The Implications of Activity Based Funding for Emergency Departments : A Comprehensive Literature Review

Executive Summary Emergency Departments (EDs) locally, nationally and internationally are becoming increasingly busy. Within this context, it can be challenging to deliver a health service that is safe, of high quality and cost-effective. Whilst various models are described within the literature that aim to measure ED ‘work’ or ‘activity’, they are often not linked to a measure of costs to provide such activity. It is important for hospital and ED managers to understand and apply this link so that optimal staffing and financial resourcing can be justifiably sought. This research is timely given that Australia has moved towards a national Activity Based Funding (ABF) model for ED activity. ABF is believed to increase transparency of care and fairness (i.e. equal work receives equal pay). ABF involves a person-, performance- or activity-based payment system, and thus a move away from historical “block payment” models that do not incentivise efficiency and quality. The aim of the Statewide Workforce and Activity-Based Funding Modelling Project in Queensland Emergency Departments (SWAMPED) is to identify and describe best practice Emergency Department (ED) workforce models within the current context of ED funding that operates under an ABF model. The study is comprised of five distinct phases. This monograph (Phase 1) comprises a systematic review of the literature that was completed in June 2013. The remaining phases include a detailed survey of Queensland hospital EDs’ resource levels, activity and operational models of care, development of new resource models, development of a user-friendly modelling interface for ED mangers, and production of a final report that identifies policy implications. The anticipated deliverable outcome of this research is the development of an ABF based Emergency Workforce Modelling Tool that will enable ED managers to profile both their workforce and operational models of care. Additionally, the tool will assist with the ability to more accurately inform adequate staffing numbers required in the future, inform planning of expected expenditures and be used for standardisation and benchmarking across similar EDs. Summary of the Findings Within the remit of this review of the literature, the main findings include: 1. EDs are becoming busier and more congested Rising demand, barriers to ED throughput and transitions of care all contribute to ED congestion. In addition requests by organisational managers and the community require continued broadening of the scope of services required of the ED and further increases in demand. As the population live longer with more lifestyle diseases their propensity to require ED care continues to grow. 2. Various models of care within EDs exist Models often vary to account for site specific characteritics to suit staffing profile, ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Existing and new models implemented within EDs often depend on the target outcome requiring change. Generally this is focussed on addressing issues at the input, throughput or output areas of the ED. Even with models targeting similar demographic or illness, the structure and process elements underpinning the model can vary, which can impact on outcomes and variance to the patient and carer experience between and within EDs. Major models of care to manage throughput inefficiencies include: A. Workforce Models of Care focus on the appropriate level of staffing for a given workload to provide prompt, timely and clinically effective patient care within an emergency care setting. The studies reviewed suggest that the early involvement of senior medical decision maker and/or specialised nursing roles such as Emergency Nurse Practitioners and Clinical Initiatives Nurse, primary contact or extended scope Allied Health Practitioners can facilitate patient flow and improve key indicators such as length of stay and reducing the number of those who did not wait to be seen amongst others. B. Operational Models of Care within EDs focus on mechanisms for streaming (e.g. fast-tracking) or otherwise grouping patient care based on acuity and complexity to assist with minimising any throughput inefficiencies. While studies support the positive impact of these models in general, it appears that they are most effective when they are adequately resourced. 3. Various methods of measuring ED activity exist Measuring ED activity requires careful consideration of models of care and staffing profile. Measuring activity requires the ability to account for factors including: patient census, acuity, LOS, intensity of intervention, department skill-mix plus an adjustment for non-patient care time. 4. Gaps in the literature Continued ED growth calls for new and innovative care delivery models that are safe, clinically effective and cost effective. New roles and stand-alone service delivery models are often evaluated in isolation without considering the global and economic impact on staffing profiles. Whilst various models of accounting for and measuring health care activity exist, costing studies and cost effectiveness studies are lacking for EDs making accurate and reliable assessments of care models difficult. There is a necessity to further understand, refine and account for measures of ED complexity that define a workload upon which resources and appropriate staffing determinations can be made into the future. There is also a need for continued monitoring and comprehensive evaluation of newly implemented workforce modelling tools. This research acknowledges those gaps and aims to: • Undertake a comprehensive and integrated whole of department workforce profiling exercise relative to resources in the context of ABF. • Inform workforce requirements based on traditional quantitative markers (e.g. volume and acuity) combined with qualitative elements of ED models of care; • Develop a comprehensive and validated workforce calculation tool that can be used to better inform or at least guide workforce requirements in a more transparent manner.

Publishing, postage, and prizes : classic Australian children’s literature in the public eye

2012 saw the publication of competing and complementary lines of Australian “classics”: “A&R Australian Classics” (HarperCollins) and “Text Classics” (Text Publishing). While Angus and Robertson were key in establishing a canon of Australian children’s classics in the twentieth century, it was the Text Classics line which included a selection of young people’s titles in their 2013. In turn, Penguin Australia launched a selection of “Australian Children’s Classics”. In so doing, these publishers were drawing on particular literary and visual cultural traditions in Australian children’s literature. Public assertions of a particular selection of children’s books reveals not only contemporary assumptions about desirable childhood experiences but about the operation of nostalgia therein. In encouraging Australian adults to judge books by their covers, such gestures imply that Australian children may be similarly understood. Importantly, the illusion of unity, sameness, and legibility which is promised by circumscribed canons of “classic” children’s literature may well imply a desire for similarly illusory, unified, legible, “classic” childhood. This paper attends to public attempts to materialise (and legitimise) a canon of classic Australian children’s literature. In particular, it considers the ways in which publishing, postage stamps, and book awards make visible a range of children’s books, but do so in order to either fix or efface the content or meaning of the books themselves. Moving between assertions of the best books for children from the 1980s to today, and of the social values circulated within those books, this paper considers the possibilities and problematics of an Australian children’s canon.

Literature review: Student centred schools make the difference

Student-centred schools focus on designing learning experiences that recognise and respond to the individual needs of each of their students. They encourage all members of their school community to be active learners, working to enhance the educational opportunities available at their school. This literature review seeks to address and explore the hypothesis that studentcentred schools make the difference. The review commences by defining the concept of student-centred schooling and the various learning and educational theories that underpin related research. The authors present a model comprising six core elements of learning environments that student-centred schools demonstrate, with a focus on leadership. They also link their findings to the five professional practices in AITSL’s Australian Professional Standard for Principals to illustrate how these leadership practices drive and sustain studentcentred schools. Drawing from Viviane Robinson’s work on the dimensions of student-centred school leadership, together with several further dimensions identified through an environmental scan of literature, the authors consider how and in what ways student-centred schools make the difference.

Literature review : A culture of trust enhances performance

In this environmental scan of research and policy literature, the authors consider various definitions of trust as they seek to address and inform the hypothesis that ‘a culture of trust enhances performance’ in schools. The discussion draws on the work of the Australian Institute for Teaching and School Leadership in school leadership and research by Caldwell and Harris (2008) to consider ways in which trust is linked to performance in schools and organisations. It explores the concept of trust as a form of capital available to schools, and highlights how successful school leaders work to align trust, strategy and passion in implementing effective change. At the heart of the review is the relationship between trust and school improvement. An adapted model of the elements of a culture of trust developed by Bryk and Schneider in their influential study of trust in school reform in Chicago is used to frame this aspect of the review. The authors identify four essential categories of relationships that enable schools to be described as having a culture of trust. The review concludes with a discussion of the relationship between trust and school governance.

Developing intercultural understanding through Asian-Australian children’s literature.

This PETAA paper discusses how the cross-curriculum priority concerned with developing Asia literacy, namely ‘Asia and Australia’s engagement with Asia’, can be significantly advanced through the study of children’s literature. The discussion proceeds from a brief overview of the historical development of Asia literacy to its current place within the Australian Curriculum. It then considers the potential of literature for assisting students and teachers in realising this priority through the Asian-Australian Children’s Literature and Publishing dataset, a research project on AustLit. Finally, it discusses a small selection of texts – two picture books and a novel – with suggestions or prompts for raising students’ intercultural understanding.

A critical look at cryptographic hash function literature

The cryptographic hash function literature has numerous hash function definitions and hash function requirements, and many of them disagree. This survey talks about the various definitions, and takes steps towards cleaning up the literature by explaining how the field has evolved and accurately depicting the research aims people have today.

A Survey of the 2010 Quartz Crystal Microbalance Literature

In 2010 there has again been an increase in the number of papers published involving piezoelectric acoustic sensors, or quartz crystal microbalances (QCM), when compared to the last period reviewed 2006-2009. The average number of QCM publications per annum was 124 in the period 2001-2005, 223 in the period 2006-9, and 273 in 2010. There are trends towards increasing use of QCM in the study of protein adsorption to surfaces (93% increase), homeostasis (67% increase), protein-protein interactions (40% increase), and carbohydrates (43% increase). New commercial systems have been released that are driving the uptake of the technology for characterisation of binding specificities, affinities, kinetics and conformational changes associated with a molecular recognition event. This article highlights theoretical and practical aspects of the principals that underpin acoustic analysis, then reviews exemplary papers in key application areas involving small molecular weight ligands, carbohydrates, proteins, nucleic acids, viruses, bacteria, cells, and membrane interfaces.

Irregular readers : Arthur Conan Doyle’s “six dirty scoundrels”, boyhood and literacy in contemporary Sherlockian children’s literature

Young adult (YA) literature is a socialising genre that encourages young readers to take up particular ways of relating to historical or cultural materials. The first decade of the twenty-first century witnessed a boom in Sherlockian YA fiction using the Conan Doyle canon as a context and vocabulary for stories focused on the Baker Street Irregulars as figures of identification. This paper reads YA fiction’s deployment of Conan Doyle’s fictional universe as a strategy for negotiating anxieties of adolescent masculinity, particularly in relation to literacy and social agency.

Criminological research and institutional ethics protocols : empowering the indigenous other or the academy?

Indigenous commentators have long critiqued the way in which government agencies and member of academic institutions carry out research in their social context. Recently, these commentators have turned their critical gaze upon activities of Research Ethics Boards(REBs). Informed by the reflections on research processes and by Indigenous Canadian and New Zealand research participants, as well as the extant literature, this paper critiques the processes employed by New Zealand REBs to assess Indigenous‐focused or Indigenous‐led research in the criminological realm.

The making of control : an ethnomethodology of choosing management accounting systems [La fabrique du controle : une ethnomethodologie du choix des outils de gestion]

This paper sets out to contribute to the literature on the design and the implementation of management control systems. To this end, we question what is discussed when a management control system is to be chosen and on what decision-making eventually rests. This study rests upon an ethnomethodology of the Salvation Army’s French branch. Operating in the dual capacity of a researcher and a counsellor to management, between 2000 and 2007, we have unrestricted access to internal data revealing the backstage of management control: discussions and interactions surrounding the choosing of control devices. We contribute to understanding the arising of a need for control, the steps and process followed to decide upon a management control system, and controls in nonprofits. [Cet article vise à contribuer à la littérature sur la mise en place des systèmes de contrôle de gestion. À cette fin, nous questionnons ce qui est discuté lors du choix d’un système de contrôle et sur quoi repose in fine la décision. Cet article est fondé sur une approche ethnométhodologique de l’Armée du Salut en France permise par notre double qualité de chercheurs mais également de conseiller auprès de la direction de l’organisation entre 2000 et 2007. Un accès illimité à des données internes nous permet ainsi de mettre en lumière les aspects méconnus et invisibles du contrôle de gestion : les discussions et interactions entourant le choix d’outils. Nous contribuons à la compréhension de l’émergence du besoin de contrôle, des étapes et du processus de choix d’outils et enfin du contrôle de gestion dans une organisation à but non lucratif.]

Can physical activity prevent physical and cognitive decline in postmenopausal women? A systematic review of the literature

Background Participation in regular physical activity is among the most promising and cost effective strategies to reduce physical and cognitive decline and premature death. However, confusion remains about the amount, frequency, and duration of physical activity that is likely to provide maximum benefit as well as the way in which interventions should be delivered. Aims This paper aimed to review research on the impact of leisure-time and general physical activity levels on physical and cognitive decline in postmenopausal women. In a systematic review of the literature, empirical literature from 2009-2013 is reviewed to explore the potential impact of either commencing or sustaining physical activity on older women’s health. Results All studies found that physical activity was associated with lower rates of cognitive and physical decline and a significant reduction in all-cause mortality. In this review we found that exercise interventions (or lifestyle activities) that improved cardiorespiratory exercise capacity showed the most positive impact on physical health. Conclusions Findings suggest that programs should facilitate and support women to participate in regular exercise by embedding physical activity programs in public health initiatives, by developing home-based exercise programs that require few resources and by creating interventions that can incorporate physical activity within a healthy lifestyle. The review also suggests that clinicians should consider prescribing exercise in a tailored manner for older women to ensure that it is of a high enough intensity to obtain the positive sustained effects of exercise.

Relating Across Difference : A Case Study in Transformative Learning

This chapter examines the process of “transformative learning” for the 2008 cohort of the St. Thomas More College–Intercordia Canada (STM/IC) international community service-learning program. My primary data comes from the eight students who were part of that cohort, when I was their program coordinator. That data later became the heart of my Master’s thesis and was approved by the Research Ethics Office of the University of Saskatchewan. In this chapter I focus on three of those eight participants, outlining the critical elements of their experiences that were conducive to their transformative learning. To be sure, my sample size is too small to draw generalizable conclusions, but the quality of information I received from these students and their colleagues, coupled with the follow-up conversations I had with other educators and with the accompanying literature, supports the value of reflecting at length here about these students’ comments. I have chosen to highlight the experiences of these three participants because together they provide a range of experiences that best enables an analysis of the conditions that both did and did not lead to transformative learning. This case study suggests that transformative learning occurs through: the dynamics of vulnerability, a discovery of persisting differences within inter-personal relationships, and an experience of welcome and hospitality in the host environment. In contrast to other studies that focus on the enhanced capacities, skills and subsequent employability of participants through international education, transformative learning for these students required a relinquishing of securities, a disorientation and critical interrogation of the self, and enhanced receptivity to the newly recognized Other. Moreover, consistent with the critical-humanistic educational philosophy shared in different ways by the participants of the STM/IC program, this study suggests that international community service-learning can most responsibly contribute to good global citizenship through the construction of relationships of solidarity across difference.

Diversity or perversity?: Award-winning children's literature and the Australian curriculum

Two of the three cross-curriculum priorities for the national Australian Curriculum prescribed by the Australian Curriculum Assessment and Reporting Authority (ACARA) are focussed on what might be called diversity education: “Aboriginal and Torres Strait Islander histories and culture”, and "Asia and Australia's Engagement with Asia” (ACARA, “Cross”). One need not be versed in complex rhetorical theory to understand that, laudable and legitimate as such priorities are, their existence implies that mainstream education in Australia has been or is characterised by the marginalisation or erasure of Australia's history—the original Indigenous cultures are not only living and vibrant today, but also have tens of thousands of years’ “head start” on Australia’s settler cultures—and of its geography—Australia is, after all, located in some physical proximity to Asia. Some might even suggest that Australia is in Asia. These temporal and spatial “forgettings” constitute a kind of cultural perversity which the cross-curricular priorities both seek to address and serve to reinscribe. Even as ACARA requires Australian school students to engage with Aboriginal and Asian histories, cultures, societies, they imply that such histories, cultures, and societies are “diverse”, that they are not those of the students in Australian classrooms; producing them as objects of study rather than as lived experience. This should not necessarily be surprising. Michael W. Apple has provocatively argued that: “one of the perverse effects of a national curriculum actually will be to ‘legitimise inequality.’ It may in fact help create the illusion that whatever the massive differences in schools, they all have something in common” (18). In the Australian context, attempts to mitigate such perversity are articulated via the selection of literary texts. As educators move to resource ACARA’s cross-curricular priorities, ACARA notes that “Teachers and schools are best placed to make decisions about the selection of texts in their teaching and learning programs that address the content in the Australian Curriculum while also meeting the needs of the students in their classes” (ACARA, “Advice”). This assertion appears on a webpage called “Advice on selection of literary texts” which is notable first and foremost for its total lack of any literary texts being named, and its list of weblinks pointing to lists of texts compiled elsewhere, by other organisations, and in the main, compiled to serve agendas other than the Australian curriculum. One of the major resources referred to by ACARA for literary text selection is the Children’s Book Council of Australia (CBCA). Of course, the CBCA’s annual book awards do not share ACARA’s educational priorities, but do have a history of being drawn upon by schools as a curriculum resource. In this paper, I consider the literary texts which have been prized by the CBCA in recent years attending to their engagements with Aboriginal cultures.

Green IT segment analysis : an academic literature review

Research on Green Information Technology (IT) is becoming a prevalent research theme in Green Information Systems (IS) research. This article provides a review of 98 papers published on Green IT between 2007−2013 to facilitate future research and to provide a retrospective analysis of existing knowledge and gaps thereof. While some researchers have discussed phenomena such as Green IT, motivation of Green IT and the Green IT adoption lifecycle, others have researched the importance of Green IT implementation within the organisational and individual level. Throughout the literature, scholars are trying to portray a constructive relationship between IT and the environment. Through our analysis, we can provide an assessment of the status of information systems literature on Green IT and, we provide taxonomy of segments of Green IT publications. Future research opportunities are identified based on the review.