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IV. Management, Motivation, and Communication/Collaboration, Reflection, and Technology
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GUIDELINES ON THE ESTABLISHMENT AND IMPLEMENTATION OF THE RESULTS-BASED PERFORMANCE MANAGEMENT SYSTEM IN THE DEPARTMENT OF EDUCATION I. Rationale 1. The Civil Service Commission (CSC), through the issuance of Memorandum Circular (MC) No. 06, series of 2012, sets the guidelines on the establishment and implementation of the Strategic Performance Management System (SPMS) in all government agencies. The SPMS gives emphasis to the strategic alignment of the agency’s thrusts with the day-to-day operation of the units and individual personnel within the organization. It focuses on measures of performance vis-a-vis the targeted milestones, and provides a credible and verifiable basis for assessing the organizational outcomes and the collective performance of the government employees. 2. As a learner-centered institution, the Department of Education (DepEd) is committed to continuously improve itself to better serve the Filipino learners and the community. The adoption of the SPMS in DepEd strengthens the culture of performance and accountability in the agency, with the DepEd’s mandate, vision and mission at its core. 3. There is a need to concretize the linkage between the organizational thrusts and the performance management system. It is important to ensure organizational effectiveness and track individual improvement and efficiency by cascading the institutional accountabilities to the various levels, units and individual personnel, as anchored on the establishment of a rational and factual basis for performance targets and measures. Finally, it is necessary to link the SPMS with other systems relating to human resources and to ensure adherence to the principle of performance-based tenure and incentives. 4. In view of the above, this Order aims to adopt the SPMS as the Results-based Performance Management System (RPMS). II. Scope of Policy 5. This DepEd Order provides for the establishment and implementation of the RPMS in all DepEd schools and offices, covering all officials and employees, school-based and non school-based, in the Department holding regular plantilla positions. It stipulates the specific mechanisms, criteria and processes for the performance target setting, monitoring, evaluation and development planning. IV. Policy Statement 9. The DepEd hereby sets the guidelines on the establishment and implementation of the Results-based Performance Management System (RPMS) in the Department, stipulating the strategies, methods, tools and rewards for assessing the accomplishments vis-a-vis the commitments. This will be used for measuring and rewarding higher levels of performance of the various units and development planning of all personnel in all levels. 10. For non school-based personnel, the RPMS shall provide for an objective and verifiable basis for rating and ranking the performance of units and individual personnel in view of the granting of the Performance-Based Bonus (PBB) starting 2015. 11. For school-based personnel, the RPMS shall be used only as an appraisal tool, which shall be the basis for training and development. The granting of PBB shall be governed by the existing PBB guidelines. 12. The Department shall adopt the RPMS framework shown in Annex B. 13. The DepEd RPMS shall follow the four-stage performance management system cycle as prescribed by the CSC: i. Performance planning and commitment (Phase I); ii. Performance monitoring and coaching (Phase II); iii. Performance review and evaluation (Phase III); and iv. Performance rewarding and development planning (Phase IV). V. Performance Cycle/Process 14. The RPMS shall align the performance targets and accomplishments with the Department’s mandate, vision, mission and strategic goals. It shall ensure 100% results orientation vis-a-vis the planned targets. On the other hand, the ratee’s demonstration of the required competencies shall be monitored for developmental purposes only. 15. The RPMS cycle shall cover performance for one whole year. All school-based personnel shall follow a performance cycle starting in April of the current year and ending in March of the following year; while non school-based personnel shall follow a performance cycle starting in January and ending in December. Annexes C and D illustrate the performance cycles which shall apply to school-based and non school-based personnel, respectively. 16. The performance planning and commitment shall be done prior to the beginning of the performance cycle; while the performance monitoring and coaching shall take place immediately after Phase I, and continue throughout the performance cycle. The performance review and evaluation, as well as the performance rewarding and development planning shall be done at the end of the performance cycle. A. Phase I: Performance Planning and Commitment 17. The performance planning and commitment shall be done prior to the start of the performance cycle where the rater meets with the ratee to discuss and agree on the following: i. Office KRAs, Objectives and Performance Indicators as anchored to the overall organizational outcomes; and ii. Individual KRAs, Objectives and Performance Indicators as anchored to the Office KRAs and Objectives. 18. The Office Performance Commitment and Review Form (OPCRF) shall be accomplished by the head of office to reflect the Office KRAs, Objectives and Performance Indicators. The head of office, in coordination with the Planning Office, shall ensure alignment of the office plans and commitments to the overall organizational outcomes. The OPCRF shall be equivalent to the IPCRF of the head of office. A sample of the filled out OPCRF, including the instructions for accomplishing the form, is shown in Annex E. 19. The Individual Performance Commitment and Review Form (IPCRF) shall be accomplished by the individual personnel to reflect the agreed Individual KRAs, Objectives and Performance Indicators. A sample of the filled out IPCRF, including the instructions for accomplishing the form, is shown in Annex F. 20. Defining the Key Result Areas. The head of office, in coordination with the Planning Office, shall define the office KRAs as anchored on the overall organizational outcomes. The rater and the ratee shall discuss and agree on the break down of the office KRAs into individual KRAs. Three (3) to five (5) KRAs shall be defined for each office and individual employee. KRAs are broad categories of general outputs or outcomes. It is the mandate or function of the office and/or individual employee. The KRA is the reason why an office and/or job exist. It is an area where the office and/or individual employee are expected to focus on. 21. Setting the Objectives. The head of office shall set three (3) objectives per office KRA. The rater and the ratee shall discuss and agree on three (3) objectives per individual KRA. Objectives are specific tasks, which an office and/or employee need to do to achieve their specific KRAs. In objective setting, the SMART criteria, which stands for Specific, Measurable, Attainable, Relevant, Time Bound, shall be applied. The SMART criteria are illustrated in Annex G. 22. Setting the Timeline. The timeline shall define the target date for accomplishing each of the Objectives. The timeline for the office Objectives shall be set by the head of office in coordination with the Planning Office and School Planning Team; while the timeline for the individual Objectives shall be discussed and agreed by the rater and the ratee. 23. Assigning the Weight. Assigning of weights shall be done per KRA. Weights for each office KRA shall be assigned by the head of office in coordination with the Planning Office; while the weights for each of the individual KRAs shall be discussed and agreed upon by the rater and the ratee. 24. Identifying the Performance Indicators. Using a five (5)-point rating scale, the head of office shall identify a performance indicator for each of the office objectives, while the rater and the ratee shall identify and agree on the performance indicator for each of the individual objectives. Performance indicators are exact quantification of objectives expressed through rubrics. They are assessment tools, which gauge whether a performance is positive or negative. In identifying the performance indicator, the operational definition or meaning of each numerical rating shall be indicated under each relevant dimension (i.e., quality, efficiency, or timeliness) per performance target or success indicator. This shall ensure that the rating is objective, impartial and verifiable. Table 1 below discusses the performance measures by which the indicator must satisfy. Table 1. Performance Measures CATEGORY DEFINITION Effectiveness/Quality The extent to which actual performance compares with targeted performance. The degree to which objectives are achieved and the extent to which targeted problems are solved. In management, effectiveness relates to getting the right things done. Efficiency The extent to which time or resources is used for the intended task or purpose. Measures whether targets are accomplished with a minimum amount or quantity of waste, expense, or unnecessary effort. Timeliness Measures whether the deliverable was done on time based on the requirements of the rules and regulations, and/or clients/stakeholders. Time-related performance indicators evaluate such things as project completion deadlines, time management skills and other time-sensitive expectations. Some Performances are only rated on quality and efficiency, some on quality and timeliness, and others on efficiency only. You need not use all three (3) categories. 25. Demonstration of Competencies. During Phase I, the rater shall discuss with the ratee the competencies required of the individual personnel. Competencies are defined as the knowledge, skills and behavior that individuals demonstrate in achieving one’s results. Competencies shall uphold the DepEd’s core values. They represent the way individuals define and live the values. 26. DepEd shall adopt four classes of competencies as follows: i. Core behavioral competencies are competencies, which cut across the organization; ii. Leadership competencies are competencies intended for managerial positions; a. Third level officials b. Chiefs and Assistant Chiefs c. School Heads and Department Heads iii. Staff Core Skills are competencies intended for staff and teaching-related personnel; and iv. Teaching competencies are competencies intended for teachers. The DepEd-required competencies are illustrated in Annex I. 27. The ratee’s demonstration of the required competencies shall be monitored to effectively plan the interventions needed for behavioral and professional development. The assessment in the demonstration of competencies shall not be reflected in the final rating. 28. Reaching Agreement. Once the office and individual KRAs, Objectives and Performance Indicators are clearly defined, the rater and the ratee shall commit and reach an agreement by signing the OPCRF and IPCRF. The signed/approved OPCRF and IPCRF shall be the basis for monitoring and assessment, which shall take place in Phases II and III, respectively. B. Phase II: Performance Monitoring and Coaching 29. The performance monitoring and coaching shall commence after the rater and the ratee commit on the KRAs, Objectives and Performance Indicators, and sign the OPCRF and IPCRF. This shall be done throughout the year. 30. The two (2) main components of Phase II are the following: i. Performance monitoring; and ii. Coaching and feedback. 31. Performance monitoring shall provide key inputs and objective basis for rating. It shall facilitate feedback and provide evidence of performance. Performance monitoring shall be the responsibility of both the rater and the ratee who agree to track and record significant incidents through the use of the Performance Monitoring and Coaching Form (PMCF) shown in Annex J. Significant incidents are actual events and behaviors in which both positive and negative performances are observed and documented. 32. Coaching and feedback shall be a continuous process. Coaching and feedback shall be provided by the rater and/or shall be sought by the ratee to improve work performance and behavior. The rater, as the coach or mentor of the ratee, playing a critical role in the performance monitoring and coaching, shall provide an enabling environment and intervention to improve the office performance and to manage and develop individual potentials. 33. The PMCF shall capture the significant incidents. It shall provide a record of demonstrated behaviors, competencies and performance, and shall be an effective substitute in the absence of quantifiable data. The rater and the ratee shall sign each significant incident recorded in the PMCF to ensure that agreement has been reached. C. Phase III: Performance Review and Evaluation 34. The performance review and evaluation shall be done at the end of the performance cycle to assess the office and individual employee’s performance level based on the commitments and measures as contained in the signed OPCRF and IPCRF. 35. A mid-year review is prescribed to determine the progress in achieving the Objectives. In exceptional cases, and only if the situation warrants, a one-time recalibration of office and individual Objectives shall be allowed during the mid-year review. Exceptional cases shall include instances when high level decisions are taken into effect such as changes in strategic directions, and circumstances beyond the control of the ratee such as natural and/or man-made calamities, including typhoon, earthquake and other fortuitous events. During the mid-year review, the rater shall inform in writing the ratee of the status of performance, in case of an Unsatisfactory or Poor performance. Coaching, feedback and appropriate interventions shall be provided where necessary. 36. The RPMS shall put premium on KRAs towards the realization of organizational vision, mission, strategic priorities and the OPIF logframe. Hence, rating for planned and/or intervening tasks shall always be supported by reports, documents or any output as proofs of actual performance. In the absence of said bases or proofs, a particular task shall not be rated and shall be disregarded. 37. Office and Individual Performance Assessment. The head of office, in coordination with the Planning Office, shall assess the performance of the office vis-a-vis the committed targets at the beginning of the performance cycle. The rater and the ratee shall discuss and agree on the individual assessment based on the actual accomplishments of each of the KRAs and Objectives. The final rating shall be based solely on the accomplishment of the specific objectives as measured by the Performance Indicators. The OPCRF and IPCRF shall be accomplished and completed by the rater and the ratee to: i. Reflect actual accomplishments and results; ii. Rate each of the objectives; iii. Compute for the score per objective; iv. Determine the overall rating for accomplishments; v. Reach an agreement; and vi. Assess the competencies. 38. Initial self-rating shall be encouraged prior to the rater-ratee discussion. 39. Third Level Officials, as heads of offices, shall accomplish the OPCRF for submission to the Planning Office. The individual assessment of Third Level Officials shall be contained in the CESPES Forms for submission to the Career Executive Service Board (CESB). The BHROD and Personnel Division shall be furnished a copy of both forms. 40. Actual Results. The rater and the ratee shall discuss and agree on the actual accomplishments and results based on the performance commitments and measures made at the beginning of the rating period. They shall evaluate each objective whether it has been achieved or not. The significant incidents as reflected in the PMCF shall be considered for the actual results. 41. Rating the Objectives. Based on the actual accomplishments and results, each of the Objectives shall be rated using the rating scale specified below: Table 2. The RPMS Rating Scale NUMERICAL RATING ADJECTIVAL RATING DESCRIPTION OF MEANING OF RATING 5 Outstanding Performance represents an extraordinary level of achievement and commitment in terms of quality and time, technical skills and knowledge, ingenuity, creativity and initiative. Employees at this performance level should have demonstrated exceptional job mastery in all major areas of responsibility. Employee achievement and contributions to the organization are of marked excellence. 4 Very Satisfactory Performance exceeded expectations. All goals, objectives and targets were achieved above the established standards. 3 Satisfactory Performance met expectations in terms of quality of work, efficiency and timeliness. The most critical annual goals were met. 2 Unsatisfactory Performance failed to meet expectations, and/or one or more of the most critical goals were not met. 1 Poor Performance was consistently below expectations, and/or reasonable progress toward critical goals was not made. Significant improvement is needed in one or more important areas. The final assessment shall correspond to the adjectival description of Outstanding, Very Satisfactory, Satisfactory, Unsatisfactory or Poor. The range of adjectival rating is as per attached in Forms A, B, and C. 42. Process for Computing the Score per KRA. i. The rater and ratee shall ensure that each KRA has been assigned weight according to priority. ii. As an option, the rater and ratee may assign weights to objectives which shall be equal to the total weight assigned to a particular KRA. KRA 1 – Weight assigned is 40% Objective 1 is 20% Objective 2 is 10% Objective 3 is 10% iii. The score per KRA shall be computed using the following formula: 43. Plus Factor. The plus factor shall be considered as another KRA. These are value adding accomplishments, which are not covered within the regular duties and responsibilities. The weight on the plus factor shall not exceed the weight of the highest mandated KRA. For teachers, the plus factor shall be limited to work/activities, which contribute to the teaching-learning process. 44. Determining the Overall Rating for Accomplishments. The overall rating/assessment for the accomplishments shall fall within the following adjectival ratings and shall be in three (3) decimal points: Table 3. Adjectival Ratings RANGE ADJECTIVAL RATING 4.500-5.000 Outstanding 3.500-4.499 Very Satisfactory 2.500-3.499 Satisfactory 1.500-2.499 Unsatisfactory below 1.499 Poor 45. Reaching Agreement. Upon determining the overall rating for the actual accomplishments and results, the rater and the ratee shall reach an agreement by signing the OPCRF and IPCRF. The average rating of individual staff members should not go higher than the collective performance assessment of the office. 46. Assessing the Competencies. The rater shall discuss with the ratee the set of competencies observed during the performance cycle. The competencies shall not be reflected in the final rating. Competencies shall be monitored for developmental purposes. In evaluating the individual’s demonstration of competencies, the rating scale in Table 4 shall apply: Table 4. The DepEd Competencies Scale SCALE DEFINITION 5 Role model 4 Consistently demonstrates 3 Most of the time demonstrates 2 Sometimes demonstrates 1 Rarely demonstrates 5 (role model) – all competency indicators 4 (consistently demonstrates) – four competency indicators 3 (most of the time demonstrates) – three competency indicators 2 (sometimes demonstrates) – two competency indicators 1 (rarely demonstrates) – one competency indicator D. Phase IV: Performance Rewarding and Development Planning 47. The results of the performance review and evaluation shall be used in performance rewarding and development planning. This phase shall be done after Phase III. 48. The rater shall discuss and provide qualitative comments, observations and recommendations in the individual employee’s performance commitment, competency assessment and significant incidents which shall be used for training and professional development. These can be written under the strengths and development needs column of the Part IV-Development Plans of the IPCRF. 49. The rater and the ratee shall identify and discuss the individual’s strengths and development needs, and reflect them in the Part IV-Development Plans of the IPCRF. The competencies which the ratee demonstrated consistently and the areas, where the ratee meet or exceed expectations shall be referred to as the ratee’s strengths. The competencies, which the ratee rarely demonstrates and the areas where the ratee has room for improvement and has not met the expectations, shall be identified as the ratee’s development needs. Make a situational SOLO-based questions in the context of school leadership EVALUER LE RISQUE CLIENT I Les enjeux liés au risque client II la prise de renseignements pendant la phase commerciale III L’évaluation de la solvabilité d’un prospect ou client 1. A partir du bilan comptable 2. A l’aide d’indicateurs internes IV Les outils d’évaluation des risques I Les enjeux liés au risque client 1. Définition et critères de risques On entend par risque client l’ensemble des situations dans lesquelles le client pourrait compromettre la pérennité du fournisseur. Quelques critères permettent de repérer le risque client : - la taille et l’âge de l’entreprise - le produit qu’elle propose, - son client avec ses propres clients (la sous traitance par exemple induit un lien de dépendance) - le secteur sur lequel elle évolue - la concurrence qu’elle subit - et le montant de ses disponibilités On peut ainsi répartir les degrés de risque : 2. Les impayés clients : première cause de faillite des entreprises Par principe, l’entreprise dépense avant d’encaisser. En accordant des délais de paiement, elle se prive de trésorerie. Elle a alors un besoin en fonds de roulement (BFR), c'est-à -dire besoin de disposer d’une trésorerie d’avance. Tout retard de paiement engendre donc une augmentation du BFR que l’entreprise n’est parfois plus en état de couvrir (découvert bancaire).Lorsque le client est insolvable, c’est un manque de trésorerie qui pèse sur l’entreprise et donc sur sa pérennité. La PME limite donc les risques si certains de ses clients payent comptant. Les entreprises activent donc plusieurs stratégies pour faire face à leurs impayés : 29% gèrent les relances en interne, 24% négocient des facilités de caisse avec leur banque et 19% négocient avec les fournisseurs. II la prise de renseignements pendant la phase commerciale L’entreprise qui souhaite conclure un contrat avec un prospect professionnel peut consulter un certain nombre de documents disponibles auprès d’organismes. Les organismes les plus sollicités sont : - la greffe du tribunal de commerce : elle délivre gratuitement des informations sur les entreprises immatriculées au registre du commerce et des sociétés telles que les statuts, les comptes annuels, l’état d’endettement, l’extrait kbis. L'extrait Kbis représente la véritable « carte d'identité » à jour d'une entreprise immatriculée au Registre du Commerce et des Sociétés (RCS). - les sociétés spécialisées fournissent des informations commerciales et financières, des documents comptables et des analyses payantes permettant de vérifier l’état de santé des entreprises : - les cabinets de recouvrement et sociétés d’assurance : ils réalisent des enquêtes de solvabilité et émettent un avis sur le risque de défaillance sous forme de score ou de note. - Les banques : les entreprises sont notées par les banques. La cotation de la banque mesure la capacité de l’entreprise à honorer ses engagements financiers sur 3 ans. Grâce à cette cotation, la PME peut ainsi , par l’intermédiaire de la banque, vérifier si le prospect ou client est solide financièrement. III L’évaluation de la solvabilité d’un prospect ou client La solvabilité correspond à la capacité de l’entreprise à faire face à ses engagements à long terme. L’entreprise est solvable si la valeur de ses actifs (immobilisations, créances, stocks et disponibilités) est supérieure à ses emprunts et dettes. Une entreprise peut être solvable mais peut manquer de liquidités, c'est-à -dire d’argent disponible au quotidien. La liquidé mesure donc la capacité de l’entreprise à faire face à ses engagements à court terme. 1. A partir du bilan comptable Le bilan comptable fournit des indications sur la santé financière de l’entreprise prospect Les définitions que vous devez maitriser : • Pour l’actif : C’est quoi une Immobilisation ? La notion d'immobilisation intègre l'ensemble des biens durables détenus par une entreprise sur plus d'un exercice comptable et qui ne sont pas destinés à la revente. Les immobilisations financières correspondent aux actifs financiers d'utilisation durable possédés par l'entreprise. Il s'agit notamment des titres de participation, des prêts accordés… Les immobilisations incorporelles comprennent les frais d'établissement, les frais de recherche et développement, les concessions, brevets, licences, marques, logiciels et autres droits similaires, le droit au bail, le fonds commercial. Une immobilisation corporelle correspond à un actif physique que l’entreprise entend utiliser au-delà de la clôture de l’exercice comptable en cours : les terrains, les constructions, l’agencement et les installations générales, l’outillage, le matériel, les véhicules, le mobilier et les équipements informatiques. Que signifie disponibilités ? Le poste "Disponibilités" est constitué des montants détenus en caisse (pièces et billets que l'entreprise possède) et des avoirs en banque (argent détenu sur les comptes bancaires de l'entreprise). On utilise également le terme de trésorerie. C’est quoi une valeur mobilière de placement ? Ce sont des titres financiers, actions ou obligations. En comptabilité, elles correspondent aux excédents de trésorerie placés par l'entreprise. • Pour le passif : Que signifie capitaux propres ? Les capitaux propres sont les ressources financières que possède l'entreprise Le capital social d’une entreprise est égal au montant total des apports de biens et d’argent des associés Que signifie réserves ? Cumul des bénéfices des exercices antérieurs qui n'ont pas été redistribués aux propriétaires de l'entreprise, ni intégrés dans son capital Que signifie résultat ? Il correspond aux ressources restantes à l'entreprise une fois les charges déduites du chiffre d'affaires. 2 A l’aide d’indicateurs internes Une entreprise manque souvent de temps et de moyens pour suivre l’ensemble des ses encours clients. Toutefois, il est nécessaire d’analyser régulièrement certains supports pour anticiper les problèmes de trésorerie. Elle peut - analyser son portefeuille clients via la méthode ABC (vu dans un chapitre précédent), - prendre du recul sur les retards de paiement : le service comptable signale les retards de paiement ou les demandes régulières de report d’échéances. La balance âgée permet de visualiser les clients à relancer Exemple : - mettre en place des indicateurs de suivi des impayés via un tableau Excel Exemple : IV Les outils d’évaluation des risques Les entreprises peuvent se procurer des logiciels dédiés au risque client mais il sont souvent très complexes à utiliser. Certaines entreprises utilisent le crédit management : c’est l’ensemble des procédures financières ou juridiques visant à optimiser le chiffre d’affaires de l’entreprise en accélérant les règlements clients. Une des méthodes de crédit management s’appelle la méthode des points de risque. Elle consiste à classer les clients selon leur risque afin de leur fixer des modalités de paiement adaptés. Elle permet donc d’évaluer les risques de coopération et de se prémunir au cas par cas. Exemple de tableau des points de risque7.015 Hand Hygiene: Practice observation of hand hygiene compliance via the use of a hand hygiene survey tool to be reviewed quarterly at the QAPI committee. (Chapter 10.14 Handwashing & Surgical Antisepsis) Continue infection control education through ongoing orientation to center staff routinely and annual mandatory in-service. Continue to promote hand hygiene awareness for patients and staff by means of educational materials placed throughout the center which references the CDC/WHO guidelines. Needle-stick Injuries: (Refer to Exposure Control Plan) Use of designated safety engineered needles for injections (safety glide needles for injection and autoguard IV catheters) and blood draw. New employee and annual clinical competency for injections will be provided to all staff. The staff will be trained yearly on OSHA, blood borne pathogens and PPE. 7.016 Hand Hygiene Quality in the ASCs: based on AORN (Association of periOperative Registered Nurses) Standards and guidelines Policy: All ASC staff, including physicians, nurses, and other healthcare workers, are required to perform hand hygiene before and after any direct contact with patients, before and after any procedure, and after any contact with potentially contaminated items or surfaces. Hand hygiene must be performed using either an alcohol-based hand rub or soap and water. The alcohol-based hand rub must contain at least 60% alcohol. Staff members must ensure that their hands are free of debris and visible dirt before performing hand hygiene. Hand hygiene must be performed for a minimum of 20 seconds, and hands must be dried thoroughly after washing. Staff members must be trained on proper hand hygiene techniques and will be educated on a regular basis to ensure compliance with this policy. All staff members must comply with this policy and demonstrate compliance during inspections by ASC management and regulatory agencies. Any staff member who fails to comply with this policy will be subject to disciplinary action. ASC management will monitor compliance with this policy through regular inspections and audits and will take appropriate action to address any noncompliance issues. The ASC will maintain records of staff compliance with this policy as part of its infection control program. The ASC will review and update this policy on an annual basis or more frequently as needed to ensure that it remains current with the latest guidelines and standards for hand hygiene quality.Chapter 22 Antihypertensive Drugs Hypertension Defined (JNC-8) Pharmacology Overview 7 main categories of drugs to treat HTN Adrenergic drugs (old friend) Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Calcium channel blockers (CCBs) Diuretics Vasodilators Direct renin inhibitors A. Adrenergic Drugs: 5 Subcategories and where they act A1. Adrenergic neuron blockers (central and peripheral)- we won’t talk about this A2. Alpha1 receptor blockers (peripheral) A3. Alpha2 receptor agonists (central) A4. Beta receptor blockers (peripheral) A5. Combined α and β receptor blockers (peripheral) A2. Peripherally Acting Adrenergic Drug Alpha1 Blockers (we’ve met these) Doxazosin, prazosin, alfuzosin Block alpha1-receptors which causes BP to decrease Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels Main Use: benign prostatic hyperplasia (BPH) Alpha1 Blockers REMEMBER Tamsulosin (Flomax)* is an α1 blocker BUT *Tamsulosin is not used to control BP, just for BPH. A3. Centrally Acting Adrenergic Drugs Alpha 2 agonist Clonidine and methyldopa 1- Stimulate alpha2-adrenergic receptors. in the brain Decreases sympathetic outflow from the CNS which decreases NE production 2. Stimulate alpha2-adrenergic receptors in kidneys remember alpha 2 opposes alpha 1 Dilates peripheral blood vessels → lowers peripheral resistance → Results in decreased BP So ….Clonidine (Catapres) Used primarily for its ability to decrease blood pressure in an urgent setting Also use in opioid withdrawal as previously discussed Oral (multiple times a day), and topical patch formulations Do not stop abruptly as it may lead to rebound hypertension In reality, Clonidine and methyldopa Not prescribed as first-line home antiHTN drugs High incidence of unwanted adverse effects: orthostatic hypotension, fatigue, and dizziness MIGHT be uses as adjunct drugs after other drugs have failed, in conjunction with other antiHTN such as diuretics A4. Adrenergic Drugs Selective Beta 1 Blockers Metoprolol, Atenolol Reduction of HR through β1 receptor blockade (remember adrenergic blocking of this receptor???) HR results in BP Cause reduced secretion of renin = BP A4. Adrenergic Drugs Selective Beta1 Blockers Nebivolol (Bystolic) Uses: hypertension and HF Action: blocks β1 receptors and produces vasodilatation, which results in a decrease in SVR High doses loses selectivity and blocks both β1 and β2 Less sexual dysfunction All BB- Do not stop abruptly; must be tapered over 1 to 2 weeks A4. Adrenergic Drugs NONSelective Beta Blockers Propranolol Acts equally on β1 and β2 Other uses include situational anxiety associated with public speaking, test taking As mentioned on previous slide, nebivolol at high doses becomes beta nonselective A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade) Examples are carvedilol (common) and labetalol (not as common) A5. Dual-Action Adrenergic Drugs α1 and β Receptor Blockers Carvedilol (Coreg) Widely used drug that is well tolerated Uses: HTN, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors Contraindications: severe bradycardia or unstable HF, bronchospastic conditions such as asthma, and various cardiac conduction problems Adrenergic Drugs Indications - HTN But also for Glaucoma (topical) BPH: doxazosin, prazosin, and terazosin (2 for 1) Management of severe HF when used with cardiac glycosides and diuretics Contraindications Acute HF- have to stabilize first MOAIs- yeah doesn’t everything interact with MAOIs? Peptic ulcers Severe liver/kidney disease Asthma (with beta blockers) Adrenergic Drugs: Adverse Effects Orthostatic hypotension 1st-dose syncope Rebound hypertension with abrupt discontinuation Most common: Dry mouth, drowsiness, constipation, sedation Interactions- always check for specific drug interactions Can cause additive CNS depression with alcohol, benzodiazepines, opioids Question #1 When administering an alpha-adrenergic drug for hypertension, it is most important for the nurse to assess the patient for the development of what response? Hypotension Hyperkalemia Oliguria Respiratory distress Answer A Hypotension This is a key point in patient education These drugs have strong vasodilating properties and may cause severe hypotension, especially at the beginning of therapy. B. Angiotensin-Converting Enzyme Inhibitors aka ACE Inhibitors or ACEi Large group of safe and effective drugs Currently are 10 ACEi Often used as first-line drugs for HF and hypertension May be combined with a thiazide diuretic, loop diuretic, or Calcium Channel Blocker (CCB) You need to understand the basics ACE Inhibitors: Review RAAS ACE converts angiotensin I, formed through the action of renin, to angiotensin II Angiotensin 2 is a potent vasoconstrictor and also induces aldosterone secretion by the adrenal glands Aldosterone stimulates sodium resorption (H20 follows Na Both act to raise BP which causes kidneys to reduce renin production ACEi= Great drug to treat HTN BUT contraindicated in pregnancy (2nd,3rd trimester due to fetal renal damage) and breastfeeding first few weeks after birth B. ACE Inhibitors - PRIL Lisinopril (Prinivil) super common, often the 1st drug Enalapril (Vasotec) also common Captopril (Capoten) great if liver disease present Benazepril (Lotensin) Fosinopril (Monopril) Perindopril (Aceon) Quinapril (Accupril) Ramipril (Altace) Trandolapril (Mavik) Primary Effects of the ACE Inhibitors Prevent Na (and H2O) resorption by inhibiting aldosterone secretion (volume reduction) (GO BACK TO RAAS DIAGRAM) blood volume decreases work of the heart preload, or the left ventricular end-diastolic volume which is important in HF ACE SUMMARY OF ACTIVITY 1) Prevent vasoconstriction caused by angiotensin 2 (2) Prevent aldosterone secretion  less sodium and water resorption Cardioprotective Effects of ACEi They slow progression of left ventricular hypertrophy (ventricular remodeling) after MI so considered cardioprotective ACE inhibitors have been shown to decrease morbidity and mortality in patients with HF Renal Protective Effects of ACEi ACE inhibitors: reduce glomerular filtration pressure by volume reduction Cardiovascular drug of choice for patients with diabetes since it helps protect kidneys by reducing pressure. Sometimes used low dose for kidney protection with DM without HTN B. ACEi Enalapril (Vasotec) Only ACEi available in both oral and IV Enalapril IV does not require cardiac monitoring Oral enalapril: prodrug (metabolized in liver) Improves patient’s chances of survival after an MI Reduces the incidence of HF B. ACEi Captopril (Capoten) Uses: prevention of ventricular remodeling after MI; reduce the risk of HF after MI Shortest half-life Must be administered multiple times throughout the day so this limits its use Not a prodrug so good for patient with liver disease Question #2 A patient with diabetes has a new prescription for the ACE inhibitor lisinopril. She questions this order because her provider has never told her that she has hypertension. What is the best explanation for this order? The doctor knows best The patient is confused This medication has cardioprotective properties This medication has a protective effect on the kidneys for patients with diabetes Answer D ACE inhibitors have been shown to have a protective effect on the kidneys because they reduce glomerular filtration pressure. This property makes them the cardiovascular drug of choice for patients with diabetes. Question #3 A patient with a history of pancreatitis and cirrhosis is also being treated for hypertension. Which drug will most likely be ordered for this patient? Clonidine Prazosin Diltiazem Captopril Answer D Captopril Captopril is not a prodrug; therefore, it does not need to be metabolized by the liver to be effective. This is an advantage in patients with liver disease. ACE Inhibitors: Adverse Effects *Dry, nonproductive cough, which reverses when therapy is stopped. This is a class effect Dizziness- Note: First-dose hypotensive effect may occur Headache & Fatigue Possible hyperkalemia ** Angioedema: rare but potentially fatal Not safe in pregnancy-are contraindicated during the second and third trimesters of pregnancy because of increased risk of fetal renal damage C. Angiotensin II Receptor Blockers (ARB) Considered an alternative to ACEi Less likely to cause a dry cough and hyper K+ that is common with ACE inhibitors Angiotensin II Receptor Blockers: Mechanism of Action Go back to RAAS diagram! ARBs affect primarily 2 places 1. Vascular smooth muscle - blocks vasoconstriction 2. Adrenal gland -Selectively blocks the binding of Ang 2 to certain Ang 2 receptors inhibiting secretion of aldosterone Lowers volume retention and BP Angiotensin II Receptor Blockers -ARTAN Losartan (Cozaar)- very common Eprosartan (Teveten) Valsartan (Diovan) Irbesartan (Avapro) Candesartan (Atacand) Olmesartan (Benicar) Telmisartan (Micardis) Azilsartan (Edarbi) C. ARB Losartan (Cozaar) Beneficial in patients with HTN and HF Used with caution in patients with kidney or liver dysfunction and in patients with renal artery stenosis ***Not safe for breastfeeding women and should not be used in pregnancy (Cat C 1st trimester, Cat D 2nd-3rd trimester), potential fetal toxicity Appear to be equally effective for the treatment of hypertension and well tolerated ARBs less likely to cause cough and hyperK+ but can still happen Evidence that ARBs are associated with lower mortality after MI than ACE inhibitors Never take ACEi and ARBs at the same time* 5. Calcium Channel Blockers (CCB) Primary use: HTN, angina, some dysrhythmias Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction Results in: Relaxed blood vessels to the heart Decreased peripheral smooth muscle tone Decreased SVResistance Decreased BP E. Diuretics First-line antiHTN in JNC 8 guidelines Decreases fluid volume The results from diuresis: preload, Peripheral resistance Overall effect ïƒ Decreased workload of the heart and decreased BP Thiazide diuretics are the most commonly used diuretics for HTN Ie hydrochlorothiazide (HCTZ), chlorthalidone We will discuss diuretics further in the chapter on diuretics F. Vasodilators Directly relax arterial or venous smooth muscle (or both) Results in: Decreased SVR Decreased afterload Peripheral vasodilation Indicated for treatment of HTN May be used in combination with other drugs F. Vasodilators Hydralazine (Apresoline) Orally: routine cases of essential hypertension Injectable: hypertensive emergencies BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients F. Vasodilators Sodium Nitroprusside (Nitropress) *Sodium nitroprusside and IV diazoxide are reserved for the management of hypertensive emergencies. Contraindications: severe HF, known inadequate cerebral perfusion (especially during neurosurgical procedures) F. Vasodilators Adverse Effects Hydralazine: dizziness, headache, tachycardia, edema, dyspnea, N/V/D, vitamin B6 deficiency, rash Sodium nitroprusside: hypotension, bradycardia, decreased platelet aggregation, rash G. Direct Renin Inhibitors Aliskirin (Tekturna) Blocks the RAS pathway at the point of activation. Inhibiting renin production prevents the downstream production of Ang II (potent vasoconstrictor) Adverse effects: N/V, severe hypotension, hyponatremia, hyperkalemia… Contraindicated in patients with DM taking ACEi or ARB Miscellaneous Antihypertensives Eplerenone (Inspra) Newer class of drugs called selective aldosterone blockers (remember RAAS?) Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain Indications: routine treatment of hypertension and for post-MI HF Contraindicated if serum potassium levels are high (above 5.6 mEq/L) A Special Form of HTN Treatment of Pulmonary Hypertension Sildenafil and Tadalafil Commonly used for erectile dysfunction Used for pulmonary hypertension but with different trade names Sildenafil: Revatio* (Viagra for ED) Tadalafil: Adcirca* (Cialis for ED)I Définition La proposition commerciale est une offre adressée à un client ou prospect suite à sa demande. Le commercial doit donc veiller à soigner sa présentation, car la proposition commerciale est la vitrine de l’entreprise La proposition commerciale est le support de la relation entre l’entreprise et le client/prospect. II La finalité d’une proposition commerciale La proposition commerciale permet de répondre précisément aux attentes du client qui souhaite passer une commande. Dans cette optique, la proposition doit être : - claire, - personnalisée - différenciée de celles de la concurrence. La proposition commerciale permet également de renseigner le client non pas uniquement sur les prestations proposées mais aussi sur l’entreprise elle-même grâce à son numéro d’identification (SIRET) délivré par l’INSEE III Le système d’information client Pour réaliser la proposition commerciale, le commercial doit collecter des informations sur la clientèle, sur les produits mais également sur l’environnement commercial. Elle consulte donc le système d’information client dont l’acronyme est SIC. Il est constitué de fichiers commerciaux utilisables par tous les collaborateurs de l’entreprise afin d’améliorer la connaissance de la clientèle et des propsects. Son contenu est le suivant : IV Les logiciels pour préparer une proposition commerciale. Il est possible de préparer les propositions commerciales sur un texteur, un tableur, un logiciel spécialisé en gestion commerciale ou un progiciel de gestion intégré : Logiciels pouvant être utilisés Traitement de texte (Word, Open Writer, etc.) Tableur (Excel, Open Calc, etc.) Logiciel de gestion commerciale (EBP, Ciel, etc.) PGI (Cegid, Sage, EBP) Si l’entreprise possède un PGI ou un logiciel de gestion commerciale, la proposition commerciale sera effectuée sur ce type de logiciel. Dans le cas contraire, il est recommandé d’utiliser le tableur. Le progiciel est l’outil privilégié par les entreprises car il regroupe un ensemble de logiciels (modules) intégrant les principales fonctions nécessaire à la gestion des flux monétaires et physiques de l’entreprise. Tous ces modules accèdent à des ressources communes, stockées dans une base de données unique. Les modules les plus courants sont : Ainsi, le PGI permet d’éviter les saisies redondantes, qui sont sources d’erreurs et de perte de temps. V Distinguer devis et proposition commerciale 1. Le devis C’est une offre adressée à un client ou un prospect destinée à répondre à son besoin suite à la demande du client. Son contenu se limite souvent à la référence des produits et leurs prix. Le devis est donc un engagement de l’entreprise pour réaliser une prestation ou pour délivrer un produit au prix indiqué et dans les délais annoncés. Seules la signature du client et la date donnent au devis la valeur juridique d’un contrat. Il peut donc ajouter « Lu et accepté » ou encore « bon pour travaux » par exemple. 2. La proposition commerciale Par rapport au devis, la proposition commerciale nécessite une analyse plus poussée des besoins du client, un chiffrage de l’offre plus complexe et un document plus personnalisé VI Les étapes pour réaliser une offre commerciale Les étapes de la mise en Å“uvre d’une proposition commerciale sont : – l’analyse des besoins du client ; – la recherche des informations qui permettent d’établir l’offre correspondant aux besoins du client (prix, délai de livraison, planning de production, etc.) ; – la mise en forme de la proposition : On peut donc la schématiser ainsi : VII Les mentions obligatoires à faire figurer sur la proposition commerciale VIII Les sanctions en cas de non respect des mentions obligatoires Tout manquement peut aboutir à une contravention pouvant aller jusqu’à 1500 € d’amende.IVIV-Keynote 2B-Unit 8: Better Cities-Oral and written comprehensionIV-Repaso de examen final- III