Quality issues for the National Bowel Cancer Screening Program (NBCSP)

Purpose: This two-part research project was undertaken as part of the planning process by Queensland Health (QH), Cancer Screening Services Unit (CSSU), Queensland Bowel Cancer Screening Program (QBCSP), in partnership with the National Bowel Cancer Screening Program (NBCSP), to prepare for the implementation of the NBCSP in public sector colonoscopy services in QLD in late 2006. There was no prior information available on the quality of colonoscopy services in Queensland (QLD) and no prior studies that assessed the quality of colonoscopy training in Australia. Furthermore, the NBCSP was introduced without extra funding for colonoscopy service improvement or provision for increases in colonoscopic capacity resulting from the introduction of the NBCSP. The main purpose of the research was to record baseline data on colonoscopy referral and practice in QLD and current training in colonoscopy Australia-wide. It was undertaken from a quality improvement perspective. Implementation of the NBCSP requires that all aspects of the screening pathway, in particular colonoscopy services for the assessment of positive Faecal Occult Blood Tests (FOBTs), will be effective, efficient, equitable and evidence-based. This study examined two important aspects of the continuous quality improvement framework for the NBCSP as they relate to colonoscopy services: (1) evidence-based practice, and (2) quality of colonoscopy training. The Principal Investigator was employed as Senior Project Officer (Training) in the QBCSP during the conduct of this research project. Recommendations from this research have been used to inform the development and implementation of quality improvement initiatives for provision of colonoscopy in the NBCSP, its QLD counterpart the QBCSP and colonoscopy services in QLD, in general. Methods – Part 1 Chart audit of evidence-based practice: The research was undertaken in two parts from 2005-2007. The first part of this research comprised a retrospective chart audit of 1484 colonoscopy records (some 13% of all colonoscopies conducted in public sector facilities in the year 2005) in three QLD colonoscopy services. Whilst some 70% of colonoscopies are currently conducted in the private sector, only public sector colonoscopy facilities provided colonoscopies under the NBCSP. The aim of this study was to compare colonoscopy referral and practice with explicit criteria derived from the National Health & Medical Research Council (NHMRC) (1999) Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer, and describe the nature of variance with the guidelines. Symptomatic presentations were the most common indication for colonoscopy (60.9%). These comprised per rectal bleeding (31.0%), change of bowel habit (22.1%), abdominal pain (19.6%), iron deficiency anaemia (16.2%), inflammatory bowel disease (8.9%) and other symptoms (11.4%). Surveillance and follow-up colonoscopies accounted for approximately one-third of the remaining colonoscopy workload across sites. Gastroenterologists (GEs) performed relatively more colonoscopies per annum (59.9%) compared to general surgeons (GS) (24.1%), colorectal surgeons (CRS) (9.4%) and general physicians (GPs) (6.5%). Guideline compliance varied with the designation of the colonoscopist. Compliance was lower for CRS (62.9%) compared to GPs (76.0%), GEs (75.0%), GSs (70.9%, p<0.05). Compliance with guideline recommendations for colonoscopic surveillance for family history of colorectal cancer (23.9%), polyps (37.0%) and a past history of bowel cancer (42.7%), was by comparison significantly lower than for symptomatic presentations (94.4%), (p<0.001). Variation with guideline recommendations occurred more frequently for polyp surveillance (earlier than guidelines recommend, 47.9%) and follow-up for past history of bowel cancer (later than recommended, 61.7%, p<0.001). Bowel cancer cases detected at colonoscopy comprised 3.6% of all audited colonoscopies. Incomplete colonoscopies occurred in 4.3% of audited colonoscopies and were more common among women (76.6%). For all colonoscopies audited, the rate of incomplete colonoscopies for GEs was 1.6% (CI 0.9-2.6), GPs 2.0% (CI 0.6-7.2), GS 7.0% (CI 4.8-10.1) and CRS 16.4% (CI 11.2-23.5). 18.6% (n=55) of patients with a documented family history of bowel cancer had colonoscopy performed against guidelines recommendations (for general (category 1) population risk, for reasons of patient request or family history of polyps, rather than for high risk status for colorectal cancer). In general, family history was inadequately documented and subsequently applied to colonoscopy referral and practice. Methods - Part 2 Surveys of quality of colonoscopy training: The second part of the research consisted of Australia-wide anonymous, self-completed surveys of colonoscopy trainers and their trainees to ascertain their opinions on the current apprenticeship model of colonoscopy in Australia and to identify any training needs. Overall, 127 surveys were received from colonoscopy trainers (estimated response rate 30.2%). Approximately 50% of trainers agreed and 27% disagreed that current numbers of training places were adequate to maintain a skilled colonoscopy workforce in preparation for the NBCSP. Approximately 70% of trainers also supported UK-style colonoscopy training within dedicated accredited training centres using a variety of training approaches including simulation. A collaborative approach with the private sector was seen as beneficial by 65% of trainers. Non-gastroenterologists (non-GEs) were more likely than GEs to be of the opinion that simulators are beneficial for colonoscopy training (χ2-test = 5.55, P = 0.026). Approximately 60% of trainers considered that the current requirements for recognition of training in colonoscopy could be insufficient for trainees to gain competence and 80% of those indicated that ≥ 200 colonoscopies were needed. GEs (73.4%) were more likely than non-GEs (36.2%) to be of the opinion that the Conjoint Committee standard is insufficient to gain competence in colonoscopy (χ2-test = 16.97, P = 0.0001). The majority of trainers did not support training either nurses (73%) or GPs in colonoscopy (71%). Only 81 (estimated response rate 17.9%) surveys were received from GS trainees (72.1%), GE trainees (26.3%) and GP trainees (1.2%). The majority were males (75.9%), with a median age 32 years and who had trained in New South Wales (41.0%) or Victoria (30%). Overall, two-thirds (60.8%) of trainees indicated that they deemed the Conjoint Committee standard sufficient to gain competency in colonoscopy. Between specialties, 75.4% of GS trainees indicated that the Conjoint Committee standard for recognition of colonoscopy was sufficient to gain competence in colonoscopy compared to only 38.5% of GE trainees. Measures of competency assessed and recorded by trainees in logbooks centred mainly on caecal intubation (94.7-100%), complications (78.9-100%) and withdrawal time (51-76.2%). Trainees described limited access to colonoscopy training lists due to the time inefficiency of the apprenticeship model and perceived monopolisation of these by GEs and their trainees. Improvements to the current training model suggested by trainees included: more use of simulation, training tools, a United Kingdom (UK)-style training course, concentration on quality indicators, increased access to training lists, accreditation of trainers and interdisciplinary colonoscopy training. Implications for the NBCSP/QBCSP: The introduction of the NBCSP/QBCSP necessitates higher quality colonoscopy services if it is to achieve its ultimate goal of decreasing the incidence of morbidity and mortality associated with bowel cancer in Australia. This will be achieved under a new paradigm for colonoscopy training and implementation of evidence-based practice across the screening pathway and specifically targeting areas highlighted in this thesis. Recommendations for improvement of NBCSP/QBCSP effectiveness and efficiency include the following: 1. Implementation of NBCSP and QBCSP health promotion activities that target men, in particular, to increase FOBT screening uptake. 2. Improved colonoscopy training for trainees and refresher courses or retraining for existing proceduralists to improve completion rates (especially for female NBCSP/QBCSP participants), and polyp and adenoma detection and removal, including newer techniques to detect flat and depressed lesions. 3. Introduction of colonoscopy training initiatives for trainees that are aligned with NBCSP/QBCSP colonoscopy quality indicators, including measurement of training outcomes using objective quality indicators such as caecal intubation, withdrawal time, and adenoma detection rate. 4. Introduction of standardised, interdisciplinary colonoscopy training to reduce apparent differences between specialties with regard to compliance with guideline recommendations, completion rates, and quality of polypectomy. 5. Improved quality of colonoscopy training by adoption of a UK-style training program with centres of excellence, incorporating newer, more objective assessment methods, use of a variety of training tools such as simulation and rotations of trainees between metropolitan, rural, and public and private sector training facilities. 6. Incorporation of NHMRC guidelines into colonoscopy information systems to improve documentation, provide guideline recommendations at the point of care, use of gastroenterology nurse coordinators to facilitate compliance with guidelines and provision of guideline-based colonoscopy referral letters for GPs. 7. Provision of information and education about the NBCSP/QBCSP, bowel cancer risk factors, including family history and polyp surveillance guidelines, for participants, GPs and proceduralists. 8. Improved referral of NBCSP/QBCSP participants found to have a high-risk family history of bowel cancer to appropriate genetics services.

Practice-led research and the innovation agenda : beyond the postgraduate research degree in the arts, design and media

The rise of the ‘practice-led’ research approach has given us a new way of understanding what creative practice in art, design and media can do in the academy and the world— it can materialise new ideas and forms into being as a form of experimental research. Yet, to date, attention around the world, and especially in Australia, has been chiefly directed at the postgraduate research degrees, most notably the PhD or doctoral equivalents. Recent mapping projects and surveys of practice-led research in Australia reveal much about the institutional conditions of higher degree researchers, supervisors, examiners and research training (Baker et al 2009; Evans et al 2003; Dally et al 2004; Paltridge et al 2009; Phillips et al 2009). Given this focus, we might well ask: is the practice-led approach destined to be a part of the higher degree ghetto only, or does it have an afterlife? What is the place of ‘practice-led’ beyond the postgraduate degree? After all postgraduate researchers do not remain postgraduates forever, and perhaps the practice-led approach to research may have benefits in wider university, professional and communal contexts.

ePortfolio use by university students in Australia: Informing excellence in policy and practice

In mid 2007, the Australian Learning and Teaching Council (ALTC), formerly the Carrick Institute for Learning and Teaching in Higher Education, commissioned an intensive research project to examine the use of ePortfolios by university students in Australia. The project was awarded to a consortium of four universities: Queensland University of Technology as lead institution, The University of Melbourne, University of New England and University of Wollongong.---------- The overarching aim of the research project, which was given the working title of the Australian ePortfolio Project, was to examine the current levels of ePortfolio practice in Australian higher education. The principal project goals sought to provide an overview and analysis of the national and international ePortfolio contexts, document the types of ePortfolios used in Australian higher education, examine the relationship with the National Diploma Supplement project funded by the Federal government, identify any significant issues relating to ePortfolio implementation, and offer guidance about future opportunities for ePortfolio development. The research findings revealed that there was a high level of interest in the use of ePortfolios in the context of higher education, particularly in terms of the potential to help students become reflective learners who are conscious of their personal and professional strengths and weaknesses, as well as to make their existing and developing skills more explicit. There were some good examples of early adoption in different institutions, although this tended to be distributed across the sector. The greatest use of ePortfolios was recorded in coursework programs, rather than in research programs, with implementation generally reflecting subject-specific or program-based activity, as opposed to faculty- or university-wide activity. Accordingly, responsibility for implementation frequently rested with the individual teaching unit, although an alternative centralised model of coordination by ICT services, careers and employment or teaching and learning support was beginning to emerge. The project report concludes with a series of recommendations to guide the process, drawing on the need for open dialogue and effective collaboration between the stakeholders across the range of contexts: government policy, international technical standards, academic policy, and learning and teaching research and practice.

ePortfolio use by university students in Australia : Developing a sustainable community of practice

This report documents Stage Two of the Australian ePortfolio Project (AeP2), to specifically explore the current scope of national and international ePortfolio communities of practice in order to identify the factors that have contributed to their success and sustainability. The study has built on Stage One of the Australian ePortfolio Project (Hallam, Harper, McCowan, Hauville, McAllister, & Creagh, 2008), which outlined the broad range of issues and challenges, as well as significant opportunities, that faced the higher education sector in terms of ePortfolio practice, to determine how the emergent community of ePortfolio researchers and practitioners in Australia might be advanced. ---------- The overarching aims of this project were to focus on building the Australian community of practice through an online forum and further symposium activities. Through the research activities the project sought to generate the following major outcomes: develop a forum within the ALTC Exchange to support an ePortfolio community of practice; develop strategies to encourage interest in and engagement with community of practice activities; develop and promote resources to support the diverse stakeholders in ePortfolio practice; collaborate in the establishment of a cross-sector ePortfolio community of practice; host a second Australian ePortfolio Symposium (AeP2) to disseminate the findings from the Australian ePortfolio Project, to explore innovative practice in ePortfolio use in higher education, to articulate policy developments, and to stimulate discussion on international ePortfolio issues; host an associated trade display as a forum for strengthening the higher education sector’s understanding of the features and functionality of ePortfolio platforms; develop resources to support an ePortfolio symposium model that may be adopted for future events. ----------- The project activities encompassed a survey of stakeholders, a program of semi-structured interviews with community managers and a series of case studies depicting successful ePortfolio communities. The survey of ePortfolio practitioners sought to determine the potential value of an ePortfolio CoP, the preferred focus for and the desired features of such a community, as well as the options for the technical and social architecture of an online forum. Through the semi-structured interviews it was possible to examine current examples of CoP activity, to identify the critical success factors and the challenges faced by individual ePortfolio CoPs, so that the attributes of good practice could be presented. The data collected in the interviews contributed to the development of 14 case studies, which have been beneficial in illustrating the diverse nature of CoPs in Australia and overseas.----------- The report presents a rich picture of national and international ePortfolio communities of practice, with an examination of the factors that have contributed to their success and sustainability.

Caregivers' beliefs about practice in infant child care programmes

Infant caregivers in centre-based child care were videotaped as they interacted with the children during routine and non-routine activities. During a subsequent interview, the video provided a stimulus for discussion and reflection on practices. Caregivers were also asked to write about their beliefs on good practice in caring for infants. Transcripts of the interviews and the written statements were then analysed for evidence of nave and informed beliefs about caregiving. Most caregivers held nave beliefs and only one caregiver had an informed understanding of professional practice with infants. The usefulness of the analytical framework used in this research is discussed as a means for understanding caregiving practices. It has important implications for approaches to initial professional education of early childhood teachers and for professional development programmes.

The impact of Health Information Technology (I-HIT) scale : the Australian results

One of role of the nurse in the clinical setting is that of coordinating communication across the healthcare team. On a daily basis nurses interact with the person receiving care, their family members, and multiple care providers thus placing the nurse in the central position with access to a vast array of information on the person. Through this nurses have historically functioned as “information repositories”. With the advent of Health Information Technology (HIT) tools there is a potential that HIT could impact interdisciplinary communication, practice efficiency and effectiveness, relationships and workflow in acute care settings \[1]\[3]. In 2005, the HIMSS Nursing Informatics Community developed the IHITScale to measure the impact of HIT on the nursing role and interdisciplinary communication in USA hospitals. In 2007, nursing informatics colleagues from Australia, Finland, Ireland, New Zealand, Scotland and the USA formed a research collaborative to validate the IHIT in six additional countries. This paper will discuss the background, methodology, results and implications from the Australian IHIT survey of over 1100 nurses. The results are currently being analyzed and will be presented at the conference.

Developing a culture of enquiry to sustain evidence-based practice

Evidence-based practice (EBP) is having a significant effect on the health service environment. It constructs a language that bridges the healthcare disciplines and the clinical and managerial components of health services. Most experienced clinicians in nursing, medicine and allied health now recognise that the contemporary healthcare environment calls for our practice to be justified by sound, credible evidence. There is pressure on all clinicians to accommodate innovation, while at the same time ensuring their practice is effective, safe and efficient (Forbes & Griffiths 2002). Consequently, EBP in healthcare is having a profound effect on nursing and the way we think about nursing. There are many available models for research utilisation that are dependent on organisational strategies for change. This chapter describes the relationship between organisation and culture, and explores the notion of cultural change; that is, developing a culture of inquiry that can sustain evidence-based practice. We begin this chapter with a clear conception of what we mean by EBP and what we mean by ‘culture’.

Community engagement : exploring a relational approach to consultation and collaborative practice in Australia

Community engagement is increasingly being employed by Australian organizations as a key strategy to incorporate representative community opinions into decision-making. This trend is reflected by Australian local and state governments legislating for community consultation in major infrastructure projects and the increasing role of public relations practitioners to manage these programs. This study explores community engagement founded on relational theory and proposed a typology of engagement employing a relational framework. An exploratory study of 20 Australian infrastructure projects with a mandatory consultation component is analyzed applying this framework. Results indicate little discrimination between the terms engagement, consultation, and participation; however, a range of tactics supported both collaborative and advocacy approaches. The implications for adopting a relational framework for community engagement programs are discussed.

Rephrasing voice : art, practice-led research and the limits and sites of articulacy

While my PhD is practice-led research, it is my contention that such an inquiry cannot develop as long as it tries to emulate other models of research. I assert that practice-led research needs to account for an epistemological unknown or uncertainty central to the practice of art. By focusing on what I call the artist's 'voice,' I will show how this 'voice' is comprised of a dual motivation—'articulate' representation and 'inarticulate' affect—which do not even necessarily derive from the artist. Through an analysis of art-historical precedents, critical literature (the work of Jean-François Lyotard and Andrew Benjamin, the critical methods of philosophy, phenomenology and psychoanalysis) as well as of my own painting and digital arts practice, I aim to demonstrate how this unknown or uncertain aspect of artistic inquiry can be mapped. It is my contention that practice-led research needs to address and account for this dualistic 'voice' in order to more comprehensively articulate its unique contribution to research culture.

How boards strategise : a strategy as practice view

While board involvement in strategy is seen as increasingly important, our understanding of how boards fulfil this role is limited. This article draws on indepth qualitative research with directors and senior managers to develop a Strategy as Practice view on how boards "do" strategy. Two different but complementary strategising practices - Procedural Strategising and Interactive Strategising - are identified and elaborated in terms of their underlying micro-activities. The internal boardroom factors that affect the relative emphasis on these strategies practices - the strategic stance of the board, board power and perceive legitimacy of each practice - are also identified and discussed. These findings are then integrated into a typology of board strategising. A key implication of this paper is that boards need to consciously choose the nature and extent of their involvement in strategy.

Sounds from the empty city : a practice-led case study in the confluence of music, narrative and emotion

The creative practice: the adaptation of picture book The Empty City (Megarrity/Oxlade, Hachette 2007) into an innovative, interdisciplinary performance for children which combines live performance, music, projected animation and performing objects. The researcher, in the combined roles of writer/composer proposes deliberate experiments in music, narrative and emotion in the various drafts of the adaptation, and tests them in process and performance product. A particular method of composing music for live performance is tested in against the emergent needs of a collaborative, intermedial process. The unpredictable site of research means that this project is both looking to address both pre-determined and emerging points of inquiry. This analysis (directed by audience reception) finds that critical incidents of intermediality between music, narrative, action and emotion translate directly into highlights of the performance.

Joint consumer submission to the review of the code of banking practice

This submission has been prepared on behalf of Australian consumer advocates by Nicola Howell, Faculty of Law, Queensland University of Technology (‘the researcher’), under a consultancy arrangement with the Australian Securities and Investments Commission (ASIC). The researcher has been engaged by ASIC to consult with consumer advocates across Australia in order to prepare a detailed consumer submission to the Review of the Code of Banking Practice and the Review Issues Paper.

An epidemic of pain in an Australian radiology practice

This paper presents findings from a study of an organisationally mandated assimilation process of an enterprise-wide information system in a radiology practice in Australia. A number of interviews with radiologists, radiographers and administrative staff are used to explore the impact of institutional structures on the assimilation process. The case study develops an argument that culture within and outside the Australian Radiology Practice (ARP), social structures within the ARP and organisational-level management mandates have impacted on the assimilation process. The study develops a theoretical framework that integrates elements of social actor theory (Lamb & Kling, 2003) to provide a more fine-grained analysis concentrating on the relationship among the radiology practitioners, the technology (an enterprise-wide Health Information System) and a larger social milieu surrounding its use. This study offers several theoretical and practical implications for technology assimilation in the health and radiology industry regarding the important roles social interactions, individual self-perceptions, organisational mandates and policies can play in assimilating new ICTs.

Lifting the lifegiving dollar : case samples of creative practice in health and medical research philanthropy

This study aims to stimulate thought, debate and action for change on this question of more vigorous philanthropic funding of Australian health and medical research (HMR). It sharpens the argument with some facts and ideas about HMR funding from overseas sources. It also reports informed opinions from those working, giving and innovating in this area. It pinpoints the range of attitudes to HMR giving, both positive and negative. The study includes some aspects of Government funding as part of the equation, viewing Government as major HMR givers, with particular ability to partner, leverage and create incentives. Stimulating new philanthropy takes active outreach. The opportunity to build more dialogue between the HMR industry and the wider community is timely given the ‘licence to practice’ issues and questioned trust that applies currently somewhat both to science and to the charitable sector. This interest in improving HMR philanthropy also coincides with the launch last year by the Federal Government of Nonprofit Australia Limited (NAL), a group currently assessing infrastructure improvements to the charitable sector. History suggests no one will create this change if Research Australia does not. However, interest in change exists in various quarters. For Research Australia to successfully change the culture of Australian HMR giving, the process will drive the outcomes. Obviously stakeholder buy-in and partners will be needed and the ultimate blueprint for greater philanthropic HMR funding here will not be this document. Instead it will be the one that wears the handprint and ‘mindprint’ of the many architects and implementers interested in promoting HMR philanthropy, from philanthropists to nonprofit peaks to government policy arms. As the African proverb says, ‘If you want to go fast, go alone; but if you want to go far, go with others’.