 大家好！我是5班的梁浩东。今天早上我坐车来学校的路上，我仔细观察了路上形形色色的人，有开着小车衣着精致的叔叔阿姨，有市场带着倦容的卖各种早点的阿姨，还有偶尔穿梭于人群中衣衫褴褛的乞丐。于是我问自己，十几年后我会成为怎样的自己，想成为社会成功人士还是碌碌无为的人呢，答案肯定是前者。那么十几年后我怎样才能如愿以偿呢，成为一个受人尊重，有价值的人呢？正如我今天演讲的题目是：自主管理。 大家都知道爱玩是我们孩子的天性，学习也是我们的责任和义务。要怎样处理好这些矛盾，提高自主管理呢？ 首先，我们要有小主人翁思想，自己做自己的主人，要认识到我们学习，生活这一切都是我们自己走自己的人生路，并不是为了报答父母，更不是为了敷衍老师。 我认为自主管理又可以理解为自我管理，在学习和生活中无处不在，比如通过老师，小组长来管理约束行为和同学们对自身行为的管理都属于自我管理。比如我们到一个旅游景点，看到一块大石头，有的同学特别兴奋，会想在上面刻上：某某某到此一游话。这时你就需要自我管理，你需要提醒自己，这样做会破坏景点，而且是一种素质低下的表现。你设想一下，如果别人家小孩去你家墙上乱涂乱画，你是何种感受。同样我们把自主管理放到学习上，在我们想偷懒，想逃避，想放弃的时候，我们可以通过自主管理来避免这些，通过他人或者自己的力量来完成。例如我会制定作息时间计划表，里面包括学习，运动，玩耍等内容的完成时间。那些学校学习尖子，他们学习好是智商高于我们吗，其实不然，在我所了解的哪些优秀的学霸传授经验里，就提到要能够自我管理，规范好学习时间的分分秒秒，只有辛勤的付出，才能取得优异成绩。 在现实生活中，无数成功人士告诉我们自主管理的重要性。十几年后我想成为一位优秀的，为国家多做贡献的人。亲爱的同学们，你们们？让我们从现在开始重视和执行自主管理，十几年后成为那个你想成为的人。 谢谢大家！
关于工作的英语演讲稿 【篇一：关于工作的英语演讲稿】 关于工作的英语演讲稿 different people have various ambitions. some want to be engineers or doctors in the future. some want to be scientists or businessmen. still some wish to be teachers or lawers when they grow up in the days to come. unlike other people, i prefer to be a farmer. however, it is not easy to be a farmer for iwill be looked upon by others. anyway,what i am trying to do is to make great contributions to agriculture. it is well known that farming is the basic of the country. above all, farming is not only a challenge but also a good opportunity for the young. we can also make a big profit by growing vegetables and food in a scientific way. besides we can apply what we have learned in school to farming. thus our countryside will become more and more properous. i believe that any man with knowledge can do whatever they can so long as this job can meet his or her interest. all the working position can provide him with a good chance to become a talent. 【篇二：关于责任感的英语演讲稿】 im grateful that ive been given this opportunity to stand here as a spokesman. facing all of you on the stage, i have the exciting feeling of participating in this speech competition. the topic today is what we cannot afford to lose. if you ask me this question, i must tell you that i think the answer is a word---- responsibility. in my elementary years, there was a little girl in the class who worked very hard, however she could never do satisfactorily in her lessons. the teacher asked me to help her, and it was obvious that she expected a lot from me. but as a young boy, i was so restless and thoughtless, i always tried to get more time to play and enjoy myself. so she was always slighted over by me. one day before the final exam, she came up to me and said, could you please explain this to me? i can not understand it. i
第五章老年社会工作 第一节老年社会工作概述 第二节老年社会工作的主要内容 第三节老年社会工作的主要方法 第一节老年社会工作概述 一、老年人与老年期 （一）年龄界定 生理年龄：生理指标与功能确定 心理年龄：心理活动程度确定 社会年龄：与他人交往的角色确定 （二）老年期的划分 低龄老年人：60-69岁 中龄老年人：70-79 高龄老年人：80岁以上 （三）划分的意义 1.三种年龄：不能仅凭日历年龄判断服务需求，而要关注不同个体在生理、心理与社会方面的差异。 2.三个时期：关注老年同期群的共性需要。 二、老年期的特点 （一）生理变化 1.生理变化的特点：九大生理系统老化 2.对开展老年社会工作的影响 （1）要特别关注老年人的身体健康状况； （2）处理好隐私的健康问题，如大小便； （3）帮助机构和家庭策划环境的调整。 （二）心理变化 1.智力、人格、记忆力的变化 智力：结晶智力强，但处理问题速度下降 人格：总结自己生命的意义 记忆力：记忆速度下降，动机决定是否学习 2.对开展老年社工的影响 （1）提供机会但尊重选择 （2）所有事放慢节奏 （3）关注身体健康对心理功能的重要性 （三）社会生活方面的变化 1.对老年社会生活变化的理论解释 （1）角色理论：丧失象征中年的社会角色 （2）活动理论：生活满足感与活动有积极联系 （3）撤离理论：接受减少与社会的交往 （4）延续理论：不能割裂看待老年阶段 （5）社会建构理论：老年是一个独特的个人过程 （6）现代化理论：现代化使老年人地位下降
2.理论在社会工作中的应用 （1）注意角色转变的重大生活事件 （2）注意老年个体的差异性，尊重其对生活意义的不同理解 （3）注意社会隔离可能对老年人造成的伤害 （4）改变总有可能 （5）关注社会变迁对老年人的影响，推动社会政策的调整 三、老年人的需要及问题 （一）老年人的需要 1.健康维护 2.经济保障 3.就业休闲 4.社会参与 5.婚姻家庭 6.居家安全 7.后事安排 8.一条龙照顾 （二）老年人的问题 1.慢性病问题与医疗问题 2.家庭照顾问题 3.宜居环境问题 4.代际隔阂问题 5.社会隔离问题 四、老年社会工作 （一）老年社会工作的对象 1.老年人自身：空巢、残疾、高龄老人，也包括健康老人 2.老年人周围的人：家庭成员、亲属、朋友、邻居等 3.宏观系统：单位与服务组织 （二）老年社会工作的目的 根本目标：老有所养、老有所医、老有所教、老有所学、老有所为、老有所乐 （三）老年社会工作的作用 1.个体层面：维持日常生活、获得社会支持 2.宏观层面：参与制定有关老年人的服务方案与政策 五、老年社会工作的特点 （一）老年歧视等社会价值观会影响社会工作者的态度与行为 （二）反移情是社会工作者的重要课题 （三）社会工作者要善于运用督导机制 （四）需要多学科合作 第二节老年社会工作的主要内容 一、身体健康方面的服务 二、认知与情绪问题的处理 三、精神问题的解决 四、社会支持网络的建立 五、老年人特殊问题的处理 一、身体健康方面的服务
中考英语听力口语自动化考试问答 一、听力口语自动化考试与以往考试相比有哪些主要变化 1.考试内容实行两考合一。将以往的英语口语等级测试和中考听力测试合并进行，通过计算机一次性完成考试。 2.考试方式实行人机对话。以往的英语口语等级测试方式为“师生对话”，由测试员现场提问，现场测试打分，以往的中考听力考试则在中考笔试时进行，依靠考场内广播或录音机播放听力磁带。实行人机对话后，考生坐在计算机前，戴上考试专用耳麦，由计算机播放听力录音和试题，考生用计算机作答并对着麦克风回答口语题。出题、考试、判卷、结果反馈全部由计算机完成。 3.成绩评定实行电脑评分。考试结束后，由计算机记录下考生的答案，由自动阅卷专用服务器综合各种特征给出评分，经考试组织部门确认后发布。 综上三点，听力口语自动化考试，简化了考试程序，减轻了考生负担，规范了考试要求，避免了人为因素可能造成的不利影响。 二、听力口语自动化考试如何组织 根据省教育厅统一部署，2009年起，全省中考英语听
力口语自动化考试由省教育厅统一组织，统一命制试题、统一考点设置、统一考试时间、统一考试流程、统一评分标准、统一发布成绩。 三、听力口语自动化考试考点和考场如何设置 人机对话考试对考点的要求比较高。省教育厅要求原则上以各初中学校为考点，以各学校的计算机网络机房为考场，考场计算机及相关软硬件配置均须符合考试所要求的基本条件，不符合要求的必须在升级、补充到位的基础上才能申报考点。从目前申报情况看，我市大多数初中学校已符合考场设置条件，全市大多数初中毕业生都可在本校参加听力口语自动化考试。少数不符合考场设置条件学校的学生由各地教育行政部门统一安排到就近的考点参加考试。 四、一个考场内同时有30人进行听力口语考试，会不会互相干扰 按照考场设置要求，一个考场内设置不少于33台考试机和1台监考机，每个考场同时安排30人进行考试。考试所用耳麦和话筒都是特制的，考生只能听到考试机播放的声音，话筒也只对定向的声音录音，完全不影响考试效果。2007年5月开始，省教育厅在苏州、南通、连云港部分学校进行过试点，实践证明效果良好，不会出现考生互相干