Evaluation of financial incentives as a quality improvement strategy in the public hospital context : clinician attitudes, design variables, and economic costs

In 2008, a three-year pilot ‘pay for performance’ (P4P) program, known as ‘Clinical Practice Improvement Payment’ (CPIP) was introduced into Queensland Health (QHealth). QHealth is a large public health sector provider of acute, community, and public health services in Queensland, Australia. The organisation has recently embarked on a significant reform agenda including a review of existing funding arrangements (Duckett et al., 2008). Partly in response to this reform agenda, a casemix funding model has been implemented to reconnect health care funding with outcomes. CPIP was conceptualised as a performance-based scheme that rewarded quality with financial incentives. This is the first time such a scheme has been implemented into the public health sector in Australia with a focus on rewarding quality, and it is unique in that it has a large state-wide focus and includes 15 Districts. CPIP initially targeted five acute and community clinical areas including Mental Health, Discharge Medication, Emergency Department, Chronic Obstructive Pulmonary Disease, and Stroke. The CPIP scheme was designed around key concepts including the identification of clinical indicators that met the set criteria of: high disease burden, a well defined single diagnostic group or intervention, significant variations in clinical outcomes and/or practices, a good evidence, and clinician control and support (Ward, Daniels, Walker & Duckett, 2007). This evaluative research targeted Phase One of implementation of the CPIP scheme from January 2008 to March 2009. A formative evaluation utilising a mixed methodology and complementarity analysis was undertaken. The research involved three research questions and aimed to determine the knowledge, understanding, and attitudes of clinicians; identify improvements to the design, administration, and monitoring of CPIP; and determine the financial and economic costs of the scheme. Three key studies were undertaken to ascertain responses to the key research questions. Firstly, a survey of clinicians was undertaken to examine levels of knowledge and understanding and their attitudes to the scheme. Secondly, the study sought to apply Statistical Process Control (SPC) to the process indicators to assess if this enhanced the scheme and a third study examined a simple economic cost analysis. The CPIP Survey of clinicians elicited 192 clinician respondents. Over 70% of these respondents were supportive of the continuation of the CPIP scheme. This finding was also supported by the results of a quantitative altitude survey that identified positive attitudes in 6 of the 7 domains-including impact, awareness and understanding and clinical relevance, all being scored positive across the combined respondent group. SPC as a trending tool may play an important role in the early identification of indicator weakness for the CPIP scheme. This evaluative research study supports a previously identified need in the literature for a phased introduction of Pay for Performance (P4P) type programs. It further highlights the value of undertaking a formal risk assessment of clinician, management, and systemic levels of literacy and competency with measurement and monitoring of quality prior to a phased implementation. This phasing can then be guided by a P4P Design Variable Matrix which provides a selection of program design options such as indicator target and payment mechanisms. It became evident that a clear process is required to standardise how clinical indicators evolve over time and direct movement towards more rigorous ‘pay for performance’ targets and the development of an optimal funding model. Use of this matrix will enable the scheme to mature and build the literacy and competency of clinicians and the organisation as implementation progresses. Furthermore, the research identified that CPIP created a spotlight on clinical indicators and incentive payments of over five million from a potential ten million was secured across the five clinical areas in the first 15 months of the scheme. This indicates that quality was rewarded in the new QHealth funding model, and despite issues being identified with the payment mechanism, funding was distributed. The economic model used identified a relative low cost of reporting (under $8,000) as opposed to funds secured of over $300,000 for mental health as an example. Movement to a full cost effectiveness study of CPIP is supported. Overall the introduction of the CPIP scheme into QHealth has been a positive and effective strategy for engaging clinicians in quality and has been the catalyst for the identification and monitoring of valuable clinical process indicators. This research has highlighted that clinicians are supportive of the scheme in general; however, there are some significant risks that include the functioning of the CPIP payment mechanism. Given clinician support for the use of a pay–for-performance methodology in QHealth, the CPIP scheme has the potential to be a powerful addition to a multi-faceted suite of quality improvement initiatives within QHealth.

Investigating the cost-effectiveness of video telephone based support for newly diagnosed paediatric oncology patients and their families: design of a randomised controlled trial

Background Providing ongoing family centred support is an integral part of childhood cancer care. For families living in regional and remote areas, opportunities to receive specialist support are limited by the availability of health care professionals and accessibility, which is often reduced due to distance, time, cost and transport. The primary aim of this work is to investigate the cost-effectiveness of videotelephony to support regional and remote families returning home for the first time with a child newly diagnosed with cancer Methods/design We will recruit 162 paediatric oncology patients and their families to a single centre randomised controlled trial. Patients from regional and remote areas, classified by Accessibility/Remoteness Index of Australia (ARIA+) greater than 0.2, will be randomised to a videotelephone support intervention or a usual support control group. Metropolitan families (ARIA+ ≤ 0.2) will be recruited as an additional usual support control group. Families allocated to the videotelephone support intervention will have access to usual support plus education, communication, counselling and monitoring with specialist multidisciplinary team members via a videotelephone service for a 12-week period following first discharge home. Families in the usual support control group will receive standard care i.e., specialist multidisciplinary team members provide support either face-to-face during inpatient stays, outpatient clinic visits or home visits, or via telephone for families who live far away from the hospital. The primary outcome measure is parental health related quality of life as measured using the Medical Outcome Survey (MOS) Short Form SF-12 measured at baseline, 4 weeks, 8 weeks and 12 weeks. The secondary outcome measures are: parental informational and emotional support; parental perceived stress, parent reported patient quality of life and parent reported sibling quality of life, parental satisfaction with care, cost of providing improved support, health care utilisation and financial burden for families. Discussion This investigation will establish the feasibility, acceptability and cost-effectiveness of using videotelephony to improve the clinical and psychosocial support provided to regional and remote paediatric oncology patients and their families.

An FPGA-based approach to multi-objective evolutionary algorithm for multi-disciplinary design optimisation

This paper investigates the field programmable gate array (FPGA) approach for multi-objective and multi-disciplinary design optimisation (MDO) problems. One class of optimisation method that has been well-studied and established for large and complex problems, such as those inherited in MDO, is multi-objective evolutionary algorithms (MOEAs). The MOEA, nondominated sorting genetic algorithm II (NSGA-II), is hardware implemented on an FPGA chip. The NSGA-II on FPGA application to multi-objective test problem suites has verified the designed implementation effectiveness. Results show that NSGA-II on FPGA is three orders of magnitude better than the PC based counterpart.

Robust multidisciplinary UAS design optimisation

There are many applications in aeronautical/aerospace engineering where some values of the design parameters states cannot be provided or determined accurately. These values can be related to the geometry(wingspan, length, angles) and or to operational flight conditions that vary due to the presence of uncertainty parameters (Mach, angle of attack, air density and temperature, etc.). These uncertainty design parameters cannot be ignored in engineering design and must be taken into the optimisation task to produce more realistic and reliable solutions. In this paper, a robust/uncertainty design method with statistical constraints is introduced to produce a set of reliable solutions which have high performance and low sensitivity. Robust design concept coupled with Multi Objective Evolutionary Algorithms (MOEAs) is defined by applying two statistical sampling formulas; mean and variance/standard deviation associated with the optimisation fitness/objective functions. The methodology is based on a canonical evolution strategy and incorporates the concepts of hierarchical topology, parallel computing and asynchronous evaluation. It is implemented for two practical Unmanned Aerial System (UAS) design problems; the flrst case considers robust multi-objective (single disciplinary: aerodynamics) design optimisation and the second considers a robust multidisciplinary (aero structures) design optimisation. Numerical results show that the solutions obtained by the robust design method with statistical constraints have a more reliable performance and sensitivity in both aerodynamics and structures when compared to the baseline design.

An innovative design and studio-based CS degree

The University of Queensland has recently established a new design-focused, studio-based computer science degree. The Bachelor of Information Environments degree augments the core courses from the University's standard CS degree with a stream of design courses and integrative studio-based projects undertaken every semester. The studio projects integrate and reinforce learning by requiring students to apply the knowledge and skills gained in other courses to open-ended real-world design projects. The studio model is based on the architectural studio and involves teamwork, collaborative learning, interactive problem solving, presentations and peer review. This paper describes the degree program, its curriculum and rationale, and reports on experiences in the first year of delivery.

Professional growth through working together : a study of reciprocal benefits for teacher and education advisor through classroom based professional development

Teacher professional development provided by education advisors as one-off, centrally offered sessions does not always result in change in teacher knowledge, beliefs, attitudes or practice in the classroom. As the mathematics education advisor in this study, I set out to investigate a particular method of professional development so as to influence change in a practising classroom teacher’s knowledge and practices. The particular method of professional development utilised in this study was based on several principles of effective teacher professional development and saw me working regularly in a classroom with the classroom teacher as well as providing ongoing support for her for a full school year. The intention was to document the effects of this particular method of professional development in terms of the classroom teacher’s and my professional growth to provide insights for others working as education advisors. The professional development for the classroom teacher consisted of two components. The first was the co-operative development and implementation of a mental computation instructional program for the Year 3 class. The second component was the provision of ongoing support for the classroom teacher by the education advisor. The design of the professional development and the mental computation instructional program were progressively refined throughout the year. The education advisor fulfilled multiple roles in the study as teacher in the classroom, teacher educator working with the classroom teacher and researcher. Examples of the professional growth of the classroom teacher and the education advisor which occurred as sequences of changes (growth networks, Hollingsworth, 1999) in the domains of the professional world of the classroom teacher and education advisor were drawn from the large body of data collected through regular face-to-face and email communications between the classroom teacher and the education advisor as well as from transcripts of a structured interview. The Interconnected Model of Professional Growth (Clarke & Hollingsworth, 2002; Hollingsworth, 1999) was used to summarise and represent each example of the classroom teacher’s professional growth. A modified version of this model was used to summarise and represent the professional growth of the education advisor. This study confirmed that the method of professional development utilised could lead to significant teacher professional growth related directly to her work in the classroom. Using the Interconnected Model of Professional Growth to summarise and represent the classroom teacher’s professional growth and the modified version for my professional growth assisted with the recognition of examples of how we both changed. This model has potential to be used more widely by education advisors when preparing, implementing, evaluating and following-up on planned teacher professional development activities. The mental computation instructional program developed and trialled in the study was shown to be a successful way of sequencing and managing the teaching of mental computation strategies and related number sense understandings to Year 3 students. This study was conducted in one classroom, with one teacher in one school. The strength of this study was the depth of teacher support provided made possible by the particular method of the professional development, and the depth of analysis of the process. In another school, or with another teacher, this might not have been as successful. While I set out to change my practice as an education advisor I did not expect the depth of learning I experienced in terms of my knowledge, beliefs, attitudes and practices as an educator of teachers. This study has changed the way in which I plan to work as an education advisor in the future.

Trends in policies, programs and practices in the Australasian First Year Experience literature 2000-2010. The First Year in Higher Education Research Series on Evidence-based Practice. Number 1

This publication is the first in a series of scholarly reports on research-based practice related to the First Year Experience in Higher Education. This report synthesises evidence about practice-based initiatives and pragmatic approaches in Aotearoa (New Zealand) and Australia that aim to enhance the experience of commencing students in the higher education sector. Trends in policies, programs and practices ... examines the first year experience literature from 2000-2010. It acknowledges the uniqueness of the Australasian socio-political context and its influence on the interests and output of researchers. The review surveyed almost 400 empirical reports and conceptual discussions produced over the decade that dealt with the stakeholders, institutions and the higher education sector in Australasia. The literature is examined through two theoretical constructs or “lenses”: first, a set of first year curriculum design principles and second, the generational approach to describing the maturation of initiatives. These outcomes and suggested directions for further research provide the challenges and the opportunities for FYE adherents, both scholars and practitioners, to grapple with in the next decade.

A hierarchical evolutionary algorithmic design (HEAD) system for generating and evolving building design models

This thesis develops a detailed conceptual design method and a system software architecture defined with a parametric and generative evolutionary design system to support an integrated interdisciplinary building design approach. The research recognises the need to shift design efforts toward the earliest phases of the design process to support crucial design decisions that have a substantial cost implication on the overall project budget. The overall motivation of the research is to improve the quality of designs produced at the author's employer, the General Directorate of Major Works (GDMW) of the Saudi Arabian Armed Forces. GDMW produces many buildings that have standard requirements, across a wide range of environmental and social circumstances. A rapid means of customising designs for local circumstances would have significant benefits. The research considers the use of evolutionary genetic algorithms in the design process and the ability to generate and assess a wider range of potential design solutions than a human could manage. This wider ranging assessment, during the early stages of the design process, means that the generated solutions will be more appropriate for the defined design problem. The research work proposes a design method and system that promotes a collaborative relationship between human creativity and the computer capability. The tectonic design approach is adopted as a process oriented design that values the process of design as much as the product. The aim is to connect the evolutionary systems to performance assessment applications, which are used as prioritised fitness functions. This will produce design solutions that respond to their environmental and function requirements. This integrated, interdisciplinary approach to design will produce solutions through a design process that considers and balances the requirements of all aspects of the design. Since this thesis covers a wide area of research material, 'methodological pluralism' approach was used, incorporating both prescriptive and descriptive research methods. Multiple models of research were combined and the overall research was undertaken following three main stages, conceptualisation, developmental and evaluation. The first two stages lay the foundations for the specification of the proposed system where key aspects of the system that have not previously been proven in the literature, were implemented to test the feasibility of the system. As a result of combining the existing knowledge in the area with the newlyverified key aspects of the proposed system, this research can form the base for a future software development project. The evaluation stage, which includes building the prototype system to test and evaluate the system performance based on the criteria defined in the earlier stage, is not within the scope this thesis. The research results in a conceptual design method and a proposed system software architecture. The proposed system is called the 'Hierarchical Evolutionary Algorithmic Design (HEAD) System'. The HEAD system has shown to be feasible through the initial illustrative paper-based simulation. The HEAD system consists of the two main components - 'Design Schema' and the 'Synthesis Algorithms'. The HEAD system reflects the major research contribution in the way it is conceptualised, while secondary contributions are achieved within the system components. The design schema provides constraints on the generation of designs, thus enabling the designer to create a wide range of potential designs that can then be analysed for desirable characteristics. The design schema supports the digital representation of the human creativity of designers into a dynamic design framework that can be encoded and then executed through the use of evolutionary genetic algorithms. The design schema incorporates 2D and 3D geometry and graph theory for space layout planning and building formation using the Lowest Common Design Denominator (LCDD) of a parameterised 2D module and a 3D structural module. This provides a bridge between the standard adjacency requirements and the evolutionary system. The use of graphs as an input to the evolutionary algorithm supports the introduction of constraints in a way that is not supported by standard evolutionary techniques. The process of design synthesis is guided as a higher level description of the building that supports geometrical constraints. The Synthesis Algorithms component analyses designs at four levels, 'Room', 'Layout', 'Building' and 'Optimisation'. At each level multiple fitness functions are embedded into the genetic algorithm to target the specific requirements of the relevant decomposed part of the design problem. Decomposing the design problem to allow for the design requirements of each level to be dealt with separately and then reassembling them in a bottom up approach reduces the generation of non-viable solutions through constraining the options available at the next higher level. The iterative approach, in exploring the range of design solutions through modification of the design schema as the understanding of the design problem improves, assists in identifying conflicts in the design requirements. Additionally, the hierarchical set-up allows the embedding of multiple fitness functions into the genetic algorithm, each relevant to a specific level. This supports an integrated multi-level, multi-disciplinary approach. The HEAD system promotes a collaborative relationship between human creativity and the computer capability. The design schema component, as the input to the procedural algorithms, enables the encoding of certain aspects of the designer's subjective creativity. By focusing on finding solutions for the relevant sub-problems at the appropriate levels of detail, the hierarchical nature of the system assist in the design decision-making process.

Design of flight avoidance manoeuvre alphabets for mixed centralised-decentralised separation management

This paper investigates a mixed centralised-decentralised air traffic separation management system, which combines the best features of the centralised and decentralised systems whilst ensuring the reliability of the air traffic management system during degraded conditions. To overcome communication band limits, we propose a mixed separation manager on the basis of a robust decision (or min-max) problem that is posed on a reduced set of admissible flight avoidance manoeuvres (or a FAM alphabet). We also present a design method for selecting an appropriate FAM alphabet for use in the mixed separation management system. Simulation studies are presented to illustrate the benefits of our proposed FAM alphabet based mixed separation manager.

Development of a data mining-based analysis framework for multi-attribute construction project information

Data mining techniques extract repeated and useful patterns from a large data set that in turn are utilized to predict the outcome of future events. The main purpose of the research presented in this paper is to investigate data mining strategies and develop an efficient framework for multi-attribute project information analysis to predict the performance of construction projects. The research team first reviewed existing data mining algorithms, applied them to systematically analyze a large project data set collected by the survey, and finally proposed a data-mining-based decision support framework for project performance prediction. To evaluate the potential of the framework, a case study was conducted using data collected from 139 capital projects and analyzed the relationship between use of information technology and project cost performance. The study results showed that the proposed framework has potential to promote fast, easy to use, interpretable, and accurate project data analysis.

Water-based exercise for patients with chronic arm lymphedema : a randomized controlled pilot trial

Objective: To evaluate the feasibility and effect of a water-based exercise (WBE) program on lymphedema status and shoulder range of motion (ROM) among women with breast cancer related lymphedema. Design: Single-blinded, randomized controlled pilot trial. Twenty-nine eligible breast cancer survivors (median 10 years after surgery) with arm lymphedema (median 21% inter limb difference) were included and randomized into intervention (n= 15) or control (n=14). Twenty-five participants completed the study. The intervention was at least twice weekly WBE for 8 weeks; supervised initially but performed independently during the study period. Outcomes of interest were feasibility as measured by retention and adherence, lymphedema status as measured by optoelectronic perometry, bioimpedance spectroscopy and tissue dielectric constant, and shoulder range of motion (ROM) as measured by goniometer. Results: Four participants were not measured at post-intervention and were not included in the analysis (retention). Four participants in the intervention group did not perform the minimum WBE criteria set (adherence). No effect was found on lymphedema status. Compared to the control group, median ROM change for flexion was 6 (1-10) degrees (p<0.001) and 6 (0-15.5) degrees (p=0,07) for external rotation. Clinically relevant increase in the intervention group was found for 36% in flexion (p≤0.05) and (57%) in external rotation (p≤0.05) compared to controls. Conclusions: This study shows WBE is feasible for breast cancer survivors with arm lymphedema and that shoulder ROM can be improved years after cancer treatment has been completed.

Risk-based approach to the management of on-site wastewater treatment facilities

Background On-site wastewater treatment system (OWTS) siting, design and management has traditionally been based on site specific conditions with little regard to the surrounding environment or the cumulative effect of other systems in the environment. The general approach has been to apply the same framework of standards and regulations to all sites equally, regardless of the sensitivity, or lack thereof, to the receiving environment. Consequently, this has led to the continuing poor performance and failure of on-site systems, resulting in environmental and public health consequences. As a result, there is increasing realisation that more scientifically robust evaluations in regard to site assessment and the underlying ground conditions are needed. Risk-based approaches to on-site system siting, design and management are considered the most appropriate means of improvement to the current standards and codes for on-site wastewater treatment systems. The Project Research in relation to this project was undertaken within the Gold Coast City Council region, the major focus being the semi-urban, rural residential and hinterland areas of the city that are not serviced by centralised treatment systems. The Gold Coast has over 15,000 on-site systems in use, with approximately 66% being common septic tank-subsurface dispersal systems. A recent study evaluating the performance of these systems within the Gold Coast area showed approximately 90% were not meeting the specified guidelines for effluent treatment and dispersal. The main focus of this research was to incorporate strong scientific knowledge into an integrated risk assessment process to allow suitable management practices to be set in place to mitigate the inherent risks. To achieve this, research was undertaken focusing on three main aspects involved with the performance and management of OWTS. Firstly, an investigation into the suitability of soil for providing appropriate effluent renovation was conducted. This involved detailed soil investigations, laboratory analysis and the use of multivariate statistical methods for analysing soil information. The outcomes of these investigations were developed into a framework for assessing soil suitability for effluent renovation. This formed the basis for the assessment of OWTS siting and design risks employed in the developed risk framework. Secondly, an assessment of the environmental and public health risks was performed specifically related the release of contaminants from OWTS. This involved detailed groundwater and surface water sampling and analysis to assess the current and potential risks of contamination throughout the Gold Coast region. Additionally, the assessment of public health risk incorporated the use of bacterial source tracking methods to identify the different sources of fecal contamination within monitored regions. Antibiotic resistance pattern analysis was utilised to determine the extent of human faecal contamination, with the outcomes utilised for providing a more indicative public health assessment. Finally, the outcomes of both the soil suitability assessment and ground and surface water monitoring was utilised for the development of the integrated risk framework. The research outcomes achieved through this project enabled the primary research aims and objects to be accomplished. This in turn would enable Gold Coast City Council to provide more appropriate assessment and management guidelines based on robust scientific knowledge which will ultimately ensure that the potential environmental and public health impacts resulting from on-site wastewater treatment is minimised. As part of the implementation of suitable management strategies, a critical point monitoring program (CPM) was formulated. This entailed the identification of the key critical parameters that contribute to the characterised risks at monitored locations within the study area. The CPM will allow more direct procedures to be implemented, targeting the specific hazards at sensitive areas throughout Gold Coast region.

Investigating the deployment of project management : a new perspective based on the concept of certification

Purpose – The purpose of this paper is to provide a summary description of the doctoral thesis investigating the field of project management (PM) deployment. Researchers will be informed of the current contributions within this topic and of the possible further investigations and researches. The decision makers and practitioners will be aware of a set of tools addressing the PM deployment with new perspectives. Design/methodology/approach – Research undertaken with the thesis is based on quantitative methods using time series statistics (time distance analysis) and comparative and correlation analysis aimed to better define and understand the PM deployment within and between countries or groups. Findings – The results suggest a project management deployment index (PMDI) to objectively measure the PM deployment based on the concept of certification. A proposed framework to empirically benchmark the PM deployment between countries by integrating the PMDI time series with the two dimensional comparative analysis of Sicherl. The correlation analysis within Hoftsede cultural framework shows the impact of the national culture dimensions on the PM deployment. The forecasting model shows a general continual growth trend of the PM deployment, with continual increase in the time distance between the countries. Research limitations/implications – The PM researchers are offered an empirical quantification on which they can construct further investigations and understanding of this phenomenon. The number of possible units that can be studied offers wide possibilities to replicate the thesis work. New researches can be undertaken to investigate further the contribution of other social or economical indicators, or to refine and enrich the definition of the PMDI indicator. Practical implications – These results have important implications on the PM deployment approaches. The PMDI measurements and time series comparisons facilitate considerably the measurement and benchmarking between the units (e.g. countries) and against targets, while the readiness setting of the studied unit (in terms of development and cultural levels) impacts the PM deployment within this country. Originality/value – This paper provides a summary of cutting-edge research work in the studied field of PM deployment and a link to the published works that researchers can use to help them understand the thesis research as well as how it can be extended.

Reflection in Integrated Problem Based Learning : 20 years of continuing application to the teaching of architecture

In 1984 the School of Architecture and Built Environment within the University of Newcastle, Australia introduced an integrated program based on real design projects and using Integrated Problem Based Learning (IPBL) as the teaching method. Since 1984 there have been multiple changes arising from the expectations of the architectural fraternity, enrolling students, lecturers, available facilities, accreditation authorities and many others. These challenges have been successfully accommodated whilst maintaining the original purposes and principles of IPBL. The Architecture program has a combined two-degree structure consisting of a first degree, Bachelor of Science (Architecture), followed by a second degree, Bachelor of Architecture. The program is designed to simulate the problem-solving situations that face a working architect in every day practice. This paper will present the degree structure where each student is enrolled in a single course per semester incorporating design integration and study areas in design studies, professional studies, historical studies, technical studies, environmental studies and communication skills. Each year the design problems increase in complexity and duration set around an annual theme. With 20 years of successful delivery of any program there are highlights and challenges along the way and this paper will discuss some of the successes and barriers experienced within the School of Architecture and Built Environment in delivering IPBL. In addition, the reflective process investigates the currency of IPBL as an appropriate vehicle for delivering the curriculum in 2004 and any additional administrative or staff considerations required to enhance the continuing application of IPBL.