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.

Characteristics of spatial variation, size distribution, formation and growth of particles in urban environments

This thesis is the first comprehensive study of important parameters relating to aerosols' impact on climate and human health, namely spatial variation, particle size distribution and new particle formation. We determined the importance of spatial variation of particle number concentration in microscale environments, developed a method for particle size parameterisation and provided knowledge about the chemistry of new particle formation. This is a significant contribution to our understanding of processes behind the transformation and dynamics of urban aerosols. This PhD project included extensive measurements of air quality parameters using state of the art instrumentation at each of the 25 sites within the Brisbane metropolitan area and advanced statistical analysis.

Critical care nurses' perceptions of their educational needs

A survey of nurses working in critical care units in 89 Queensland hospitals was conducted to investigate their perceptions of critical care nurses' educational needs. Two thirds of the 62 respondents were from rural units and one third were from metropolitan units. Most respondents, irrespective of geographic location, wanted critical care education to be located in hospitals and to be accredited as a graduate diploma course. Rural and metropolitan nurses had similar educational needs and many worked for hospitals that were not offering adequate orientation or inservice critical care education. The findings that nursing staff turnover was a problem in metropolitan units and that the rural workforce was more stable have implications for the development of educational programs.

Let them eat steak : food preferences of patients in a tertiary public hospital

Information on foods patients like and dislike is the essential basis for planning menus which are acceptable to patients and promote adequate consumption. The aim of this study was to obtain quantitative data on the food preferences of inpatients at a large metropolitan public hospital for use in menu planning. Methodology was based on a study by Williams et al (1988), and included additional questions about appetite and taste changes. The survey used a 9 point hedonic scale to rate foods listed in random order and was modified to incorporate more contemporary foods than those used in the originalWilliams study. Surveys were conducted by final year University of Queensland dietetics students on Food Service Practicum at the Royal Brisbane and Women’s Hospital (929 beds) in 2012. The first survey (220 questions, n = 157) had a response rate of 61%. The second included more sandwich fillings and salads (231 questions, n = 219, response rate 67%). Total number surveyed was 376. Results showed the most preferred foods were roast potato, grilled steak, ice cream, fresh strawberries, roast lamb, roast beef, grapes and banana. The least preferred foods were grapefruit, soybeans, lentils, sardines, prune juice and grapefruit juice. Patients who reported taste changes (10%) had similar food preferences to those who didn’t report taste changes. Patients who reported poor/very poor appetite (10%) generally scored foods lower than those who reported OK (22%), good/very good appetite (65%). The results of this study informed planning for a new patient menu at the RBWH in December 2012.

Enhancing student learning in the workplace through developing the leadership capabilities of clinical supervisors in the nursing discipline

The purpose of this project was to build the leadership capacity of clinical supervisors in the nursing discipline by developing, implementing and systematically embedding a leadership model into the structure and practice of student supervision. The University worked in partnership with three major metropolitan hospitals in Queensland to develop a framework and professional development program incorporating leadership and clinical supervision. The Leadership and Clinical Education (LaCE) program consisted of two structured workshops complemented by individual personal development projects undertaken by participants. Participants were supported in these activities with a purpose-built website that provides access to a wide variety of information and other learning resources. Quantitative and qualitative evaluations indicated that the approach was highly valued by participants, as it promoted useful peer dialogue, sharing of experiences and personal development in relation to assisting leadership development and student learning in the workplace. The LaCE program provides an ideal springboard for introducing the development of welltrained leaders into the clinical workplace. The resources developed have the potential to provide ongoing support for clinical supervisors to improve the learning of undergraduate nursing student. The challenge will be to achieve continued innovation within clinical education through sustainable leadership programs.

Radiographer commenting of trauma radiographs : a survey of the benefits, barriers and enablers to participation in an Australian healthcare setting

Introduction Radiographer abnormality detection systems that highlight abnormalities on trauma radiographs (‘red dot’ system) have been operating for more than 30 years. Recently, a number of pitfalls have been identified. These limitations initiated the evolution of a radiographer commenting system, whereby a radiographer provides a brief description of abnormalities identified in emergency healthcare settings. This study investigated radiographers' participation in abnormality detection systems, their perceptions of benefits, barriers and enablers to radiographer commenting, and perceptions of potential radiographer image interpretation services for emergency settings. Methods A cross-sectional survey was implemented. Participants included radiographers from four metropolitan hospitals in Queensland, Australia. Conventional descriptive statistics, histograms and thematic analysis were undertaken. Results Seventy-three surveys were completed and included in the analysis (68% response rate); 30 (41%) of respondents reported participating in abnormality detection in 20% or less of examinations, and 26(36%) reported participating in 80% or more of examinations. Five overarching perceived benefits of radiographer commenting were identified: assisting multidisciplinary teams, patient care, radiographer ability, professional benefits and quality of imaging. Frequently reported perceived barriers included ‘difficulty accessing image interpretation education’, ‘lack of time’ and ‘low confidence in interpreting radiographs’. Perceived enablers included ‘access to image interpretation education’ and ‘support from radiologist colleagues’. Conclusions A range of factors are likely to contribute to the successful implementation of radiographer commenting in addition to abnormality detection in emergency settings. Effective image interpretation education amenable to completion by radiographers would likely prove valuable in preparing radiographers for participation in abnormality detection and commenting systems in emergency settings.

Feasibility and efficacy of a church-based intervention to promote physical activity in children

Background This study evaluated the feasibility and preliminary efficacy of a church-based intervention to promote physical activity (PA) in children. Methods The study was conducted in 4 churches located in 2 large metropolitan areas and 2 regional towns in Kansas. Churches in the intervention condition implemented the "Shining Like Stars" physical activity curriculum module during their regularly scheduled Sunday school classes. Churches in the control condition delivered the same content without integrating physical activity into the lessons. In addition to the curriculum, the intervention churches completed a series of weekly family devotional activities designed to promote parental support for PA and increase PA outside of Sunday school. Results Children completing the Shining Like Stars curriculum exhibited significantly greater amounts of MVPA than those in the control condition (20 steps/min vs. 7 steps/min). No intervention effects were observed for PA levels outside of Sunday school or parental support for PA; however, relative to controls, children in the intervention churches did exhibit a significant reduction in screen time. Conclusion The findings confirm that the integration of physical activity into Sunday school is feasible and a potentially effective strategy for promoting PA in young children.

Configurations of Gender, Class and Rurality in Resource Affected Rural Australia

Historically, class has been a key concern in studies of resource affected communities (e.g., Williamson 1982, Warwick and Littlejohn 1992). While work continues, particularly in Britain, today it reflects the rationalization of the British mining sector, and thus focuses largely on mining heritage (e.g., Strangleman et al. 1999, Dicks 2008). In contrast, this chapter examines class relations as manifest in a contemporary setting in rural Australia. This site, the Ravensthorpe Shire in the south west of Western Australia, relied largely on agriculture until 2004 when BHP Billiton commenced construction of a nickel mine in the area. This affected the entire Shire as well as the two rural communities of Ravensthorpe and Hopetoun. The mine, which was officially opened in June 2008, is one of a large number of new mineral and energy developments being established in non metropolitan areas of the country as high international demand for resources fuels significant growth in the sector. In a single six month period in 2009, for example, 15 major minerals and energy projects were completed across the nation and a further 74 projects were at advanced stages (Australian Bureau of Agricultural Economics 2009). A number of these were, as was the case in Ravensthorpe, in what had been traditionally agricultural communities.

Measuring the preference for dwelling characteristics of Melbourne : railway stations and house prices

The relationship between public transportation and home values has proven to be complex, with studies providing divergent findings. Using Victorian Valuer General Data for 2009, this paper applies a hedonic pricing approach to the Melbourne metropolitan housing market in order to estimate the impacts of proximity to a train station on residential property prices. The findings reveal a negative impact on dwelling price for those properties within 125 metres from a train station and a positive relationship between dwelling price and proximity for properties more than 125 metres away.

Gentrification and the artistic dividend : the role of the arts in neighborhood change

Problem, research strategy, and findings: There is a conflict between recent creative placemaking policies intended to promote positive neighborhood development through the arts and the fact that the arts have long been cited as contributing to gentrification and the displacement of lower-income residents. Unfortunately, we do not have data to demonstrate widespread evidence of either outcome. We address the dearth of comprehensive research and inform neighborhood planning efforts by statistically testing how two different groups of arts activities—the fine arts and commercial arts industries—are associated with conditions indicative of revitalization and gentrification in 100 large U.S. metropolitan areas. We find that different arts activities are associated with different types and levels of neighborhood change. Commercial arts industries show the strongest association with gentrification in rapidly changing areas, while the fine arts are associated with stable, slow-growth neighborhoods. Takeaway for practice: This research can help planners to more effectively incorporate the arts into neighborhood planning efforts and to anticipate the potential for different outcomes in their arts development strategies, including gentrification-related displacement.

Investigating the school experiences of girls whose parents are separated or divorced : implications for practice

The study investigated the school experiences of girls whose parents are separated or divorced. The case study, conducted in a metropolitan, all-girls Catholic school in Brisbane, drew upon theoretical understandings from childhood studies and children's rights to reveal the school experiences of participants, from their own perspectives. Findings showed that students express emotions about their families while at school, are active agents in their own learning, and seek teachers' understanding of their situation, while respecting their family's privacy. The research points to the need for strengths-based, resilience-building strategies in schools, for an inclusive culture of respect for family diversity, and for understanding of students' transitions between households and family types.

A different breed altogether? Distinctions between local and metropolitan journalism cultures

While a number of scholars have explored the special exigencies of local as opposed to metropolitan journalism, rarely have studies examined such differences in relation to journalism culture as constituted by journalists’ professional views. To address the gap in our knowledge, this study reports results from a representative survey of local and metropolitan newspaper journalists in Australia. Findings suggest that territorial context accounts for some significant differences in journalists’ demographics, as well as their role perceptions. In line with past research, local newspaper journalists exhibit much stronger support for the community forum and advocacy role. At the same time, and contrary to expectations, there is very little difference in their support of the watchdog role compared with metropolitan journalists. By combining questions about journalistic ideals and enactment in their work, and finding differences in the two, this study also has important implications for the methodological development of survey studies.

Degree of value alignment : a grounded theory of rural nurse resignations

INTRODUCTION: The shortage of nurses willing to work in rural Australian healthcare settings continues to worsen. Australian rural areas have a lower retention rate of nurses than metropolitan counterparts, with more remote communities experiencing an even higher turnover of nursing staff. When retention rates are lower, patient outcomes are known to be poorer. This article reports a study that sought to explore the reasons why registered nurses resign from rural hospitals in the state of New South Wales, Australia. METHODS: Using grounded theory methods, this study explored the reasons why registered nurses resigned from New South Wales rural hospitals. Data were collected from 12 participants using semi-structured interviews; each participant was a registered nurse who had resigned from a rural hospital. Nurses who had resigned due to retirement, relocation or maternity leave were excluded. Interviews were transcribed verbatim and imported into NVivo software. The constant comparative method of data collection and analysis was followed until a core category emerged. RESULTS: Nurses resigned from rural hospitals when their personal value of how nursing should occur conflicted with the hospital's organisational values driving the practice of nursing. These conflicting values led to a change in the degree of value alignment between the nurse and hospital. The degree of value alignment occurred in three dynamic stages that nurses moved through prior to resigning. The first stage, sharing values, was a time when a nurse and a hospital shared similar values. The second stage was conceding values where, due to perceived changes in a hospital's values, a nurse felt that patient care became compromised and this led to a divergence of values. The final stage was resigning, a stage where a nurse 'gave up' as they felt that their professional integrity was severely compromised. The findings revealed that when a nurse and organisational values were not aligned, conflict was created for a nurse about how they could perform nursing that aligned with their internalised professional values and integrity. Resignation occurred when nurses were unable to realign their personal values to changed organisational values - the organisational values changed due to rural area health service restructures, centralisation of budgets and resources, cumbersome hierarchies and management structures that inhibited communication and decision making, out-dated and ineffective operating systems, insufficient and inexperienced staff, bullying, and a lack of connectedness and shared vision. CONCLUSIONS: To fully comprehend rural nurse resignations, this study identified three stages that nurses move through prior to resignation. Effective retention strategies for the nursing workforce should address contributors to a decrease in value alignment and work towards encouraging the coalescence of nurses' and hospitals' values. It is imperative that strategies enable nurses to provide high quality patient care and promote a sense of connectedness and a shared vision between nurse and hospital. Senior managers need to have clear ways to articulate and imbue organisational values and be explicit in how these values accommodate nurses' values. Ward-level nurse managers have a significant responsibility to ensure that a hospital's values (both explicit and implicit) are incorporated into ward culture.

Nearness and revealing : The edible veil of the sensible being.

Taking cues from the fragility and grace enfolded within Asian cuisine, this paper explores recent experimentation of an edible rice paper veil. The veil fashions a 'secondary skin', what Jeffery Schnapp the author of 'The Fabric of Modern Times', calls an "object for prosthetic shelf extension...bearing a uniquely intimate and direct relation to the human body" (Schnapp, 1997:197). The process reveals a layered material mutable to moisture and humidity, changing its elastic state in relation to body and surroundings. The moving, breathing, sweating surface of the body further modifies both veil and bodily experience drawing forth deeper emotional responses. The implications here offer a reciprocal affect, a revealing, where new materiality evokes the threshold to a new sensible being, one aware of the depth of material consciousness and inter-corporeal engagement, and which extends the relations between thinking and being of Heidegger and Shklovsky's seminal works.

A survey of radiographers' confidence and self-perceived accuracy in frontline image interpretation and their continuing educational preferences

Introduction The provision of a written comment on traumatic abnormalities of the musculoskeletal system detected by radiographers can assist referrers and may improve patient management, but the practice has not been widely adopted outside the United Kingdom. The purpose of this study was to investigate Australian radiographers’ perceptions of their readiness for practice in a radiographer commenting system and their educational preferences in relation to two different delivery formats of image interpretation education, intensive and non-intensive. Methods A cross-sectional web-based questionnaire was implemented between August and September 2012. Participants included radiographers with experience working in emergency settings at four Australian metropolitan hospitals. Conventional descriptive statistics, frequency histograms, and thematic analysis were undertaken. A Wilcoxon signed-rank test examined whether a difference in preference ratings between intensive and non-intensive education delivery was evident. Results The questionnaire was completed by 73 radiographers (68% response rate). Radiographers reported higher confidence and self-perceived accuracy to detect traumatic abnormalities than to describe traumatic abnormalities of the musculoskeletal system. Radiographers frequently reported high desirability ratings for both the intensive and the non-intensive education delivery, no difference in desirability ratings for these two formats was evident (z = 1.66,P = 0.11). Conclusions Some Australian radiographers perceive they are not ready to practise in a frontline radiographer commenting system. Overall, radiographers indicated mixed preferences for image interpretation education delivered via intensive and non-intensive formats. Further research, preferably randomised trials, investigating the effectiveness of intensive and non-intensive education formats of image interpretation education for radiographers is warranted.