Setting hospital infection control policy : a decision-making framework incorporating health economics and healthcare epidemiology

Background: Reducing rates of healthcare acquired infection has been identified by the Australian Commission on Safety and Quality in Health Care as a national priority. One of the goals is the prevention of central venous catheter-related bloodstream infection (CR-BSI). At least 3,500 cases of CR-BSI occur annually in Australian hospitals, resulting in unnecessary deaths and costs to the healthcare system between $25.7 and $95.3 million. Two approaches to preventing these infections have been proposed: use of antimicrobial catheters (A-CVCs); or a catheter care and management ‘bundle’. Given finite healthcare budgets, decisions about the optimal infection control policy require consideration of the effectiveness and value for money of each approach. Objectives: The aim of this research is to use a rational economic framework to inform efficient infection control policy relating to the prevention of CR-BSI in the intensive care unit. It addresses three questions relating to decision-making in this area: 1. Is additional investment in activities aimed at preventing CR-BSI an efficient use of healthcare resources? 2. What is the optimal infection control strategy from amongst the two major approaches that have been proposed to prevent CR-BSI? 3. What uncertainty is there in this decision and can a research agenda to improve decision-making in this area be identified? Methods: A decision analytic model-based economic evaluation was undertaken to identify an efficient approach to preventing CR-BSI in Queensland Health intensive care units. A Markov model was developed in conjunction with a panel of clinical experts which described the epidemiology and prognosis of CR-BSI. The model was parameterised using data systematically identified from the published literature and extracted from routine databases. The quality of data used in the model and its validity to clinical experts and sensitivity to modelling assumptions was assessed. Two separate economic evaluations were conducted. The first evaluation compared all commercially available A-CVCs alongside uncoated catheters to identify which was cost-effective for routine use. The uncertainty in this decision was estimated along with the value of collecting further information to inform the decision. The second evaluation compared the use of A-CVCs to a catheter care bundle. We were unable to estimate the cost of the bundle because it is unclear what the full resource requirements are for its implementation, and what the value of these would be in an Australian context. As such we undertook a threshold analysis to identify the cost and effectiveness thresholds at which a hypothetical bundle would dominate the use of A-CVCs under various clinical scenarios. Results: In the first evaluation of A-CVCs, the findings from the baseline analysis, in which uncertainty is not considered, show that the use of any of the four A-CVCs will result in health gains accompanied by cost-savings. The MR catheters dominate the baseline analysis generating 1.64 QALYs and cost-savings of $130,289 per 1.000 catheters. With uncertainty, and based on current information, the MR catheters remain the optimal decision and return the highest average net monetary benefits ($948 per catheter) relative to all other catheter types. This conclusion was robust to all scenarios tested, however, the probability of error in this conclusion is high, 62% in the baseline scenario. Using a value of $40,000 per QALY, the expected value of perfect information associated with this decision is $7.3 million. An analysis of the expected value of perfect information for individual parameters suggests that it may be worthwhile for future research to focus on providing better estimates of the mortality attributable to CR-BSI and the effectiveness of both SPC and CH/SSD (int/ext) catheters. In the second evaluation of the catheter care bundle relative to A-CVCs, the results which do not consider uncertainty indicate that a bundle must achieve a relative risk of CR-BSI of at least 0.45 to be cost-effective relative to MR catheters. If the bundle can reduce rates of infection from 2.5% to effectively zero, it is cost-effective relative to MR catheters if national implementation costs are less than $2.6 million ($56,610 per ICU). If the bundle can achieve a relative risk of 0.34 (comparable to that reported in the literature) it is cost-effective, relative to MR catheters, if costs over an 18 month period are below $613,795 nationally ($13,343 per ICU). Once uncertainty in the decision is considered, the cost threshold for the bundle increases to $2.2 million. Therefore, if each of the 46 Level III ICUs could implement an 18 month catheter care bundle for less than $47,826 each, this approach would be cost effective relative to A-CVCs. However, the uncertainty is substantial and the probability of error in concluding that the bundle is the cost-effective approach at a cost of $2.2 million is 89%. Conclusions: This work highlights that infection control to prevent CR-BSI is an efficient use of healthcare resources in the Australian context. If there is no further investment in infection control, an opportunity cost is incurred, which is the potential for a more efficient healthcare system. Minocycline/rifampicin catheters are the optimal choice of antimicrobial catheter for routine use in Australian Level III ICUs, however, if a catheter care bundle implemented in Australia was as effective as those used in the large studies in the United States it would be preferred over the catheters if it was able to be implemented for less than $47,826 per Level III ICU. Uncertainty is very high in this decision and arises from multiple sources. There are likely greater costs to this uncertainty for A-CVCs, which may carry hidden costs, than there are for a catheter care bundle, which is more likely to provide indirect benefits to clinical practice and patient safety. Research into the mortality attributable to CR-BSI, the effectiveness of SPC and CH/SSD (int/ext) catheters and the cost and effectiveness of a catheter care bundle in Australia should be prioritised to reduce uncertainty in this decision. This thesis provides the economic evidence to inform one area of infection control, but there are many other infection control decisions for which information about the cost-effectiveness of competing interventions does not exist. This work highlights some of the challenges and benefits to generating and using economic evidence for infection control decision-making and provides support for commissioning more research into the cost-effectiveness of infection control.

Sustainable housing implementation through mutual benefits to stakeholders : a decision making approach

Improved public awareness and strong sentiments towards environmental issues will continue to create increasing demand for sustainable housing (SH) in the coming years. Despite this potential, the up-take rate of sustainable housing in new build and through home renovation is not as high as expected within the housing industry. This is in contrast to the influx of emerging building technologies, new materials and innovative designs seen in exemplar homes built worldwide. How we should use the increasing awareness of SH and emerging technologies as an impetus to change the un-sustainable designs and practices of the building industry is high on the agenda of the government and majority of the stakeholders involved. This warrants the study of multifaceted strategies that meet the needs of multiple stakeholders and integrated seamlessly into housing development processes. Specifically, the different perceptions, roles and incentives of stakeholders, who inevitably need to ensure their benefits and commercial returns, should be highlighted and acted upon. ----- This paper discusses the preliminary findings of a research project that aims to promote SH implementation by identifying and materializing the mutual benefits among key stakeholders. The aim is to be achieved through questionnaire surveys, structural equation modelling, interviews and case studies with seven major stakeholders within the Australian housing industry. This research identifies the influence and relationship of relevant factors, investigates preferences, similarities and differences between stakeholders on perceived benefits and in turn explores the mutual-benefit strategy package that facilitates decision making towards sustainable housing development.

Incorporating sustainability measures in life-cycle financial decision making for highway construction

Public awareness and the nature of highway construction works demand that sustainability measures are first on the development agenda. However, in the current economic climate, individual volition and enthusiasm for such high capital investments do not present as strong cases for decision making as the financial pictures of pursuing sustainability. Some stakeholders consider sustainability to be extra work that costs additional money. Though, stakeholders realised its importance in infrastructure development. They are keen to identify the available alternatives and financial implications on a lifecycle basis. Highway infrastructure development is a complex rocess which requires expertise and tools to evaluate investment options, such as environmentally sustainable features for road and highway development. Life-cycle cost analysis (LCCA) is a valuable approach for investment decision making for construction works. However, LCCA applications in highway development are still limited. Current models, for example focus on economic issues alone and do not deal with sustainability factors, which are more difficult to quantify and encapsulate in estimation modules. This paper reports the research which identifies sustainability related factors in highway construction projects, in quantitative and qualitative forms of a multi-criteria analysis. These factors are then incorporated into past and proven LCCA models to produce a new long term decision support model. The research via questionnaire, model building, analytical hierarchy processes (AHP) and case studies have identified, evaluated and then processed highway sustainability related cost elements. These cost elements need to be verified by industry before being integrated for further development of the model. Then the Australian construction industry will have a practical tool to evaluate investment decisions which provide an optimum balance between financial viability and sustainability deliverables.

Best practices in prediction for decision-making : lessons from the atmospheric and earth sciences

Predictions that result from scientific research hold great appeal for decision-makers who are grappling with complex and controversial environmental issues, by promising to enhance their ability to determine a need for and outcomes of alternative decisions. A problem exists in that decision-makers and scientists in the public and private sectors solicit, produce, and use such predictions with little understanding of their accuracy or utility, and often without systematic evaluation or mechanisms of accountability. In order to contribute to a more effective role for ecological science in support of decision-making, this paper discusses three ``best practices'' for quantitative ecosystem modeling and prediction gleaned from research on modeling, prediction, and decision-making in the atmospheric and earth sciences. The lessons are distilled from a series of case studies and placed into the specific context of examples from ecological science.

Treating an unhealthy organisational culture : the implications of the Bundaberg Hospital inquiry for managerial ethical decision making

This paper explores the interplay between individual values, espoused organisational values and the values of the organisational culture in practice in light of a recent Royal Commission in Queensland, Australia, which highlighted systematic failures in patient care. The lack of congruence among values at these levels impacts upon the ethical decision making of health managers. The presence of institutional ethics regimes such as the Public Sector Ethics Act 1994 (Qld) and agency codes of conduct are not sufficient to counteract the negative influence of informal codes of practice that undermine espoused organisational values and community standards. The ethical decision-making capacity of health care managers remains at the front line in the battle against unethical and unprofessional practice. What is known about the topic? Value congruence theory focusses on the conflicts between individual and organisational values. Congruence between individual values, espoused values and values expressed in everyday practice can only be achieved by ensuring that such shared values are an ever-present factor in managerial decision making. What does this paper add? The importance of value congruence in building and sustaining a healthy organisational culture is confirmed by the evidence presented in the Bundaberg Hospital Inquiry. The presence of strong individual values among staff and strong espoused values in line with community expectations and backed up by legislation and ethics regimes were not, in themselves, sufficient to ensure a healthy organisational culture and prevent unethical, and possibly illegal, behaviour. What are the implications for practitioners? Managers must incorporate ethics in decision making to establish and maintain the nexus between individual and organisational values that is a vital component of a healthy organisational culture.

Geographical information systems : an effective planning and decision-making platform for community health coalitions in Australia

The development of locally-based healthcare initiatives, such as community health coalitions that focus on capacity building programs and multi-faceted responses to long-term health problems, have become an increasingly important part of the public health landscape. As a result of their complexity and the level of investment, it has become necessary to develop innovative ways to help manage these new healthcare approaches. Geographical Information Systems (GIS) have been suggested as one of the innovative approaches that will allow community health coalitions to better manage and plan their activities. The focus of this paper is to provide a commentary on the use of GIS as a tool for community coalitions and discuss some of the potential benefits and issues surrounding the development of these tools.

A conceptual framework for ethical decision making in project procurement

There is a lack of research which identifies the role of the public-sector client in relation to ethical practice in plan procurement. This paper discusses a conceptual framework for ethical decision making in project procurement, focusing on public sector clients within the Malaysian construction industry. A framework is proposed to ensure that effective ethical decision making strategies are deployed to ensure that plan procurement is carried out with a transparent process so that the public sector clients are able to adopt. The conceptual framework adopts various factors that contribute to ethical decision making at the early stage of procurement and consists of the procurement system, individual factors, project characteristics, and organizational culture as the internal factors and professional code of conduct and government policies as the external factors. This framework rationalizes the relationships between systems, psychology and organizational theory to form an innovative understanding of making ethical decisions in plan procurement. It is expected that this proposed framework will be useful as a foundation for identifying the factors that contribute to ethical decision making focusing on the planning stage of procurement process.

Planning online : a community-based interactive decision-making model

The first use of computing technologies and the development of land use models in order to support decision-making processes in urban planning date back to as early as mid 20th century. The main thrust of computing applications in urban planning is their contribution to sound decision-making and planning practices. During the last couple of decades many new computing tools and technologies, including geospatial technologies, are designed to enhance planners' capability in dealing with complex urban environments and planning for prosperous and healthy communities. This chapter, therefore, examines the role of information technologies, particularly internet-based geographic information systems, as decision support systems to aid public participatory planning. The chapter discusses challenges and opportunities for the use of internet-based mapping application and tools in collaborative decision-making, and introduces a prototype internet-based geographic information system that is developed to integrate public-oriented interactive decision mechanisms into urban planning practice. This system, referred as the 'Community-based Internet GIS' model, incorporates advanced information technologies, distance learning, sustainable urban development principles and community involvement techniques in decision-making processes, and piloted in Shibuya, Tokyo, Japan.

A conceptual decision-making framework for the delivery of innovative change in organisations

Research found that today’s organisations are increasingly aware of the potential barriers and perceived challenges associated with the successful delivery of change — including cultural and sub-cultural indifferences; financial constraints; restricted timelines; insufficient senior management support; fragmented key stakeholder commitment; and inadequate training. The delivery and application of Innovative Change (see glossary) within a construction industry organisation tends to require a certain level of ‘readiness’. This readiness is the combination of an organisation’s ability to part from undertakings that may be old, traditional, or inefficient; and then being able to readily adopt a procedure or initiative which is new, improved, or more efficient. Despite the construction industry’s awareness of the various threats and opportunities associated with the delivery of change, research found little attention is currently given to develop a ‘decision-making framework’ that comprises measurable elements (dynamics) that may assist in more accurately determining an organisation’s level of readiness or ability to deliver innovative change. To resolve this, an initial Background Literature Review in 2004 identified six such dynamics, those of Change, Innovation, Implementation, Culture, Leadership, and Training and Education, which were then hypothesised to be key components of a ‘Conceptual Decision-making Framework’ (CDF) for delivering innovative change within an organisation. To support this hypothesis, a second (more extensive) Literature Review was undertaken from late 2007 to mid 2009. A Delphi study was embarked on in June 2008, inviting fifteen building and construction industry members to form a panel and take part in a Delphi study. The selection criterion required panel members to have senior positions (manager and above) within a recognised field or occupation, and to have experience, understanding and / or knowledge in the process of delivering change within organisations. The final panel comprised nine representatives from private and public industry organisations and tertiary / research and development (R&D) universities. The Delphi study developed, distributed and collated two rounds of survey questionnaires over a four-month period, comprising open-ended and closed questions (referred to as factors). The first round of Delphi survey questionnaires were distributed to the panel in August 2008, asking them to rate the relevancy of the six hypothesised dynamics. In early September 2008, round-one responses were returned, analysed and documented. From this, an additional three dynamics were identified and confirmed by the panel as being highly relevant during the decision-making process when delivering innovative change within an organisation. The additional dynamics (‘Knowledge-sharing and Management’; ‘Business Process Requirements’; and ‘Life-cycle Costs’) were then added to the first six dynamics and used to populate the second (final) Delphi survey questionnaire. This was distributed to the same nine panel members in October 2008, this time asking them to rate the relevancy of all nine dynamics. In November 2008, round-two responses were returned, analysed, summarised and documented. Final results confirmed stability in responses and met Delphi study guidelines. The final contribution is twofold. Firstly, findings confirm all nine dynamics as key components of the proposed CDF for delivering innovative change within an organisation. Secondly, the future development and testing of an ‘Innovative Change Delivery Process’ (ICDP) is proposed, one that is underpinned by an ‘Innovative Change Decision-making Framework’ (ICDF), an ‘Innovative Change Delivery Analysis’ (ICDA) program, and an ‘Innovative Change Delivery Guide’ (ICDG).

Ethical decision making and health care managers : developing managerial profiles based on ethical frameworks and other influencing factors

Whether the community is looking for “scapegoats” to blame, or seeking more radical and deeper causes, health care managers are in the firing line whenever there are woes in the health care sector. The public has a right to question whether ethics have much influence on the everyday decision making of health care managers. This thesis explores, through a series of published papers, the influence of ethics and other factors on the decision making of health care managers in Australia. Critical review of over 40 years of research on ethical decision making has revealed a large number of influencing factors, but there is a demonstrable lack of a multidimensional approach that measures the combined influences of these factors on managers. This thesis has developed an instrument, the Managerial Ethical Profile (MEP) scale, based on a multidimensional model combining a large number of influencing factors. The MEP scale measures the range of influences on individual managers, and describes the major tendencies by developing a number of empirical profiles derived from a hierarchical cluster analysis. The instrument was developed and refined through a process of pilot studies on academics and students (n=41) and small-business managers (n=41), and then was administered to the larger sample of health care managers (n=441). Results from this study indicate that Australian health care managers draw on a range of ethical frameworks in their everyday decision making, forming the basis of five MEPs (Knights, Guardian Angels, Duty Followers, Defenders, and Chameleons). Results from the study also indicate that the range of individual, organisational, and external factors that influence decision making can be grouped into three major clusters or functions. Cross referencing these functions and other demographic data to the MEPs provides analytical insight into the characteristics of the MEPs. These five profiles summarise existing strengths and weaknesses in managerial ethical decision making. Therefore identifying these profiles not only can contribute to increasing organisational knowledge and self-awareness, but also has clear implications for the design and implementation of ethics education and training in large scale organisations in the health care industry.

Information sharing in Onesocialweb using a multiple profile manager to better informed medical decision making processes

The study shows an alternative solution to existing efforts at solving the problem of how to centrally manage and synchronise users’ Multiple Profiles (MP) across multiple discrete social networks. Most social network users hold more than one social network account and utilise them in different ways depending on the digital context (Iannella, 2009a). They may, for example, enjoy friendly chat on Facebook1, professional discussion on LinkedIn2, and health information exchange on PatientsLikeMe3 In this thesis the researcher proposes a framework for the management of a user’s multiple online social network profiles. A demonstrator, called Multiple Profile Manager (MPM), will be showcased to illustrate how effective the framework will be. The MPM will achieve the required profile management and synchronisation using a free, open, decentralized social networking platform (OSW) that was proposed by the Vodafone Group in 2010. The proposed MPM will enable a user to create and manage an integrated profile (IP) and share/synchronise this profile with all their social networks. The necessary protocols to support the prototype are also proposed by the researcher. The MPM protocol specification defines an Extensible Messaging and Presence Protocol (XMPP) extension for sharing vCard and social network accounts information between the MPM Server, MPM Client, and social network sites (SNSs). . Therefore many web users need to manage disparate profiles across many distributed online sources. Maintaining these profiles is cumbersome, time-consuming, inefficient, and may lead to lost opportunity. The writer of this thesis adopted a research approach and a number of use cases for the implementation of the project. The use cases were created to capture the functional requirements of the MPM and to describe the interactions between users and the MPM. In the research a development process was followed in establishing the prototype and related protocols. The use cases were subsequently used to illustrate the prototype via the screenshots taken of the MPM client interfaces. The use cases also played a role in evaluating the outcomes of the research such as the framework, prototype, and the related protocols. An innovative application of this project is in the area of public health informatics. The researcher utilised the prototype to examine how the framework might benefit patients and physicians. The framework can greatly enhance health information management for patients and more importantly offer a more comprehensive personal health overview of patients to physicians. This will give a more complete picture of the patient’s background than is currently available and will prove helpful in providing the right treatment. The MPM prototype and related protocols have a high application value as they can be integrated into the real OSW platform and so serve users in the modern digital world. They also provide online users with a real platform for centrally storing their complete profile data, efficiently managing their personal information, and moreover, synchronising the overall complete profile with each of their discrete profiles stored in their different social network sites.

The four principles: Can they be measured and do they predict ethical decision making?

Background The four principles of Beauchamp and Childress - autonomy, non-maleficence, beneficence and justice - have been extremely influential in the field of medical ethics, and are fundamental for understanding the current approach to ethical assessment in health care. This study tests whether these principles can be quantitatively measured on an individual level, and then subsequently if they are used in the decision making process when individuals are faced with ethical dilemmas. Methods The Analytic Hierarchy Process was used as a tool for the measurement of the principles. Four scenarios, which involved conflicts between the medical ethical principles, were presented to participants and they made judgments about the ethicality of the action in the scenario, and their intentions to act in the same manner if they were in the situation. Results Individual preferences for these medical ethical principles can be measured using the Analytic Hierarchy Process. This technique provides a useful tool in which to highlight individual medical ethical values. On average individuals have a significant preference for non-maleficence over the other principles, however, and perhaps counter-intuitively, this preference does not seem to relate to applied ethical judgements in specific ethical dilemmas. Conclusions People state they value these medical ethical principles but they do not actually seem to use them directly in the decision making process. The reasons for this are explained through the lack of a behavioural model to account for the relevant situational factors not captured by the principles. The limitations of the principles in predicting ethical decision making are discussed.

The applicability of aesthetic knowledge in organizational decision making processes

We argue that aesthetic knowledge, which is a form of tacit knowledge of beauty and related concepts, is an important, yet under-researched, topic in the study of organizational decision making processes. The significance of aesthetic knowledge for decision making processes is derived from its universal application by humans to commonplace practices; its use as the basis of decision criteria in complex situations to which the effective application of logic and reason is difficult; and its role both in assisting cognition in general and in enabling the choice of solutions generated from rational decision making processes. Despite its importance, the empirical research examining the application of aesthetic knowledge in organizational decision making processes is limited. Further detailed study of aesthetic knowledge in the context of organizational decision making processes is required to extend the recent movement in the field aimed at examining the role that extrarational, human-centered factors play in organizational decisions.

Teacher decision making in early childhood education

The study investigated early childhood teacher decision making at the preschool level in the state of Victoria, Australia. Victorian teachers at the preschool level were in an interesting position in 2004. Unlike most other Australian states Victoria did not have a curriculum framework guiding educational content and pedagogy. Consequently, this study was able to take advantage of this situation and examine teacher decision making at a time when early childhood teachers were relatively autonomous in deciding curriculum content. The opportunity to study teacher decision making in this way has since passed, as Victorian preschool teachers are now regulated by newly introduced state and national curricula frameworks. To identify influences affecting teacher decision making three preschool teachers were interviewed and curricula related policies were analysed. The data were analysed using Fairclough’s critical discourse analysis (CDA) technique. Critical discourse analysis enabled a close analysis of influences on teacher decision making illustrating how discourse is legitimated, marginalised, and silenced in certain curricula practices. Critical theory was the underpinning framework used for the study and enabled taken-for-granted understandings to be uncovered within early childhood policies and teacher interviews. Key findings were that despite there not being a government-mandated curricula framework for Victorian preschool education in 2004, teachers were held accountable for their curricula practice. Yet as professionals, early childhood teachers were denied public acknowledgment of their expertise as they were almost invisible in policy. Subsequently, teachers’ authority as professionals with curricula knowledge was diminished. The study found that developmentally appropriate practice (DAP) was a dominant discourse influencing teacher decision making (TDM). It operated as legitimated discourse in the 2004 Victorian preschool context. Additionally, the study found that teacher directed practice was legitimated, marginalised, and silenced by teachers. The findings have implications for early childhood teacher decision making at the practice, research, and policy levels. Findings show that the dominance of the DAP discourse informing teacher decision making limits other ways of thinking and practising.