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ISEB-PM1 - Foundation Certificate in Project(R) Management - Dump Information

Vendor : ISEB
Exam Code : ISEB-PM1
Exam Name : Foundation Certificate in Project(R) Management
Questions and Answers : 625 Q & A
Updated On : April 24, 2019
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ISEB-PM1 Questions and Answers

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ISEB-PM1 Foundation Certificate in Project(R) Management

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ISEB-PM1 exam Dumps Source : Foundation Certificate in Project(R) Management

Test Code : ISEB-PM1
Test Name : Foundation Certificate in Project(R) Management
Vendor Name : ISEB
Q&A : 625 Real Questions

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ISEB Foundation Certificate in Project(R)

tuition of Rochester analyzing program showing promise in RCSD | killexams.com Real Questions and Pass4sure dumps

Carol St. George  |  guest Essayist

Nora Ephron mentioned, “studying is bliss” and Frederick Douglass instructed us, “when you learn to read, you might be continuously free.” however for the about 32 million illiterate adults in the united states, simple initiatives like grocery looking, reading bus schedules, menus, road signs and prescriptions, filling out forms, and discovering employment are a continuing problem.

in the neighborhood, many RCSD college students have struggled with literacy discovering. contemporary state reading assessments reveal growth; despite the fact, simplest eleven.4 percent of scholars scored informed. analysis means that students who aren't analyzing at grade degree through third grade, are much less more likely to graduate and meet future educational success. as much as 3rd grade you're getting to know to read, after 3rd grade you are studying to be trained because studying comprehension is critical for all of the content areas.

With feelings of urgency to increase literacy studying, mission read, an intervention application partnering the U of R’s Warner college of schooling and RCSD became began in school #36. When college #36 closed, the program moved to college #33 and lately increased to East excessive’s lessen college.

Generously supported by means of the William and Sheila Konar groundwork, Warner graduate college students working toward certification in literacy and supervised with the aid of a literacy expert, work without delay with at-chance 1st and sixth graders in the colleges. The mission’s goal is to assist infants strategy any literacy task with self belief and ability so that they are in a position to study and write superior and in the end improve their school success. getting ready brilliant future literacy specialists is an additional intention of venture read.

consequences were encouraging. facts suggests tremendously more desirable reading levels of collaborating first grade students enabling them to catch as much as their peers and correctly complete first grade on par and sometimes exceeding their classmates. additionally observed is elevated engagement in college, greater enthusiasm towards analyzing, better attendance and greater self assurance in themselves as newbies. Many participating Warner literacy graduates are now employed as studying consultants, most within the RCSD. We plan to continue the program next year.

The little ones exhibit brilliant promise and are desperate to be taught to read. via our work, we’ve realized that for success, it’s basic to advance close trusting relationships as a way to build their self belief and conceit, thereby aiding their attempts to take researching dangers leading to their literacy construction. college students’ actual and emotional needs need to be met first and greatest. consequences of poverty—hunger, trauma, worry, concern and anxiety—bog down researching. Literacy is lifestyles changing and may function an antidote to poverty. decent literacy instruction is a social justice subject and rely of equity.

Carol St. George, Ed.D. is an associate professor and director of the analyzing and Literacies application at the school of Rochester's Warner school of education.


VERBATIM: outcomes of the 64th Annual Northeast Indiana Regional Science and Engineering fair | killexams.com Real Questions and Pass4sure dumps

These effects have been offered in a statement for the 64th Annual Northeast Indiana Regional Science and Engineering fair, March 16, at Purdue fortress Wayne. college students advancing to the statewide competitors are on the end.

native Awards

* American Chemical Society; $150, certificate and Invitation to Annual Dinner assembly - Devesh Vamadevan, Woodside MS

* Environmental Stewardship Award, sponsored with the aid of Aqua Indiana; $a hundred reward card - Grace Geradot, toes. Wayne area Homeschools; Evan McMahon, Woodside MS; Mia Sartain, New Tech Academy

* castle Wayne babies’s Zoo fit Planet Award; certificate, bag, sweatshirt, and invitation to be part of young adults for Nature management application - Elijah Bass, Leo Jr/Sr HS; Evan McMahon, Woodside MS; Isaac Maurer and Naomi Maurer, feet. Wayne enviornment Homeschools

* fort Wayne city Utilities Water useful resource Award; engraved plaque - Brie Montel, Coesse elementary; Annika Valluru, Aishani Valluru and Emma Murphy, Canterbury school

* Fox Island Alliance; Membership, certificates and $25 - Annika Valluru, Aishani Valluru and Emma Murphy, Canterbury faculty; Tessa Chesney-Jordan, Towles New Tech; Grace Geradot, ft. Wayne area Homeschools; Khyree Bowe, Canterbury college

* Huntington school; certificates and $50 - Biology: Tate Bonin, Leo Jr/Sr HS; actual Sciences: Kevin Wang, Carroll HS; fitness Sciences: Bethany Petry, ft. Wayne area Homeschools; Mathematical Sciences: Demetrious Allen, Luke LaGranger and Landen Livingston, Leo Jr/Sr HS

* Institute of Electrical and electronic Engineers; $50 - Julie Wojtanik, Covington basic; Lydia Moran, toes. Wayne enviornment Homeschools

* Institute of Electrical and electronic Engineers; $75 - Kevin Wang, Carroll HS; Korben Hatfield, Irwin elementary

* Isaac Knapp District Dental Society Award; $50 and certificates - Katie Keefer, Saint Charles Borromeo; Abigail Valdez, Robert C. Harris elementary

*Little River Wetlands venture; $25 present Card, Membership - Grace Geradot, ft. Wayne area Homeschools; Annika Valluru, Aishani Valluru and Emma Murphy, Canterbury college; Khyree Bowe, Canterbury faculty

* N Maxine and David W. Ford STEM Award; certificates, $one hundred and periodic desk poster - Clara Moran, toes. Wayne area Homeschools

* N Maxine and David W. Ford STEM Award; certificates, $one hundred fifty and periodic table poster - Sarah Rodenbeck, R. Nelson Snider HS

* Northeast Indiana Veterinary medical affiliation; money award - Chloe Park, Canterbury school; Bryce McNear, ft. Wayne enviornment Homeschools; Jada Coverstone, o.k.View; Lyla Ward, Huntertown; Grace Geradot, toes. Wayne enviornment Homeschools

* Purdue institution faculty of Agriculture; certificates - Evan Brubaker, Huntertown; Evan McMahon, Woodside MS

* Purdue university school of Agriculture; $50 & certificates - Tate Bonin, Leo Jr/Sr HS

* Purdue fortress Wayne college Tribute Award for Creativity; $50 - Adalyn Moran, toes. Wayne enviornment Homeschools

* Purdue institution castle Wayne branch of Psychology Award; $25 Amazon present card - Bethany Petry, feet. Wayne enviornment Homeschools

* Society of manufacturing Engineers, fortress Wayne Chapter fifty six; $50 - Lydia Moran toes. Wayne enviornment Homeschools; Kevin Wang, Carroll HS

* Science applications overseas enterprise - Kevin Wang, Carroll HS; Lydia Moran, toes. Wayne enviornment Homeschools

* Science and Regulatory Consultants, finest analyze Design, fundamental, $25; Junior $50; Senior, $75 - Austin Meyer, Saint Charles Borromeo; Lydia Moran, toes. Wayne area Homeschools; Bethany Petry, ft. Wayne enviornment Homeschools

ISEF Awards

* U.S. Air force; Sling pack, folder, energy financial institution charger, and USB power and charger - Chloe Park, Canterbury school; Noquisi guest, Towles; Gracie Clark, Sydney Holub and Isabela Ogg, Leo Jr/Sr HS; Bethany Petry, ft. Wayne enviornment Homeschools

* American Meteorological Society; certificates - Elijah Ray Bass, Leo Jr/Sr HS; Annika Valluru, Aishani Valluru and Emma Murphy, Canterbury college

* ASM materials schooling groundwork; certificates - Michael Meza, Summit MS

* American Psychological affiliation; certificate - Sarah Rodenbeck, R. Nelson Snider HS

* Mu Alpha Theta country wide mathematics Honor Society, certificate - Demetrious Allen, Luke LaGranger and Landen Livingston, Leo Jr/Sr HS

* NASA Earth system Science Award - Lydia Moran, ft. Wayne area Homeschools

* country wide Oceanic & Atmospheric Administration, Taking the pulse of the Planet Award; certificates - Khyree Bowe, Canterbury college

* Ricoh business enterprise; certificate - Khyree Bowe, Canterbury faculty

* U.S. Metric affiliation; certificates - Katie Schubert, Saint Charles Borromeo

U.S. Navy and Marine Corps Awards; Senior, $50 certificates and medallion; Junior, medallion - Joshua Harroff, Towles Intermediate; Katie Schubert, Saint Charles Borromeo; Mia Sartain, New Tech Academy; Bethany Petry, toes. Wayne enviornment Homeschools

* Yale Science and Engineering association; certificate and medallion - Kevin Wang, Carroll HS

* Broadcom MASTERS; certificate and chance to apply to country wide competitors - Lydia Moran, ft. Wayne area Homeschools; Clara Moran, ft. Wayne enviornment Homeschools; Chloe Park, Canterbury school

elementary Placement Awards

Grade 4

* Third area - Korben Hatfield, Irwin basic; Brandtly Hike, Saint John the Baptist; Dalen Martin, Irwin elementary; Krishna Patel, Perry Hill fundamental

* 2nd vicinity - Elliot Goss, Canterbury school; Adalyn Moran, feet. Wayne enviornment Homeschools; Julie Wojtanik, Covington fundamental

* First area and administrators Award Winner $a hundred - Branson Birkey, Deer Ridge elementary

Grade 5

* Third region - Zaraab Habib and Parker Jaeger, o.k.View fundamental; Noah Weimer, Saint Jude Catholic college; Lyla Ward, Huntertown fundamental

* second region - Tessa Chesney-Jordan, Towles Intermediate; Lydia Knuth, Deer Ridge fundamental; Evan Brubaker, Huntertown basic; Andrew Thum, Haverhill elementary

* First region and directors Award Winner $one hundred - Grace Geradot, ft. Wayne area Homeschools

* Arthur Friedel Most Promising young Scientist Award, elementary; $one hundred - Tessa Chesney-Jordan, Towles Intermediate

Certificates of Excellence

* Animal Science - Chloe Park, Canterbury college; Isaac Maurer and Naomi Maurer, feet. Wayne area Homeschools; Bryce McNear, feet. Wayne area Homeschools; Tate Bonin, Leo Jr/Sr HS

* Biomedical & health Science - Brayden Kaiser and Saif Ahmad, Woodside MS; Reid Smith, Saint Charles Borromeo Catholic college

* Behavioral Science - Brigit Delaney, Saint Jude Catholic faculty; Sophie Sordelet, Saint Charles Borromeo Catholic faculty; Gracie Clark, Sydney Holub and Isabela Ogg, Leo Jr/Sr HS; Sarah Rodenbeck, R. Nelson Snider HS; Bethany Petry, feet. Wayne enviornment Homeschools

* Chemistry - Devesh Vamadevan, Woodside core; Lillian Brumbaugh, Huntington Catholic

* Earth and Environmental Science - Annika Valluru, Aishani Valluru and Emma Murphy,  Canterbury college; Joshua Harroff, Towles Intermediate; Evan McMahon, Woodside MS; Khyree Bowe, Canterbury faculty

* Engineering - Michael Meza, Summit MS; Lydia Moran, ft. Wayne area Homeschools

* arithmetic - Demetrious Allen, Luke LaGranger and Landen Livingston, Leo Jr/Sr HS

* Physics - Clara Moran, toes. Wayne enviornment Homeschools; Katie Schubert, Saint Charles Borromeo Catholic faculty; Kevin Wang, Carroll HS

Placement Awards

JUNIOR DIVISION – middle college

* Third place - Chloe Park,  Canterbury faculty

* 2nd vicinity - Clara Moran, feet. Wayne enviornment Homeschools

* First area and Junior fabulous task, $100 - Lydia Moran, feet. Wayne area Homeschools

SENIOR DIVISION

* Third region - Gracie Clark, Sydney Holub and Isabela Ogg, Leo Jr/Sr HS

* second vicinity - Sarah Rodenbeck, R. Nelson Snider HS

* First region and Senior awesome assignment Award, $100 - Bethany Petry, feet. Wayne enviornment Homeschools

Representatives to the Hoosier Science and Engineering fair on Saturday, March 30, at the middle in Indianapolis

* fundamental - Branson Birkey, Deer Ridge elementary; Grace Geradot, feet. Wayne area Homeschools

* center faculty - Lydia Moran, feet. Wayne area Homeschools; Clara Moran, feet. Wayne enviornment Homeschools; Chloe Park, Canterbury school; Sophie Sordelet, St. Charles Borromeo; Katie Schubert, St. Charles Borromeo; Emma Murphy, Canterbury school; Aishani Valluru, Canterbury school; Annika Valluru, Canterbury college; Devesh Vamadevan, Woodside center

excessive faculty - Bethany Petry, ft. Wayne enviornment Homeschools; Sarah Rodenbeck, R. Nelson Snider HS; Gracie Clark, Leo Jr/Sr HS; Sydney Holub, Leo Jr/Sr HS; Isabela Ogg, Leo Jr/Sr HS; Kevin Wang, Carroll HS; Miranda Freeman, Leo Jr/Sr HS; Aubrey Parmalee, Leo Jr/Sr HS; Olivia Prahl, Leo Jr/Sr HS; Elijah Bass, Leo Jr/Sr HS; Mia Sartain, Wayne New Tech; Maria Solis Valtierra, Bishop Luers high faculty


TravelSky announces 2018 Annual effects; total profits up 11.0 % to RMB7,472.1 Million | killexams.com Real Questions and Pass4sure dumps

HONG KONG, Mar 29, 2019 - (ACN Newswire) - TravelSky know-how restricted ("TravelSky" or the "neighborhood"; HKEX stock code: 00696), a leading company of information technology solutions for China's aviation and go back and forth industries, introduced its audited annual outcomes for the 12 months ended 31 December 2018.

In 2018, the whole revenue of TravelSky amounted to RMB7,472.1 million, representing a rise of 11.0% yr-on-12 months. income before taxation increase 0.7% to RMB2,650.four million. income because of the house owners of the enterprise increase three.4% to RMB2,325.1 million. fundamental and diluted revenue per share were RMB0.79. The Board of administrators counseled a closing cash dividend of RMB0.269 per share.

throughout the 12 months beneath review, revenue of aviation counsel know-how features expanded via 7.three% to RMB4,a hundred and sixty.1 million, accounting for 55.7% of the whole profits. revenue of accounting, contract and clearing functions expanded with the aid of 4.4% to RMB579.four million, accounting for 7.eight% of the overall income. earnings of gadget integration capabilities increase by means of 27.2% to RMB946.9 million, accounting for 12.7% of the full profits. earnings of facts network and others extended through 14.7% to RMB1,785.7 million, accounting for 23.eight% of the full profits.

For aviation counsel expertise features, the neighborhood's digital commute Distribution ("ETD") gadget processed about 643.9 million flight bookings on home and overseas commercial airlines, representing a rise of about 9.eight% over the same duration in 2017. among which, the processed flight bookings on industrial airlines in China improved with the aid of approximately 10.2%, whereas those on overseas and regional commercial airways accelerated by means of about 1.7%. The variety of overseas and regional commercial airlines with direct links to the laptop reservation gadget ("CRS") of the business reached 149, with income percentage via direct hyperlinks exceeding 99.eight%.

In 2018, the enterprise additional carefully aligned the research and construction focus with the industrial trend and consumers' demand and persisted to enhance its aviation-connected guidance know-how functions and its extended features, with an goal to satisfy the demand of industrial airways for the assistance expertise options on shuttle convenience, e-commerce, auxiliary features and international features. As a strategic accomplice of the speedy go back and forth task of IATA, the time-honored self-service examine-in system (CUSS) has been launched in 183 major home and overseas airports, and the online examine-in service has been applied in 316 airports at home and overseas. Such items and functions, in conjunction with the cell verify-in provider and SMS check-in service, processed a complete of approximately 296 million departing passengers. The variety of clients of our self-developed mobile software, "Umetrip", has witnessed reliable growth, with Shanghai Pudong, Changsha and different airports conducting "airport zone" cooperation, growing a couple of airport application innovative products, and improving the exceptional of provider for passengers, airlines and airports. right through the yr, apart from the adoption of our APP capabilities by using all predominant industrial airways within the PRC, more international and regional industrial airways have been using the business's APP equipment capabilities, multi-host connecting program features and the Angel Cue platform connecting functions, ensuing in the increase of the number of such clients to 154, with approximately 18.8 million of passenger departures processed in a hundred and five airports.

For accounting, settlement and clearing functions, the group has endured to consolidate and expand its accounting, settlement and clearing market, wholly promoted value-brought products of passenger transport agreement system, and gained new consumers in cargo transport and airport company areas. in the meantime, the device analysis and construction and production have been conducted as scheduled. The third technology of contract gadget started research and construction work of an order-primarily based salary contract system that meets NDC/ONE ORDER industry requisites and meets e-commerce retail demand of industrial airlines. Such system has been put into creation in Sichuan airlines Co., Ltd. With building led by way of scientific and technological innovation, the agreement business has acquired the skills of hello-tech companies, bought the assessment certificates of application corporations, and changed into appraised as "2018 precise 100 firms in complete power classification in application and guidance service industry of Beijing". In 2018, there were about 957.6 million transactions processed with the accounting, agreement and clearing device of the community and approximately 395.7 million BSP tickets processed with our BSP records processing services. in the equal length, passenger, cargo and mail profits, miscellaneous fees in addition to foreign and home clearing quantity settled by way of brokers amounted to approximately USD10.67 billion, and the transaction volume of the electronic charge equipment became approximately RMB99.75 billion.

For distribution assistance know-how capabilities, the community's commute carrier distribution network contains over 70,000 income terminals owned by using greater than 8,000 travel agencies and commute carrier distributors. The community processed over 542.three million transactions all the way through the 12 months with transaction amount up to RMB513 billion. moreover, the group persevered to advance overseas distribution pipelines while increasing R&D and construction of, and expanding the market of, the key items of distribution of suggestions know-how features. also, in Australia and New Zealand, the group joined BSP and signed foreign places revenue agreements with 12 chinese language business airlines to be organized for increasing income pipelines for overseas markets.

For airport assistance know-how capabilities, the neighborhood continued to boost analysis and building and promoting of airport assistance technology provider and product, secured the market share of the traditional departure front end provider and product, actively participated in construction tasks of domestic airport assistance system. The departure entrance end gadget of the new-generation APP dominated China's massive and medium-sized airports. moreover, the gadget assisted commercial airline businesses in offering quite a lot of functions for passengers, reminiscent of, boarding, transit and connection, in 164 overseas or regional airports. The person times of departure passengers receiving such features reached about 43.9 million, accounting for 91.6% of the variety of passengers getting back from distant places of such business airline agencies. The Airport Shared Connectivity and Infrastructure Integration (ASCII) has been extended to 22 new, rebuilt and improved airports in Urumqi, Shanghai Hongqiao, Ningbo, Qingdao and etc. The enterprise has promoted the construction of "Facial recognition & id Authentication" product for protection inspection. With a mix of biometric technology and protection inspection suggestions system, such product has helped know the assessment of passenger's insensitive facial recognition to their identity within the security inspection hall, now not most effective greatly improving the accuracy and professionalism of airport protection inspection certification, but also improving the effectivity of airport protection inspection operation. Airport operation command platform has been conventional in Shenzhen, Changsha, Qingdao, Urumqi, Dalian, Mianyang and different airports. this can support promote the clever construction of airport operation.

For air freight logistics suggestions know-how services and public suggestions know-how services, the group, as per the country wide "The Belt and highway Initiative" strategy and air transport safety policy, continued to enhance and promote air cargo transport logistics counsel technology carrier and product. The neighborhood has effectively bid a few freight system projects, including Qingdao Airport, Guangzhou Baiyun Airport and Beijing Daxing foreign Airport. The group also endured to expand customer base and quicken steps to place key initiatives into operation.

Mr. Cui Zhixiong, the Chairman of TravelSky mentioned, "The year 2019 marks the Seventieth Anniversary of the founding of the individuals's Republic of China. it is the key 12 months to build a neatly-off society in an all-circular manner and achieve the dreams of the first century. It gives effective ancient construction opportunities for the community to additional consolidate its market place, expand its company, and provides full play to its industry event and technological benefits. The community will continue to firmly focus on its construction strategy to work hard in key areas and hyperlinks of reform, promote the optimization of its operation and management gadget as a whole, and scientifically plan its key reform tasks. on the same time, it's going to additionally continue to stick to creating development whereas preserving steadiness, make clear the development pattern, focal point on strategic priorities, speed up the growth of core capacity and perpetually beef up followings: in the beginning, the foundation of operation and maintenance. build a brand new operation and protection equipment tailored to the current open ambiance and the development of new technologies sooner or later by improving the means of operation and upkeep support. Secondly, the supply of scientific research and entrepreneurship. increase the sustainable aggressive potential via bettering the ability of scientific research and development. Thirdly, the important thing market areas for prosperity. increase its market competitiveness with a purpose to play a extra crucial function in industry fashion analysis and judgment, business general construction, typical product planning and so forth. Fourthly, its carrier. by enhancing consumer carrier capabilities, construct a provider device for meeting market needs and consumer wants."

TravelSky technology restrained (HKEX inventory Code: 00696)TravelSky expertise confined is a leading provider of counsel technology options for China's aviation and shuttle industry, standing at a core tache alongside the value chain of China's aviation and travel carrier distribution. The group has been dedicated to serving the needs of all business members starting from business airlines, airports, travel products and capabilities providers, shuttle businesses, commute carrier distributors, company valued clientele, tourists and cargo shippers, in addition to principal international organisations reminiscent of international Air Transport association (IATA) and govt our bodies, with the scope of capabilities covering the availability of critical assistance methods on flight manage, air ticket distribution, check-in, boarding and load planning, accounting, contract and clearing, and so forth.. With more than three a long time of tenacious development, the community has built up a complete industry chain for aviation and trip tips expertise capabilities, centered a comparatively finished, affordable product line of aviation and travel suggestions technology functions with potent performance. For extra particulars related to to TravelSky, please visit its web site at http://www.travelskyir.com/.

theme: Press release summarySectors: daily Finance, every day Newshttp://www.acnnewswire.comFrom the Asia company news community

Copyright © 2019 ACN Newswire. All rights reserved. A division of Asia corporate information community.


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MacRae and Williams join Macro Consultants as directors, project management | killexams.com real questions and Pass4sure dumps

Manhattan, NY According to Macro Consultants, Rory MacRae and Dodie Williams have joined the firm as directors, project management. MacRae joins Macro following his tenure at NYU Langone Health as the assistant director of construction, Kimmel Program. 

Williams will be based in Philadelphia.

Macro’s managing principal, Michael Glatt, spoke on behalf of the organization on the importance of Rory’s new role. “Having known Rory for several years in the industry, we have long been impressed with Rory’s subject matter expertise in areas of design and construction. That foundation, combined with Rory’s commitment to organization development and operational excellence, allows Rory to be well positioned within Macro’s fast growing healthcare practice. With that as a backdrop, we are confident in the value Rory will bring to all aspects of Macro’s work.”

MacRae has made a name for himself in the construction industry as a motivated and energetic leader and team player. He worked closely with Macro as he guided numerous project teams through industry-leading best practices on NYU Langone Health’s Kimmel Pavilion construction project, deemed “one of the most digitally integrated and sophisticated inpatient facilities in the country” by U.S. News & World Report. MacRae’s experience managing several capital projects simultaneously, along with his astute oversight coordinating various large-scale teams, makes him an ideal fit within Macro.

MacRae is equally enthusiastic about joining Macro Consultants. “I have firsthand experience working with Macro, and I have consistently admired the quality they bring to the project management space. Indeed, I regard them as the best in the business,” he said. “They deliver a superior level of customer service to their clients. I am excited to join the Macro family and play a part as the company continues to grow its footprint.”

Prior to working at NYU, MacRae held various roles in construction management, including as the owner’s representative, builder, and project manager, at premier companies such as LPE Management Services, Healthcare Builders, and Lendlease. MacRae holds a Graduate Certificate in Construction Project Management from New York University and a Bachelor’s degree in Behavioral Science from Mercy College.


Foundation Wants Revamp in Calif.'s Death Certificate Project | killexams.com real questions and Pass4sure dumps

Some 800,000 Californians now on high-dose opioids are at risk of harm if their physicians taper them off their pain medications too quickly, as some may be doing in fear of disciplinary action. The number of patients who use illicit drugs could double, and rates of suicidal ideation or self-harm may quadruple.

Those are some of the potential "unintended consequences" stemming from the Medical Board of California's highly controversial Death Certificate Project, according to Kelly Pfeifer, MD, director of high-value care for the influential California Health Care Foundation. She detailed numerous concerns and recommendations for change in a letter to the medical board earlier this month. The board released the letter on Thursday in response to a request. (Pfeifer and the medical board both declined to comment further.)

The project, intended to curtail opioid-related deaths, began years ago as the board obtained death certificates for patients who fatally overdosed in 2012 and 2013. The effort has enabled board staff to link the names of those deceased patients with the names of the physicians who wrote prescriptions for them for controlled substances up to three years earlier.

After reviewing the physician's prescribing history, the board sent some 450 letters of investigation pegged to a complaint to hundreds of physicians suspected of overprescribing. The letters seek the deceased patient's medical records and physician's explanation, and threaten a subpoena and heavy fines if the physician fails.

Thus far the board has filed formal accusations against 23 physicians alleging a pattern of negligent overprescribing, among other things. They face being publicly reprimanded, or could lose some or all of their license to practice, depending on decisions from an administrative law judge.

But rather than curtailing opioid overprescribing, Pfeifer's letter said the project may be hurting patients. "On the surface, it may seem harmless to send out 500 letters to identify 23 physicians with violations," wrote Pfeifer, who also directs the foundation's $5-million opioid safety initiative. "However, there is a growing concern that the letters are causing harm," because after they receive such a letter or know someone who has, physicians are "changing their prescribing practice to the detriment of patient care."

Pfeifer's letter, on CHCF letterhead, is noteworthy because the foundation plays an important role in California healthcare and is not a physician advocacy group. It has about $800 million in assets and funds programs on improving access and value of healthcare for underserved groups -- with a specific focus on reducing harm from opioid prescription drugs. Last year it spent about $40 million on grants, direct charitable activities, and program support. CHCF was founded 21 years ago with community benefit funds stemming from Blue Cross of California's conversion from non-profit to for profit.

Pfeifer said she has concerns the project "could exacerbate the shortage of providers" willing to treat patients with pain. "Many clinicians have mentioned to me their growing fear that their license could be at risk by continuing to care for complex patients on high opioid doses."

She gave examples of how physicians' practices have already been affected after receiving letters from the medical board. One has stopped prescribing; another lost patients after becoming fearful and abruptly tapering doses for several of them; and two addiction specialists said they had patients who switched to heroin after being "kicked off" high-dose prescription opioids without being offered alternatives.

Numerous physicians, including pain management specialists, organized medicine groups including the American Medical Association have expressed horror at the project, saying the letters and investigatory process they bring has "terrorized" physicians and is essentially a "witch hunt" against physicians who are just trying to alleviate patients' pain, as they were taught.

Changes needed, foundation says

Pfeifer recommended the following approach in identifying physicians whose prescribing may be endangering patients:

  • Instead of looking at death certificates first, the board should start by sampling clinicians in the top one percentile of opioid and benzodiazepine prescriptions, obtained through the state's CURES (Controlled Substance Utilization Review and Evaluation System) database. Those are the "physicians at the most risk of doing harm," Pfeifer said, citing a study published in the Journal of Primary Prevention. That study concluded that within this one percentile, 32% to 77% had written a prescription within 30 days of a patient's overdose death.
  • Rather than focusing on opioid-repeated deaths that occurred six years ago or more, limit investigations to deaths after 2017, because most physicians have now changed their prescribing practices to align with safer guidelines.
  • Decrease turnaround time between notification and resolution of each case. Pfeifer noted that the current lag is more than 500 days or more, and some clinicians have waited for a resolution on their letters for more than 16 months. "Long investigation times could harm patients," she wrote.
  • Pfeifer also pointed to the lack of clarity in state or federal guidelines on how physicians should manage patients who are already on high-dose opioids. Her letter recommended against involuntary opioid tapering, and all tapering "should be halted if the patient shows signs of medical or psychiatric instability."

    "While the 800,000 Californians on high-dose opioids and the almost 700,000 Californians on opioids and benzodiazepines are clearly at risk of harm if they stay on these regimens, they are also at risk if tapered off altogether," she wrote.

    "A physician could be practicing safe medicine by simultaneously prescribing high-dose opioids and benzodiazepines if the patient has been taking these medications for years." But if the patient fatally overdoses and comes under review of the Death Certificate project, "the regimen is very likely to be judged by an expert as unsafe. This, despite that fact that the prescriber would have been following CDC guidance to avoid involuntary tapers," Pfeifer wrote.

    Pfeifer has asked state health officials to analyze data to see if involuntary tapering is leading to hospitalizations and deaths, but such a review will take up to a year.

    Cheryl Clark has been awarded stipends funded by the California Health Care Foundation to attend journalists' meetings.

    1969-12-31T19:00:00-0500

    last updated 12.21.2018


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    ISEB ISEB-PM1 Exam (Foundation Certificate in Project(R) Management) Detailed Information



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