Brain Injury Business Practice College 2011 Brain Injury Association of America

Traumatic Brain Injury 2011 Business Practice College

Brain Injury Association of America authorizes me to post the following upcoming event:

Register Now for BIAA's 2011 Brain Injury Business Practice College

The Brain Injury Association of America will present 2011 Brain Injury Business Practice College at The Menger Hotel in San Antonio, TX on February 22-24, 2011.

Sessions especially designed for: CEOs, COOs, Human Services & Sales/Marketing Professionals

Learn exemplary strategies to ensure access to quality health care.

The 2011 Brain Injury Business Practice College offers sessions on:

  • Process Improvement and Customer Service
  • Business Ethics
  • An Update on Health Care Reform
  • Ever-popular Case Studies

Round-Table Discussions Including:

  • Territory Management
  • Cost and Risk Management
  • Staff Development and Succession Planning

Last year's attendees said:

  • "This year's conference was terrific! Truly met (and exceeded) my expectations."
  • "I thoroughly enjoyed and learned from the Brain Injury Business Practice College. I feel that all of the information was useful and important. Networking with the competitors is so important."
  • "Great conference. Good sessions. It was fabulous."


Click here for more information.

Headline News Brain and Spine Injury Law Blog Commentary September 2010

Political Commentary

First let me disclaim what I am about to write by asserting my apolitical views on politics. Second, I am not without opinion, but feel they are similar to AHs and everybody has one. But I do get caught up in the media, who can’t? So here I go.

 Obama

Why are some conservative (Republicans and Tea Partiers) still claiming our President is somehow not American because his dad was from Indonesia and returned shortly after Obama’s birth? My father’s parents were both from Italy but my father is both a taxpaying, card-carrying American. (Who also collects a tidy pension from the State of New York as a retired policeman, disability for a condition that does not stop him from enjoying his retirement, and social security). DISTRACTION.

Was FDR castrated when he developed socialized retirement care? Taking from a younger working, income producing group, to pay for the non-working, non-income producing group? Did change happen overnight? How is that not the “socialism” decried by conservatives.

And I just got back from Canada. Only so much health care to go around and that is how they keep costs down. It means you may have to wait longer to get an MRI – unless it is an emergency. It actually sounds like a conservatives dream: deprive benefits in the name of cost savings. Canada has a surplus and law against carrying a deficit. Instead U.S. conservatives want to keep their “choice” of physicians as the hold card when health care reform is proposed.

Give Obama a fair shake. It took Clinton several years to balance the budget and put us in a surplus! Does one year of getting policy in place really give President Obama a fair amount of time? No.

We now know that the conservative movement happily gave over the economic tragedy former President Bush created with, among many other things, an incomprehensibly expensive war. Where were the conservative cheers to “cut spending” then? Is the effort to democratize other countries a social agenda? Or are we ready to admit it was about securing dirty energy – oil? 

So Obama steps into a Wall Street Market and Real Estate meltdown and Bush leaves with a goodbye “stimulus” that lacked effective oversight. 

Does anyone remember that? Has the past year wiped out all memories? We’re riding a new horse; we should not switch midstream. Let it play out I say. And if tax cuts to the rich means those making more than $200,000 to $250,000, that may be good for me but not the country I profess allegiance to. But the “let me keep what I earn” argument really slaps down those who can be helped. And the argument about “letting me choose where my charity dollars go, rather then the Federal or State Government,” is a bit lame.   And yes, if Wallstreet bankers make billions of dollars using the same commonwealth as other New Yorkers, Chicagoans, and other big city residents earning much less, they should pay more for that commonwealth, or higher taxes. Trickle Down/Reaganomics is not the saving grace conservatives espouse.

Frankly, I like getting my mail, going to the library, driving on resurfaced streets and I am willing to pay for those American qualities of life. But I do not like giving money to foreign countries, whether to destroy or build up, while at the same time denying and not contributing to the disrepair in this country.

Democrats want to pay (Republican’s frame it as “tax and spend”) for things to bolster this country and this economy. But you do not accomplish that with a war with no clear purpose other than the knee-jerk reaction of 9/11.

My idea (although not really my hope) is that if the Republican or Tea Party Movement takes over congress in the coming election, they inherit the same lackluster economy President Bush left to President Obama. We now know that conservatives were giddy that a democratic president could be their fall guy when things did not change in one year. Won’t it be interesting if the Republican congress becomes the fall guys/gals for a too slowly recovering economy?

Angle v Reid

This to me is a no brainer. Let’s compare apples to apples. Lets for a moment accept that both Sharon Angle and Harry Reid are both good for the State of Nevada – all things being equal. Reid is the Senate Majority Leader. SENATE MAJORITY LEADER! He has the ear of the president and the entire Senate. Whatever your political slant, why replace this coveted, most high, position with a freshman Senator with no proven record. This, I have been told by more than one educated person, would be “bad for Washington.”

Now let’s take sides. More of an apples and oranges approach. Why can’t folks allow a party to have control in the name of getting things done? I mean how bad can it really get? If democrats continue implementing their theories on health care, tort reform, marriage, religious tolerance (not to mention the polarizing issue of abortion), what is the worst that can happen? Alternatively, if Republicans regain control of congress, democrats may draw the line in the sand like republicans have done this past year with filibusters. End result, nothing gets done. Compromises are viewed with suspicion and we go nowhere. 

So let the process work. I personally hope democrats or liberal republicans are put in place to keep the policy change coming. And let’s remember none of us are totally on one side or the other and that means compromise. We are “bi-conceptual.” For example, I agree with some conservative ideas and some democratic ideas. Some ideas I reject all together; from either side. Point is I am bi-conceptual as to issues – not a blind party line voter.

Vote for Reid, whatever you may dislike, get over it; he will be able to rally change with the president and Angle will not.

Dis-Information

And remember the power of the media, its hypnotizing, and trance inducing power. You make important decisions regarding your representatives. And so much of our information and decisions are based on our own deep seated biases. Karl Rove was very good at getting into the deep seated biases and causing people to act the way he wanted. That is indeed a talent, one I experience as a lawyer every day.

But who owns the studios that bring you the news. How much of it supports one side or the other? Do you even have a clue? There must be so many back deal discussions and events that we, the weary public, have no insight to. And sometimes there are leaks, but I would wager not nearly as often as you might think. Here again, Obama ran on the promise of a transparent government. But be realistic, we just do not know much. And if we did it would most certainly guide our choices for representatives.

Instead we have smear campaigns. I am most familiar with the trash between Angle and Reid. And that contributes so much to our decisions.   God, force or human nature, help us.  And so it goes.

Cleveland Clinic Lou Ruvo Center for Brain Health Las Vegas Nevada

Lou Ruvo Brain Center - Working Together to Fight Alzheimer’s

This month I continue covering the Cleveland Clinic Lou Ruvo Center for Brain Health. Recall last month a new Director was appointed. This month the Center is emphasizing its progress and plans for future progress.

Some perspective: There are 5.3 million Americans with Alzheimer’s disease (including 29,000 Nevadans). This number is estimated to reach 16 million by 2050. September 21 is World Alzheimer's Day – a day when the Alzheimer's Association joins with organizations and people around the globe to raise awareness about Alzheimer's and its impact on our families, communities and nations. Today, 35 million people worldwide are affected by Alzheimer's and related dementias, and this number is growing rapidly. World Alzheimer's Day is an opportunity to raise awareness about Alzheimer's disease and the need for more education, support and research.

The Lou Ruvo Center, located in downtown Las Vegas is consistently performing clinical studies and reaches out to all volunteers to help. Education is the goal, Jeffrey Cummings, a medical director at Lou Ruvo Center for Brain Health explains, “Patients must participate in trials if there is to be any progress in developing new treatments for Alzheimer’s disease. Trials are critically important partnerships among patients and families, doctors and scientists to advance new treatments for the Alzheimer’s disease.” Las Vegas Sun Sept. 19, 2010.

The Lou Ruvo Center for Brain Health has been in various stages of opening as construction was completed and is now fully operational. World Alzheimer’s day is September 21 and The Center announces it has great plans and hopes for finding a cure. And of course this gives Las Vegas some notoriety in the field of medicine – something most would agree is sorely needed.

First, While most previous drugs have failed, the drugs being tested today are based on years old science (it takes 7 to 10 years for a drug to be approved by the FDA) Since we now have a better understanding of which proteins damage the brain (build up of a toxic peptide called beta amyloid) we can be more focused. (See my post on July 15, 2009.)

Second, newer and better brain imaging technology and spinal fluid tests significantly affect drug development. This is revolutionizing the way we think about Alzheimer’s disease. These new imaging techniques give researchers a clearer picture of those likely to develop Alzheimer’s later in life at an earlier age.

Third, early diagnosis is a major goal. Since we are able to detect disease onset sooner, a patient may still make crucial decisions regarding care and more while their faculties are still more or less intact.   Participation in health care and other life decisions prior to intellectual decline is an important aspect of any patient’s care.

If you are interested in participating in clinical trials contact Cleveland Clinic’s Lou Ruvo Center for Brain Health by clicking here.

Headline: Study of Best Test for Alzheimer's

PET Scans Affirmed

New research has identified the memory and brain scan tests that appear to predict best whether a person with cognitive problems might develop Alzheimer's disease. The research is published in the June 30, 2010, online issue of Neurology®, the medical journal of the American Academy of Neurology. (AAN)

Longevity tests are tests that examine data over time rather than at one moment in time.  The study looked at participants between the ages of 55 and 90 and were followed for an average of 1.9 years. During that time, 28 of the participants developed Alzheimer's disease.

People who showed abnormal results on both PET scans (positron emission tomography) and episodic memory tests were nearly 12 times more likely to develop Alzheimer's disease than those who scored normally on both measures.

Thin people statistically face higher risks of dementia

Researchers at Milan University examined a total of 245 patients averaging 74 years old who had been suffering from mild cognitive impairment for approximately two-and-a-half years. The mental capabilities of about half the patients remained stable during that period. About two thirds of those whose condition had deteriorated developed Alzheimer's Disease. The remaining third developed another form of dementia. Those whose cognitive disturbance deteriorated had a significantly lower BMI (mean value of 23.81) than those whose condition had remained unchanged (BMI mean of 25.47). Especially significant was the elevated risk of deterioration among those patients with a BMI of 23 or under. 

Illustration of patient inside scanner
 

Legislative Update September 2010

The Brain Injury Association of America authorizes this update:

Appropriations Update

This week Congress weighed the possibility of utilizing a stopgap funding measure to keep much of the government running in the new fiscal year, which starts Oct. 1. However, it is not yet clear if Congress will opt to approve a stand-alone continuing resolution (CR), or to attach the measure to one of the regular spending bills.

BIAA will monitor the situation closely and continue to advocate for increased funding for brain injury programs in Fiscal Year 2011.

Health Care Reform Update

On August 27, 2010, BIAA, as part of the Consortium for Citizens with Disabilities (CCD), submitted comments to the Department of Health and Human Services and the Department of Labor regarding the health care reform law implementation of Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections, (otherwise known as the Patients’ Bill of Rights). 

CCD detailed support of the many patient protections outlined in the proposed regulation and also suggested some language that would strengthen patients’ rights further. For full viewing, a copy of the document can be found on our Web site.

Veterans’ Traumatic Brain Injury Rehabilitative Services Improvements Act

On September 17, 2010, BIAA officially endorsed The Veterans’ Traumatic Brain Injury Rehabilitative Services Improvements Act of 2010 (HR6123) which was introduced by Congressman Tim Walz and includes Congressman Bill Pascrell, Jr., co-chairman of the Congressional Brain Injury Task Force, as a co-signer. The bill ensures wounded warriors suffering from traumatic brain injury (TBI) receive a more comprehensive and holistic rehabilitation plan that is focused not only on physical restoration but also on mental health, independence, and quality of life.  

Additionally, the legislation would aid veterans in maintaining the gains they have made in rehabilitation programs by requiring the VA to develop rehabilitation plans that stress restoration and maintenance of functioning rather than simply restoration. Both BIAA and our partners at the Wounded Warrior Project as well as several other veterans’ groups have endorsed the measure and BIAA is advocating for additional co-sponsors and consideration by the Veterans’ Affairs Committee this fall.

ConTACT Act

  

On September 8, 2010, the House Energy and Commerce Committee, Subcommittee on Health held a field hearing regarding the ConTACT Act (HR 1347) in Newark, NJ entitled “Protecting School-aged Athletes from Sports-related Concussion Injury.” The Brain Injury Association of New Jersey (BIANJ) testified on BIAA’s behalf about their experiences in New Jersey including their proposed state legislation, opinions on how the ConTACT Act could be modified to reflect the current situation in states across the country, and why it is important to continue the push towards protecting student athletes from second impact syndrome.

 

On September 16, 2010, the Health Subcommittee of the Energy and Commerce Committee voted to approve the ConTACT Act and send it on to full committee consideration. The subcommittee adopted several changes to the legislation suggested by BIAA including ensuring that the measure works in concert with state legislative efforts, providing that any type of cognitive tests, not just computerized tests, be eligible to receive state grants under the baseline testing provision, and encouraging the Department of Health and Human Services (HHS) to work with BIA state affiliates and other relevant organizations during the law’s implementation period.

 

BIAA continues to work alongside the House Energy and Commerce Committee, the House Education Committee and both Congressman Pascrell and Platts to move the ConTACT Act and its companions through the full committees and on to the House floor. Full Energy and Commerce Committee consideration is expected to take place next week. BIAA will monitor the situation closely and alert grassroots advocates if action becomes necessary.

 

 

State Medicaid Funding

 

 

In August, Congress approved a $26.1 billion state-aid package (HR 1586) that extends enhanced federal Medicaid funding to states through June, 2011. The enhanced funding was originally authorized by the economic stimulus law and, as a result, bolstered the Federal Medical Assistance Percentage (FMAP) through Dec. 31, 2010.

 

Because December is halfway through the fiscal year for states and a discontinuation in December would cause serious state budget shortfalls, BIAA, its chartered state affiliates, BIAA’s grassroots network and the National Association of State Head Injury Administrators (NASHIA) advocated strongly to ensure that the enhanced funding would be extended through June, 2011. The extension is a major victory for the brain injury community as Congress struggled for several months to find a way to procure funding offsets in order to approve this measure.

 

 

Health Resources and Services Administration (HRSA) Long-term Plan

 

During the August recess, as a follow up to a meeting held on June 15, 2010, representatives from HRSA and various TBI stakeholders held a teleconference to plan work on a long-term plan for the Federal TBI Program and also to discuss possible changes to the TBI Act come reauthorization in 2012. 

 

HRSA, BIAA and the National Association of State Head Injury Administrators (NASHIA) have begun to assemble an advisory board to work on the long-term plan and to also manage and incorporate public comment and transparency. BIAA is encouraged by the partnership forged between TBI stakeholders and HRSA and is looking forward to elevating the Federal TBI Program within HRSA and to advocating for increased funding for the program by leveraging agency cooperation in program improvement and efficiency on Capitol Hill.

Concussion Training for Youth Sports

Concerned about Concussion in Youth Sports?

A New FREE CDC Online Training Helps Prepare Coaches and Parents in Less than 30 Minutes

Heads Up: Concussion in Youth Sports is a free online training available to coaches, parents, and others helping to keep athletes safe from concussion. The training was developed by CDC’s Injury Center in partnership and other leading organizations. It features interviews with leading experts and interactive exercises to help coaches and parents recognize a concussion and know how to respond if their athlete might have a concussion.

Coaches and Parents Will Learn:

  • To understand a concussion and the potential consequences of this injury,
  • To recognize concussion signs and symptoms and how to respond,
  • About steps for returning to activity (play and school) after a concussion, and
  • To focus on prevention and preparedness to help keep athletes safe season-to-season.

Remember, if you think an athlete has a concussion:

  • Do not assess it yourself,
  • Take him/her out of play, and
  • Seek the advice of a health care professional.

When in doubt, sit them out!

Learn more about concussion at www.cdc.gov/Concussion.

  

Learn more about concussion at the Center for DiseaseControl www.cdc.gov/Concussion.

Research and Hope for Alzheimer's Patients

New research supported in part by grants from the National Institute of Aging, part of the federal government's National Institutes of Health, and the U.S. Department of Defense, brings hope to the understanding and treatment of Alzheimer's Disease.

Reported in the Sept. 2 issue of the journal Nature,  the problem in Alzheimer's disease,  is beta-amyloid, a protein that accumulates in the brain and causes nerve cells to weaken and die.

Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 60.

Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person’s daily life and activities. Estimates vary, but experts suggest that as many as 5.1 million Americans may have Alzheimer’s.

Drugs designed to eliminate plaques made of beta-amyloid have a fatal problem: they need to enter the brain and remove the plaques without attacking healthy brain cells.  Scientists have learned an enormous amount about how beta-amyloid plaques are formed and the toxic effects that these structures as well as the earlier forms of beta-amyloid have on neurons and synapses. These findings have opened up new avenues of investigation and new possibilities for therapeutic targets. New research from the laboratory of Nobel Prize winner Paul Greengard, however, suggests that treatments modeled on the blockbuster cancer drug Gleevec could be the solution. 

Gleevec has the unique ability to bind to a protein that triggers the production of beta-amyloid plaques. The new research from Greengard's lab shows that this protein, called gamma-secretase activating protein (GSAP), dramatically and selectively increases the production of beta-amyloid peptide, which makes up the senile plaques found in the brains of most people with Alzheimer's. 

We are still far from shouting "success" and "cure" but we are inching closer.  Scientists are conducting studies to learn more about plaques, and other features of Alzheimer’s disease. They can now visualize plaques by imaging the brains of living individuals. They are also exploring the very earliest steps in the disease process. Findings from these studies will help them understand the causes of Alzheimer’s.

All this for a Punch?

A local Las Vegas news story was published in the Review Journal entitled “Man arrested for punching a man who later died of a brain injury.” While the sad fact that the man who got punched died of severe brain injury, the reality of how actions we typically do not relate to serious injury or death happen every day.

Basically, a man and his girlfriend were taking the dog for a walk when another man started publicly urinating. When the first man asked the urinating man to cover up, the urinating man challenged him to a fight. That is when the walking man punched urinating man which, as a result, caused urinating man to get wobbly knees, fall to the ground and hit his head. Urinating man died of severe brain damage a few days later.

And the walking man said to police while being arrested on suspicion of murder, “All this for a Punch?”
 

Reducing Golf Injury

Over the years, golf has become an increasingly popular sport, attracting new players of almost all ages and socioeconomic groups. Golf is practiced by up to 10 to 20% of the overall adult population in many countries. Beyond the enjoyment of the sport itself, the health-related benefits of the exercise involved in walking up to 10km and of relaxing in a pleasant natural environment are often reported to be the main motives for adhering to this activity by recreational golfers. Golf Injuries: An Overview Sports Medicine, Volume 26, Number 1, July 1998 , pp. 43-57(15).

Although golf is becoming more popular, there is a lack of reliable epidemiological data on golf injuries and overuse syndromes, especially regarding their severity.  Now a new study attempts to determine how to reduce injury from Golf.

Although golf has not been recognized as a sport associated with injuries, epidemiological studies document that back and elbow injuries are most common in male amateur golfers. Lower back and wrist injuries occur in the male golf professional while female professional golfers are more likely to suffer injuries to the wrist and lower back, respectively.  See, The frequency of golf injuries, McCarrol.

 In an effort to reduce golf injuries, many of which are treated by orthopedic surgeons, the AAOS American Association of Orthopedic Surgeons, recommends the following golf injury-prevention tips:

- Dress for comfort and make sure to wear the appropriate golf shoes; short cleats are best on the course.

- Do not hunch your neck or shoulders over the ball; it may predispose you to neck strain and rotator cuff tendinitis.

- To avoid golfer's elbow, caused by a strain of the muscles in the inside of the forearm -- perform wrist and forearm stretching exercises and try not to overemphasize your wrists when swinging.

- To avoid lower back pain caused by a poor swing -- try rowing and/or pull down exercises to improve flexibility and muscle strength. 

To return to golf after hip or knee replacement, the AAOS suggests the following safety guidelines below:

- Always warm up and stretch well before playing, but avoid undue strain on your replaced joint.

- Get back into the game slowly. Begin with chipping and putting before hitting irons and then woods. Also, it is best to play just nine holes initially; once this can be done comfortably you can try a full 18.

- Use a riding cart initially. Those who like to walk while playing should wait until they can play comfortably with a cart and then try walking. It's best to use a pull cart rather than carrying your bag.

- Be aware of weather conditions; wet weather can predispose you to falls, especially when the legs are still weak.

- Use "soft spikes" (required by most courses now) or even tennis shoes (if ground is not wet). This will reduce torque on the hip and knee.

- Don't get frustrated when you resume playing. You may not hit the ball as far as you did prior to surgery because the leg will be weak; this will get better as strength returns.

- Be careful about squatting down to line up a putt. This can put too much pressure on the knee and could possibly cause a dislocation of a hip prosthesis.

- Continue a regular exercise program to maintain as much strength in the leg as possible. 

 According to the U.S. Consumer Product Safety Commission (CPSC), more than 115,000 Americans were treated for golf-related injuries in 2009.   Be careful and enjoy the sport longer.

Psychological Bait for the Sexes

What attracts men to women?  What do women want in men?  A psychology professor in Rochester, New York, has some interesting ideas.  Study results show that the color red worn by men increases their chances with most women.  Similarly, a man's station in life registers high on the aphrodisiac scale.  And of course romance.

But before you agree or disagree, know that the Journal of Experimental Psychology: General published an article supporting those findings.  And not just among human test subjects.

"In many nonhuman species of vertebrates, females are attracted to red on male conspecifics. Red is also a signal of male status in many nonhuman vertebrate species, and females show a mating preference for high-status males," says Dr. Elliot Andrew.

And women like their men macho.  Being metrosexual ranks more of a turn off for women then the traditional rugged look.  In Psychology of Men and Masculinity, modesty in men is seen as the less likely to cause attraction.  The article is entitled When men break the gender rules: Status incongruity and backlash against modest men.

And the results for men? "Heterosexual women bear the brunt of narcissistic heterosexual men's hostility, while heterosexual men, gay men and lesbian women provoke a softer reaction," according to psychologist Dr. Scott Keiller from Kent State University in Sex Roles: A Journal of ResearchSex Roles is an interdisciplinary behavioral science journal offering a feminist perspective.

Another piece of information in the universe to think about.

FMCSA Releases Safety Measurement System to Motor Carriers

The U. S. Department of Transportation’s Federal Motor Carrier Safety Administration (FMCSA) is pleased to announce the next step in the rollout of Comprehensive Safety Analysis 2010 (CSA 2010).

CSA 2010 Data Preview
Commercial motor vehicle carriers may now view their individual safety assessments on the Data Preview Website. This updated Website provides motor carriers with information on where they stand in each Behavior Analysis and Safety Improvement Category (BASIC) based on roadside data and investigation findings. Each motor carrier’s BASIC assessments are visible only to them (and to enforcement staff) until December of 2010. In December, assessments will be made available to the public. Also, enforcement agencies will use these assessments to prioritize the Agency’s enforcement and compliance assistance workload. By providing carriers with this information now, FMCSA’s approach gives carriers the earliest possible opportunity to improve compliance.

FMCSA is providing motor carriers with this early look at the new Safety Measurement System (SMS) so they can see their performance data, can address safety compliance issues right away and can update and verify their data online. Release of this safety performance information underscores FMCSA’s commitment to data integrity and the motor carrier industry’s responsibility for ensuring commercial vehicle safety. This important step is designed to allow motor carriers to identify and address unsafe behaviors that can lead to crashes. What can motor carriers do now to prepare for the new system? Motor carriers should look at their assessment on the Data Preview Website, identify any data mistakes, verify and update their motor carrier census data, in particular power units (PU) and vehicle miles travelled (VMT) on the MCS-150 form, and take the necessary steps to correct unsafe driver and/or company safety practices.

Last year I handled a case where one motor carrier failed to review another hired motor carrier's Safe Stat scores which hovered around a 97 which put it in the bottom 3%.  This type of negligent, even reckless. behavior may be reduced with new procedures like the new regulations being tested and passed. 

Conservative Republicans scream "no government regulation" until one of their own is critically injured in a crash with a semi tractor trailer.  Without regulation, truck corporations are governed by only one thing - profit.

More Information
Complete details on the Data Preview are available through Data Preview Guidance (FAQs), the new SMS Methodology Version 2.0 and SMS Changes Explanation. FMCSA has responded to field test results and stakeholder feedback to improve SMS.