When to Use Already and Yet in English for ESL Students

The words  already  and  yet  are common words in English that generally refer to an event that has or has not happened before another event in the past or present: She hasnt finished her assignment yet. The event has not been completed up to the present moment in time. Jennifer had already eaten by the time he arrived. The event occurred before another event took place. Present Perfect Both already and yet refer to  activities that have or havent occurred before the present moment in time. In both cases, the adverb  recently  could be substituted with the same meaning: I have already finished my lunch. Ive recently finished my lunch. Have you seen Tom yet? Have you seen Tom recently? They havent visited Rome yet. ï » ¿They havent visited Rome recently. Referring to a Past Event Already is used to indicate that something that happened before the moment of speaking. However, it refers to something that affects the present moment in time. Lets take a look at a few examples: I have already finished the report. This sentence could be used to express the idea that I finished the report and it is ready to read now. She has already seen that film. This sentence might express that the woman saw the film in the past, so she has no desire in the present moment to see the film. They have already eaten. This sentence would probably be used to state that they are no longer hungry. The key to using already is to remember that an action that has happened in the past  Ã¢â‚¬â€Ã‚  often in the recent past  Ã¢â‚¬â€Ã‚  affects the present moment or a decision about the present moment in time. Therefore, already  and  yet  are  used with the present perfect tense. Sentence Placement Already is placed between the auxiliary verb have  and the participle form of the verb. It is used in the positive form and should not be used in the negative: Subject have / has already past participle objects I have already seen that film.Mary has already been to Seattle. Incorrect usage: I have seen already that film. Already is generally not used in the question form. However, when expressing surprise in a rhetorical question it is sometimes used in informal conversations and added to the end of the sentence: Have you eaten already?!Have you finished already?! Asking Questions Yet is used to check whether something has occurred up to the present moment: Have you seen that film yet?Has Tim done his homework yet? Yet  is generally used to ask about something closer to the present moment. Yet is often used when someone expects something to have occurred before the moment of speaking: Have you finished that report yet? ï » ¿In this case, a colleague expects the report to be finished soon. Question Placement Yet is always placed at the end of a question. Notice that yet is not used with question words as questions with yet are yes/no questions: Have subject past participle objects yet ? Have you finished that report yet?Has she bought a new car yet? Negative Form Yet is also used in the negative to express that something that is expected has not yet happened. In this case, yet is placed at the end of the sentence. Subject have not / has not past participle objects yet She hasnt finished the report yet.Doug and Tom havent telephoned yet. With the Past Perfect Already can also be used with the past perfect to express that something had happened before something else: She had already eaten when he arrived.Jackson had already done his homework when he was asked for help. With the Future Perfect Already is also used with the future perfect to express that something will have been completed before something else occurs: She will have already finished the paperwork before the meeting.Frank will have already prepared the report by the time the boss asks for it. Coordinating Conjunction Finally,  yet  can also be used as a coordinating conjunction with the same meaning as  but  to connect two simple sentences into one. Place  yet  after a comma to introduce a dependent clause: Theyd like to go to that new restaurant, yet they cant get a reservation.ï » ¿Hed already bought tickets to the play, yet he wasnt able to attend the performance.

Critical Thinking And Relational Ethics Essay - 942 Words

Critical Thinking and Relational Ethics in Nursing Practice: A Case Study Analysis A registered nurse s role in patients recovery post surgery is greatly related to the concepts of relational ethics and critical thinking, which are inherent in every interaction between human beings. These concepts will be described and then used to analyze a case study of a patient s experience with health-care. Associated research will be used to support the case study analysis. What Are Relational Ethics and Critical Thinking? Critical Thinking The ability to think critically is vital to a nurse s role as nurses are faced with constant decision-making in which the answers are often not completely clear or definitive but the consequences of which affect human lives. Critical thinking involves the use of a specific thought process to guide complex clinical decision-making (Arnold Boggs, 2011). According to Arnold and Boggs (2011), to apply critical thinking, one must: clarify concepts, identify his or her own values, integrate data and identify missing data, obtain new data, identify the significant problem, examine skeptically, apply criteria, generate options and look at alternatives, consider whether factors change if the context changes, make the final decision. Barriers include attitudes, habits, cognitive dissonance, and clashing of personal and professional values. Some important characteristics to a nurse being able to think critically are: the ability to reflect onShow MoreRelatedChristian Theolo gy And Feminist Theology1699 Words   |  7 Pagesinfluence how a person approaches their own theology. Considered a â€Å"prolific theologian,† Stanley Grenz was a leader among evangelical theologians (Warner, 2005, p. 42). 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(as cited in Downey, D., Porter, S., 2009). God is an intelligent, creative, relational Being. God created all that exists (Gen 1-2) and right from the beginning God affirmed and blessed man’s participation in His creation (Gen 1:28-30, Gen 2:19-20). He created man in His image (Gen 1:26-27, 2:7) and for His fellowship (Gen 3:9)Read MoreEssay on Working at Relational Depth2600 Words   |  11 PagesIMPACT HAS THE RELATIONAL APPROACH, AS DESCRIBED IN ‘BEYOND EMPATHY’ AND MEARNS AND COOPER’S ‘WORKING AT RELATIONAL DEPTH’, HAD ON YOUR CLIENT WORK. ILLUSTRATE YOUR ANSWER WITH REFERENCE TO A SINGLE SESSION WITH A CLIENT. Introduction This essay will be looking at the importance of relational depth and further more I will attempt to demonstrate my growing awareness of my relationship with my clients and how it has impacted on my client work. What is Relational depth? Relational Depth comes

Escape of the Gymnasium Free Essays

As I sat in a managerial meeting, nervously taking the wrath from demanding hierarchy management, my mind began to drift back to an incident in my early childhood†¦ â€Å"Nice shot Shrimps!† There I was shooting the basketball in gym class, all five foot four inches, 125 pounds of me. I am known as â€Å"Shrimps,† but my real name is Donald I am a small kid, with the heart of a kitten. Patiently waiting for the school bell to ring, to notify me and the rest of the school it was time to go home for the day and come back again in a week and half, I could hardly wait to get home and show my parents my straight A report card. We will write a custom essay sample on Escape of the Gymnasium or any similar topic only for you Order Now It seemed like two life times had passed already, but I was still stuck there waiting to hear the ring of the damn bell. All of a sudden, I realized Lenord was headed into my vicinity. My pulse began to race, sweat dripping from my forehead; I continued to shoot the basketball. Soon I became scared, so scared I thought I was going to wet myself. The threat was real, very real, but this wasn’t the first time I’d been in danger and sure seemed like it wouldn’t be the last. I can still see him even now, with a crystal clear vivid image of him. How could anyone forget what he looked like? Everyone in the school knew him as J Dog, but behind the slang name J Dog, he was known to all too many as Lenord. Lenord was double the size of any average Joe his age, standing tall looking over the top of his peer’s heads desperately awaiting someone to step in his way. J Dog, the big fat aggressive pain in everyone’s bottom, the school bully. J Dog was always with four of his immediate peers. J Dog generally picked fights with weaker students. He would abuse them with his strength and powerful vocal cords, which built his ego on his victims. For nearly the past seven years I have watched him and his four man mafia pick on younger boys. I can not even count the times on my twenty fingers and toes that I was the onlooker, watching sadly from the â€Å"birds eye view,† waiting for their time to come and be put in their place. One incident I witnessed was when J Dog and his four man mafia picked a fight with a varsity football player. As I observed the attack through the bathroom stall the fight seemed too unfair. J Dog and his crew attacked the peer in the boys’ bathroom. They all took their turns aggressively punching and kicking the peer. I sat in the stall curled up on the toilet, bracing myself nearly feeling every blow. Showing no remorse they continued on their brutal attack until they seemed too tired to go on. The fight ended with a vicious kick to the face by J Dog. Constantly and repetitively J Dog and his crew moved away from the school handbook and the countless school policies that it entailed. Yes indeed I knew what they were doing, as well as everyone else at the school including the school staff, but no one took the time to create a peaceful environment. It just seemed that no one would stand up to their mischievous behavior. I never understood why this was this way. Why do we all sit here back on our heels and watch this reckless’ abandon go on with his terror? We were all equally guilty, guilty as J Dog and his fellow perpetrators. The longer we stood back and accepted their behavior and the longer they were able to rage throughout the school, the stronger they became. This was not a good thing for me, or for the entire school. J Dog and his four brotherhood boys came for me one spring morning. In fact it was the last day of school prior to a well anticipated eleven day Easter break. I’d been playing basketball with a few of my peers in the schools’ gymnasium. Looking on the other side of the gym behind a set of bleachers, sat J Dog and his fellow four up to no good teasing and laughing at fellow students. The obnoxious jerk himself, Lenord, and his four manned mafia soon came to the side of the gym where I was playing basketball. Before I had the chance to warn my friends I heard abruptly, â€Å"Donald, you four-eyed worthless piece of shit,† the bully said. â€Å"It’s your turn.† My heart hit rock bottom, feeling myself gasp for air, I asked myself â€Å"oh no here we go, I think it is my turn to be plum bulled, or isn’t it?† Such simple words, so much unsaid. I didn’t need any further explanations. I knew what they wanted and it was not their sanity back. As mentioned earlier I’d seen others after they’d had their turn. It was never a pretty sight. Too many times over the years I have witnessed the brutal attacks on my fellow classmates. In time they would have progressed beyond schoolyard aggression, sinking lower into the anti-social status of the criminal underworld. They’d never be leaders of any kind, just straight up thugs. They’d been well schooled in this art. I had never once in my life been in a fight. Well unless my sister counts? To say I was scared of the upcoming attack would have been an understatement. I was petrified. I knew if I was not careful in what I said or did I may end up dead. As I sat there overshadowed by five ruthless thugs, I knew that even in a fair fight I couldn’t possibly win. Other students swirled around us, isolating our little group. It was well known everyone in the oval knew of the intended attack. Sweating profusely, I was nearly drowned in my own sweat, knowing what was waiting for me, wondering why he didn’t just lash out and end this mockery, this teasing. I did not even realize then that he’d had to work himself into a frenzy so he could just hit, and hit, and hit. â€Å"What’s up, Shrimps? Don’t you want your pretty boy face all smashed up like everyone else in this school? Or will you be upset because you will need a face lift?† As I sat there I could only think of dumb things like this girl name Ashley sucking her thumb and my friend telling me to imagine my peers naked while giving a speech. Only the sight of these two things registered on my numbed, frightened brain. â€Å"Why don’t you leave me alone? Go annoy someone else.† I took the basketball and dropped it at my feet. â€Å"Are you throwing the basketball at me, Shrimps?† He snorted, searching for any excuse to start a fight with me. I didn’t want to give him an excuse. He stood there warlike; hands on hips, wearing his all blue attire. His stomach fat erupted through ragged holes in his once blue t-shirt. Supporting the color blue was what J Dog felt was the holiest color known to mankind. â€Å"Don’t be silly, I just dropped it at my feet,† I whined, not at all mentally prepared for the brutal assault. â€Å"I know you didn’t just call J Dog silly,† one of his collogues shouted. â€Å"Or I’ll flatten you myself. Come on J Dog, give the idiot a reason to talk back and let’s get the hell out of here. It is just too hot in here to have to put up with all of this shit,† he added as he grinded his teeth, showing the enormous gap in his bottom teeth, so enormous I could kick a field goal through it. â€Å"You call me silly, did you? You’re nothing but a poor excuse for human life. You can run to the teachers all you like, see, I am not afraid of them.† Thoughts began to race inside me. I wondered why school authorities put up with him. Too many times Lenord and his four mates’ behavior were over looked. School fights happened; sometimes students went home a little worse for wear. I could not help to notice that in a mere two minutes the bell would sound. Thinking to myself will that bell ever ring and let me out of this mess I got myself into? I responded to this coward known to too many as J Dog, â€Å"I didn’t call you silly; I just said I did not throw the basketball at you.† I was answered by a heavy push in the chest, the first sign of physical violence. Staggering back, it was followed by another massive blow from the aggressive J Dog. He stepped back up to me, face to face, as J Dogs four amigos stood close beside him, crowding me like flies on dead carcass. â€Å"Won’t you stay and fight?† He spit little specks of salvia at me but I dared not acknowledge them. â€Å"Bloody little coward.† He’d been right; I was a coward, so scared I couldn’t run, even if I wanted to, even if there’d been somewhere to go and get away from the mess I was in. I silently choked back sobs, fighting to hold back tears of terror. The panic controlled me; I stood there looking like a buffoon right in front of Lenord, his four friends, my best friend, twenty other students, and one especially hot girl named Cindy. Again the palms of his massive hands stabbed at my chest and, again, I staggered back. I felt the impact of his hands long after they’d abruptly returned to his hips. The five men closed back up on me as we danced further away from the gymnasium bleachers or what I like to call protection from a fall and embarrassment. I felt my grip on reality slipping further and further away. Others were here to only see another beating set forth by J Dog and to witness my shame. Not that J Dog and his mates wouldn’t let everyone know how well, or poorly, I took the abuse. There was a certain honor in taking your licking like a man. I hadn’t felt like a man, and had been sure there was little honor in J Dog. However, I couldn’t hide for the rest of my life. It had been time to stop the hopelessness and stand up for myself and for the rest of the school population. It had to be all or nothing. I preferred nothing, but in the back of my head I wanted nothing more than to set the example. Putting on a brave face, I firmed my voice and looked the outsized buffoon in the eye. â€Å"I know you can beat me like a red headed step daughter, I don’t doubt it at all.† As the jittered mess in my voice came out I wanted to look and feel confident in what I said to this animal. â€Å"But Lenord,† I added, â€Å"Just remember one thing. When I hit the ground, so too will your front teeth, you worthless coward. I’ll get one punch in, you know I will, and that punch will be directed right for your front teeth. When I am done with you, you will no longer look like the donkey you look and smell like now! Is beating me up worth losing your front teeth?† I was being optimistic, I doubted that I could even get in one punch; I doubted even if delivered I could have knocked out any of his teeth. The reaction from the overweight J Dog was almost priceless. Suddenly it was the bully who backed off, looked lost, looked everywhere but at his bewildered fellows or me. â€Å"Er†¦ er†¦Ã¢â‚¬  he stuttered, â€Å"you’re not worth the effort, you are just a waste of my breath, you little crap headed pansy. I wouldn’t waste my spit on you. You better get away from me before I change my mind and pound the crap out of you.† Now I was the one standing aggressively, hands on hips, watching the fast disappearing of the other bullies as they soon walked away in disbelief. Cocky in my arrogance, I spit out a final mouth of spit in their vicinity. It had been the most rewarding victory of my life, standing there on that field of honor, knowing that I had conquered the mighty, invincible J Dog. I wanted to shout it out to the rest of the school and let everyone in the school district know of J Dog’s defeat. My mind switched off that near death episode, back to the present, to the here and now. Hierarchy management surrounded me, trying to pressure me and abide to their will. Tacky school clothes were replaced with tailored business suits, the overt threat of violence with an undercurrent of raw power. Things hadn’t changed. As before, I was the underdog, the potential victim. These smiling men were planning on beating me far worse than the luckless J Dog could ever have imagined. Here I was fighting for my life, my work life, and for the future of my family and myself. I could lose everything. I felt too old to start everything all over again. These smiling piranhas had planned on chewing me up and spitting out the bones. I had to fight for myself and for what I knew was right, and it was time to either stand up and fight their smirking aggression, or lie down and die like a dog. I thought again of J Dog the bully, remembering how quickly he’d collapsed after I stood in his way of destruction. Clearing my throat, I looked straight in the owner’s eyes. â€Å"This is what should happen,† I began, as an idea rushed into my mind. Fully knowing what I was going to say, I continued as I spilled out the beans. How to cite Escape of the Gymnasium, Papers

Case Study Construction of Quota Park Pathway †Free Samples

Question: Discuss about the Construction of Quota Park Pathway. Answer: Introduction The application of the continuous improvement plan within the project allows in improving the quality and standard of the undertake project. According to Goetsch, and Davis, (2014), the project manager needs to identify the particular area of improvement within the project for the achieving the particular level of quality within the project. Improving the particular quality in the project allowed in ensuring the customer satisfaction. In this assignment, the construction of the shared pathway in Quota Park has been considered as the required construction project involved in the implementation of the continuous improvement plan (Dannapfel, Poksinska, and Thomas, 2014). The construction of the shared pathway is sponsored by Mackay regional council for the construction of a shared footpath inside the Quota Park. Continuous Improvement Plan The application PCDA model is one of the classical approach for including the continuous improvement plan within the project (Aziz, and Hafez, 2013). The use of PDCA methods enables incremental improvement in the project quality and standard. The process of PDCA includes four major phases including planning, doing, checking and acting. Plan: The plan module of the PDCA model allows the project manager to identify the particular area that required the improvement for meeting the particular standard within the project (Santos, Wysk, and Torres, 2014). The project manager evaluates and analysis the various processes and techniques of theproject management plan and methodology for identification of the improvement scope within the project. The planning of the improvement plan is developed with the collaboration of all the team members working in the project (Andersen, Rvik, and Ingebrigtsen, 2014). The project manager developed a detailed plan for implementing the identified scope of improvement that will be established over the next phase of PDCA model. Do: The approval of the developed planning in the Plan Phase of the PDCA model initiated this particular phase (Modi, and Thakkar, 2014). In this phase, the approved plan are being executed to achieve the required level of quality. Check: After the implementation of the required modification the project manager continuously monitors and evaluates the impact and quality of the change implemented in the project. Act: This includes the last phase of the PDCA cycle that determines whether the implemented change is successful in improving the quality of the undertaken project (Martin, and Osterling, 2014). Procedural Documents Required in Improvement Plan During the establishment and development of continuous improvement plan for the Quota Park Shared Pathway Establishment project, the project manager needs to follow and record the information obtained during the project (McCarthy, and Rich, 2015). The development of proper documentation during the construction project ensures the proper flow of information among the team members and effective establishment of the plans (Merlino et al., 2015). The following are the examples of procedural documents that will be used during the improvement plan of Quota Park Project. Procurement Documents Importance Project Charter Project charter is one of the significant document required during the project improvement plan (Tyagi et al., 2015). The detailed project charter includes the requirements and scope of developing the shared pathway in Quota Park. The project charter is reviewed and approved by the Mackay regional council. Therefore, the application of the project charter ensures that that improvement plan follows and achieves the project deliverable and scope. Project ManagementPlan Theproject management plan illustrated the required plan, techniques and procedure that needs to be followed during the construction of the shared pathway in Quota Park. Project Management Plan demonstrates the applicant of the waterfall model for the construction project. Therefore, during the improvement process, the project manager needs to follow the waterfall project development technique (Dennis, 2016). In addition to that, the application of the project management documents assist the project team in developing the improvement plan while ensuring the elimination of the risks identified in the procedural documents. Project Risk Management Documents Risk Management documents developed during the project allows the project manager to identify the risks associated in the path construction with the possible relevant mitigation plan for eliminating or reducing the impact of the risks. Following the risk document during the improvement plan, assist the construction team to avoid the possible risks through the improvement plan and implementation of the pathway improvement process. Project Budget and Schedule documents The project schedule and budget documents are developed during the project planning phase. The required schedule and budget estimated for the construction of the shared pathway are included within this document (Gfu, Ionescu, and Teodorescu, 2014. During the improvement planning, the project manager needs to include the allocated budget and time for completing the improvement for the quota park pathway. Internal Audits The construction of the shared pathway for the Quota park involves significant amount of financial amount that is being sponsored by the Mackay regional council. The continuous improvement plan aims at ensuring the proper quality of the process followed during the construction (Thirkell, and Ashman, 2014). The application of the internal audits allows the project manager in documenting the area and scope that can be improved during the construction project. Quality Documents The project is continuously reviewed and quality of the path is under continuous monitoring and analysis. The quality report includes and identified that required area, process and techniques that is followed during the construction of the Quota Park having the possibility of improvement (Chaplin, and ORourke, 2014). The quality documents allows the project manager to plan for the particular are included in the continuous development process. Improvement Plan used in Quota Park Project The application of the lean improvement plan aims at including sustainable project management culture and leadership commitment for the construction of the shared pathway in the Quota Park. The proper application of procedure and principle of the lean methodology helps in achieving required efficiency, quality and safety during the construction of the shared pathway in Quota Park. For the improvement of the construction project, the project manager needs to identify and implement five significant principles in according to the lean thinking process (Clark, 2016). The following are the principles that needs to be implemented during the improvement plan of the shared pathway: Value Specification: The value specification process in the construction project helps in the identification of the customer need and activities that needs to be performed in the project. The project manager in this phase, evaluated the requirements and scope as identified and approved by Mackay regional council for the construction of the shared pathway. From the project assessment, the constriction of the shared pathway requires the installation of signage, paving, fencing, turf, concrete footpaths and pipe culverts while ensuring the environment, safety and traffic management at the Quota Park. Value Stream Identification: The Value Stream Identification in the project allows the project manager to identify the process, tools and areas that are not required in the project and eliminate them from the project plan (Poksinska, Fialkowska-Filipek, and Engstrm, 2017). Therefore, during the construction planning of the improvement plan, the project manager identifies the various process in the construction methods that are not required for the successful completion of the shared pathway. In this construction project, the project manager continuously change the project plan when something goes wrong during the project. During the construction phase, the use of unnecessary process, material transportation, labor workforce movement, and the storage of materials required for construction. The project manager ensures the proper evaluation of the time and budget provided to the construct for ensuring the required quality of the constructed pathway. Flow: Ensuring the flow of the construction process and improvement methodology allows the project team to focus on delivering the quality of the pathway constructed during the project. The project manager of the Quota Park construction project ensures that the required raw materials including concrete materials, fencing materials, pipe culverts materials required for the complete construction of the shared pathway. This allowed in the identification of the value stream within the Quota Park construction project. Pull: The principle of pull methodology needs to be applied instead of push for the construction of the shared pathway. This allowed the project manager to plan and construct the shared pathway with the exact requirement as mentioned by the Mackay regional council. In addition to that, this particular principle allows the construct team to incorporate any modification or new requirement in the shared pathway construction. This results in the time reduction and application of Just in Time project management tool for ensuring the completion of the shared pathway within the allocated time and budget. Perfection: The application of the perfection solution in the construction of the shared pathway within the Quota pathway enables the application of the continuous improvement plan in the construction project enables the construction team to deliver the pathway construction while ensuring the requirement and specification of Mackay regional council for developing the shared pathway. For meeting the required specification and Mackay regional councils satisfaction, the project manager ensure effective and continuous communication through the effective communication channel throughout the project. The application of the lean thinking process in the construction of the pathway in the Quota Park aims at minimizing the waste materials while ensuing the environment, safety and traffic management during the construction of the shared pathway. The application of the lean thinking procedure helps in increasing the effectiveness and productivity of the construction project. The significant determinants of the pathway construction of the Quota Park Pathway is to increase the labor flow and workflow reliability as the increment of the construction of the shared pathway. The project manager needs to apply concurrent engineering process for ensuring parallel execution of the construction work. The project manager would allocate multidisciplinary project team for obtaining the required productivity, quality of the required shared pathway. Project Manager uses Pert and CPM Network Analysis for appropriately scheduling the construction process and techniques. Furthermore, conducting the over lapping activities and parallel tasks during the construction of the pathway allows the completion of the entire project within the allocated and scheduled time. The application of the concurrent engineering focuses on the information sharing, communication and enhancing the team effort during the construction of the pathway. The project needs to incorporate the use of daily meetings and brainstorming sessions to share various views and ideas for improving the quality of the construction process. Furthermore, the project manager needs to ensure safety of the construction team and work environment at the construction location of the Quota Park. The alignment of the safety process and techniques during the construction procedure allows the project manager in reducing the environment pollution during the construction procedure. The modification of the quality based on conformance to the quality developed from the source can be identified with the application of the Quality Management T ools. The application of the TQM tools and techniques allowed in the evaluation and deification of the obtained quality needed for the construction of the Quota Park shared pathway. Furthermore, for ensuring the quality and improving the standard of the construction project, the project manager applies the visual inspection tools for identifying the uneven nature of the pathway and construction of the path. The modification of the pathway with the acceleration of the construction processes while ensuring the elimination of the possible risks ensures in achieving the required quality in the construction project. The project manager needs to regularly monitor and control the quality of the process and techniques used for the construction of the shared pathway in the Quota Park for effective continuous improvement plan. Conclusion The implementation of the lean thinking process for ensuring the continuous improvement plan for the construct of the shard pathway in the Quota Park allowed in improving and monitoring the quality of the construction project. Since, Quota Park project involved the construction of a pathway, the implementation of the improvement project involves the continuous monitoring and assessment of the quality during the improvement plan. The illustrated plan for improving the quality and pathway standard helps in ensuring the required quality of the undertaken construction project. References Andersen, H., Rvik, K.A. and Ingebrigtsen, T., 2014. Lean thinking in hospitals: is there a cure for the absence of evidence? A systematic review of reviews.BMJ open,4(1), p.e003873. 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