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.

An autonomous surface vehicle for water quality monitoring

This paper describes a novel Autonomous Surface Vehicle capable of navigating throughout complex inland water storages and measuring a range of water quality properties and greenhouse gas emissions. The 16 ft long solar powered catamaran can collect this information throughout the water column whilst the vehicle is moving. A unique feature of this ASV is its integration into a storage scale floating sensor network to allow remote mission uploads, data download and adaptive sampling strategies. This paper provides an overview of the vehicle design and operation including control, laser-based obstacle avoidance, and vision-based inspection capabilities. Experimental results are shown illustrating its ability to continuously collect key water quality parameters and compliment intensive manual monitoring campaigns.

Designing for Awareness: An Experience-focused HCI Perspective

Within Human-Computer Interaction (HCI) and Computer Supported Cooperative Work (CSCW) research, the notion of technologically-mediated awareness is often used for allowing relevant people to maintain a mental model of activities, behaviors and status information about each other so that they can organize and coordinate work or other joint activities. The initial conceptions of awareness focused largely on improving productivity and efficiency within work environments. With new social, cultural and commercial needs and the emergence of novel computing technologies, the focus of technologically-mediated awareness has extended from work environments to people’s everyday interactions. Hence, the scope of awareness has extended from conveying work related activities to people’s emotions, love, social status and other broad range of aspects. This trend of conceptualizing HCI design is termed as experience-focused HCI. In my PhD dissertation, designing for awareness, I have reported on how we, as HCI researchers, can design awareness systems from experience-focused HCI perspective that follow the trend of conveying awareness beyond the task-based, instrumental and productive needs. Within the overall aim to design for awareness, my research advocates ethnomethodologically-informed approaches for conceptualizing and designing for awareness. In this sense, awareness is not a predefined phenomenon but something that is situated and particular to a given environment. I have used this approach in two design cases of developing interactive systems that support awareness beyond task-based aspects in work environments. In both the cases, I have followed a complete design cycle: collecting an in-situ understanding of an environment, developing implications for a new technology, implementing a prototype technology to studying the use of the technology in its natural settings.

Transmedia Practice : A Collective Approach

This volume introduces a collective approach that positions transmedia as a dynamic phenomenon which undergoes constant innovation as it absorbs current trends and advances in its constituent disciplines. The first section, 'Sustaining Future Practices', explores emerging models for defining stakeholder needs, understanding resource requirements and measuring the value and success of transmedia productions. The focus then shifts to 'Intersecting Contexts of Transmedia Practices', which uses the juxtaposition of a diverse collection of case studies to transcend not only the debates about how to define transmedia, but also the professional and disciplinary boundaries that impose artificial constraints upon the way transmedia projects are approached and understood. This inter-disciplinary dialogue aims to promote an ongoing conversation on the challenges and opportunities associated with sustaining this vital creative industry.

Statistical analysis of reduction in tensile strength of cotton strips as a measure of soil microbial activity

The cotton strip assay (CSA) is an established technique for measuring soil microbial activity. The technique involves burying cotton strips and measuring their tensile strength after a certain time. This gives a measure of the rotting rate, R, of the cotton strips. R is then a measure of soil microbial activity. This paper examines properties of the technique and indicates how the assay can be optimised. Humidity conditioning of the cotton strips before measuring their tensile strength reduced the within and between day variance and enabled the distribution of the tensile strength measurements to approximate normality. The test data came from a three-way factorial experiment (two soils, two temperatures, three moisture levels). The cotton strips were buried in the soil for intervals of time ranging up to 6 weeks. This enabled the rate of loss of cotton tensile strength with time to be studied under a range of conditions. An inverse cubic model accounted for greater than 90% of the total variation within each treatment combination. This offers support for summarising the decomposition process by a single parameter R. The approximate variance of the decomposition rate was estimated from a function incorporating the variance of tensile strength and the differential of the function for the rate of decomposition, R, with respect to tensile strength. This variance function has a minimum when the measured strength is approximately 2/3 that of the original strength. The estimates of R are almost unbiased and relatively robust against the cotton strips being left in the soil for more or less than the optimal time. We conclude that the rotting rate X should be measured using the inverse cubic equation, and that the cotton strips should be left in the soil until their strength has been reduced to about 2/3.

Disaster resilience in tertiary hospitals : a cross-sectional survey in Shandong Province, China

Background: Hospital disaster resilience can be defined as a hospital’s ability to resist, absorb, and respond to the shock of disasters while maintaining critical functions, and then to recover to its original state or adapt to a new one. This study aims to explore the status of resilience among tertiary hospitals in Shandong Province, China. Methods: A stratified random sample (n = 50) was derived from tertiary A, tertiary B, and tertiary C hospitals in Shandong Province, and was surveyed by questionnaire. Data on hospital characteristics and 8 key domains of hospital resilience were collected and analysed. Variables were binary, and analysed using descriptive statistics such as frequencies. Results: A response rate of 82% (n = 41) was attained. Factor analysis identified four key factors from eight domains which appear to reflect the overall level of disaster resilience. These were hospital safety, disaster management mechanisms, disaster resources and disaster medical care capability. The survey demonstrated that in regard to hospital safety, 93% had syndromic surveillance systems for infectious diseases and 68% had evaluated their safety standards. In regard to disaster management mechanisms, all had general plans, while only 20% had specific plans for individual hazards. 49% had a public communication protocol and 43.9% attended the local coordination meetings. In regard to disaster resources, 75.6% and 87.5% stockpiled emergency drugs and materials respectively, while less than a third (30%) had a signed Memorandum of Understanding with other hospitals to share these resources. Finally in regard to medical care, 66% could dispatch an on-site medical rescue team, but only 5% had a ‘portable hospital’ function and 36.6% and 12% of the hospitals could surge their beds and staff capacity respectively. The average beds surge capacity within 1 day was 13%. Conclusions: This study validated the broad utility of a framework for understanding and measuring the level of hospital resilience. The survey demonstrated considerable variability in disaster resilience arrangements of tertiary hospitals in Shandong province, and the difference between tertiary A hospitals and tertiary B hospitals was also identified in essential areas.

Introducing telemetrics

This paper introduces a new methodology for analyzing and measuring engagement with television content by users of Twitter. Drawing on factors such as the network, viewing audience, and date of broadcast to establish a baseline expectation for volume of tweets around a television show, and applying techniques from the field of sabermetrics to create neutral volume figures (‘weighted tweets’) which exclude these variables, our metrics provide new insights into television’s social media presence. The methodology provides a variety of new measures for analysing the social media strategies of individual television programs, channels and networks, for comparing users’ engagement with programs, channels or networks, and for predicting future volumes of tweets.

Morphogenetic analysis of architectural elements within the townscape

When a new form is inserted in an existing townscape, its consonance within the urban fabric is dependent on the level of attention paid to the evaluation and management of its architectural elements. However, despite the established principles and methods of urban morphology that enable the systematic analysis of the built environment, a formula for ensuring that new development relates to its context so as to achieve congruent outcomes is still lacking. This paper proposes a new method of evaluating and measuring architectural elements within evolving urban forms, with particular emphasis on a three-dimensional study of buildings. In a case study, detailed mapping of both current and past forms provides the basis for evincing predominant characteristics that have changed over time. Using this method, it is possible to demonstrate objectively how the townscape has been affected through changes in its architectural configuration.

A suitable method for journal bearing wear measurement

Purpose – Ideally, there is no wear in hydrodynamic lubrication regime. A small amount of wear occurs during start and stop of the machines and the amount of wear is so small that it is difficult to measure with accuracy. Various wear measuring techniques have been used where out-of-roundness was found to be the most reliable method of measuring small wear quantities in journal bearings. This technique was further developed to achieve higher accuracy in measuring small wear quantities. The method proved to be reliable as well as inexpensive. The paper aims to discuss these issues. Design/methodology/approach – In an experimental study, the effect of antiwear additives was studied on journal bearings lubricated with oil containing solid contaminants. The test duration was too long and the wear quantities achieved were too small. To minimise the test duration, short tests of about 90 min duration were conducted and wear was measured recording changes in variety of parameters related to weight, geometry and wear debris. The out-of-roundness was found to be the most effective method. This method was further refined by enlarging the out-of-roundness traces on a photocopier. The method was proved to be reliable and inexpensive. Findings – Study revealed that the most commonly used wear measurement techniques such as weight loss, roughness changes and change in particle count were not adequate for measuring small wear quantities in journal bearings. Out-of-roundness method with some refinements was found to be one of the most reliable methods for measuring small wear quantities in journal bearings working in hydrodynamic lubrication regime. By enlarging the out-of-roundness traces and determining the worn area of the bearing cross-section, weight loss in bearings was calculated, which was repeatable and reliable. Research limitations/implications – This research is a basic in nature where a rudimentary solution has been developed for measuring small wear quantities in rotary devices such as journal bearings. The method requires enlarging traces on a photocopier and determining the shape of the worn area on an out-of-roundness trace on a transparency, which is a simple but a crude method. This may require an automated procedure to determine the weight loss from the out-of-roundness traces directly. This method can be very useful in reducing test duration and measuring wear quantities with higher precision in situations where wear quantities are very small. Practical implications – This research provides a reliable method of measuring wear of circular geometry. The Talyrond equipment used for measuring the change in out-of-roundness due to wear of bearings indicates that this equipment has high potential to be used as a wear measuring device also. Measurement of weight loss from the traces is an enhanced capability of this equipment and this research may lead to the development of a modified version of Talyrond type of equipment for wear measurements in circular machine components. Originality/value – Wear measurement in hydrodynamic bearings requires long duration tests to achieve adequate wear quantities. Out-of-roundness is one of the geometrical parameters that changes with progression of wear in a circular shape components. Thus, out-of-roundness is found to be an effective wear measuring parameter that relates to change in geometry. Method of increasing the sensitivity and enlargement of out-of-roundness traces is original work through which area of worn cross-section can be determined and weight loss can be derived for materials of known density with higher precision.

Changes in preservice teachers’ personal epistemologies

While much has been written about the relationship between personal epistemologies and learning-teaching approaches, outcomes, and intentions, little has focused specifically on these relationships in the context of teacher education. This chapter addresses changes in preservice teachers’ personal epistemologies by overviewing this emerging body of research and arguing for a new approach to conceptualizing and supporting changes in personal epistemologies based on reflexivity. The overview includes definitions of key concepts and research traditions that have been used since the 1970s and a discussion of the emerging role of epistemic justification as a key mechanism of change in the process of belief development.

Measuring the use of information and communication technologies (ICTs) in the classroom

In 2003, the “ICT Curriculum Integration Performance Measurement Instrument” was developed froman extensive review ofthe contemporary international and Australian research pertaining to the definition and measurement of ICT curriculum integration in classrooms (Proctor, Watson, & Finger, 2003). The 45-item instrument that resulted was based on theories and methodologies identified by the literature review. This paper describes psychometric results from a large-scale evaluation of the instrument subsequently conducted, as recommended by Proctor, Watson, and Finger (2003). The resultant 20-item, two-factor instrument, now called “Learning with ICTs: Measuring ICT Use in the Curriculum,” is both statistically and theoretically robust. This paper should be read in association with the original paper published in Computers in the Schools(Proctor, Watson, & Finger, 2003) that described in detail the theoretical framework underpinning the development of the instrument.