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.

Party On! A call for entrepreneurship research that is more interactive, activity based, cognitively hot, compassionate, and prosocial

It is the Journal of Business Venturing's (JBV) 30th birthday. Although the community of entrepreneurship scholars deserves to celebrate JBV's achievements over the last 30 years (and congratulate the journal's parents—Ian Macmillan and S. Venkataraman), my focus is more on the future of entrepreneurship (and by extension JBV). A focus on entrepreneurship is both timeless and timely. On the one hand, entrepreneurship is timeless given the long-recognized importance of entrepreneurs to economies and societies (e.g., Jean Baptiste who supposedly coined the term in about 1800). On the other hand, a discussion of entrepreneurship is timely because now that the field of entrepreneurship has achieved legitimacy, it faces both opportunities and threats. It is thus timely to acknowledge the threats and think about opportunities to advance the field. A discussion of entrepreneurship is also timely because society faces a number of grand challenges (including the durability of poverty, environmental degradation [ Dorado and Ventresca, 2013]), challenges well suited to entrepreneurial responses...

The democratic deficit and school-based management in Australia

Purpose: The paper seeks to apply the theory of the democratic deficit to school-based management with an emphasis on Australia. This theory was developed to examine managerial restructuring of the Australian Public Service in the 1990s. Given similarities between the use of managerial practices in the public service and government schools, the authors draw on recent literature about school-based management in Australia and apply the democratic deficit theory to it. ----- ----- Design/methodology/approach: This paper is conceptual in focus. The authors analyse literature in terms of the three components of the democratic deficit – i.e. the weakening of accountability, the denial of the roles and values of public employees, and the emergence of a “hollow state” – and in relation to the application of this theory to the Australian Public Service.----- ----- Findings: A trend towards the three components of the democratic deficit is evident in Australia although, to date, its emergence has not been as extensive as in the UK. The authors argue that the democratic principles on which public schooling in Australia was founded are being eroded by managerial and market practices.----- ----- Practical implications: These findings provide policy makers and practitioners with another way of examining managerial and market understandings of school-based management and its impact on teachers and on students. It offers suggestions to reorient practices away from those that are exclusively managerial-based towards those that are public-sector based.----- ----- Originality/value: The value of this paper is that it applies the theory of the democratic deficit to current understandings of school-based management.

Simple as ABC? An examination of Activity Based Costing (ABC) Implementation in Fiji

We review the level of Activity Based Costing (ABC) in Fiji in this article. This exercise is important in furthering our understanding of the use of ABC in Fiji. ABC is a popular costing system and strategic tool for organizations in developed countries (Chenhall and Langfield-Smith 1998). However, little is known about the benefits and challenges of implementing ABC in developing countries. Such an understanding could stimulate discussion on the development or modification of ABC to suit developing country circumstances. The article also has a practical objective in informing and education organizations in Fiji regarding the benefits and challenges of ABC implementation in Fiji and also provides practical suggestions for improving and easing the implementation of ABC.

Using collaborative and activity-based learning for engaging IT students

Active and collaborative learning are becoming essential strategies to attract, engage and retain students. These methods have been adopted within the Science and Engineering Faculty of Queensland University of Technology for use in its Science, Information Technology and Engineering degrees. This paper describes the adoption and application of these techniques in a specific first year unit in a new Bachelor of Information Technology degree which has majors in Computer Science and Information Systems. The paper reports on the design, development and implementation of this foundation subject and discusses how it uses active and collaborative learning to teach design thinking through a series of design challenges, and how it uses critiquing and reflection to ensure that students become more aware of design and team processes.

Experienced-based management of IMRT quality assurance

This study uses the detailed, bulk analyses of a set of treatment planning and quality assurance data from one radiotherapy centre to provide an illuminating example of the provision evidence-based advice on the management, and potential reduction, of an IMRT quality assurance workload.

Use of physical activity self-management strategies by high school students

Teaching adolescents to use self-management strategies (SMS's) may be an effective approach to promoting lifelong physical activity (PA). However, the extent to which adolescents use SMS's and their impact on current PA have not been studied previously. The aims of this study were: 1) describe the prevalence of SMS use in adolescents; and 2) determine relationships between SMS use, PA self-efficacy, and PA participation. 197 students completed questionnaires measuring use of SMS's, self-efficacy, and PA behavior. The most prevalent SMS's (>30%) were thinking about the benefits of PA, making PA more enjoyable, choosing activities that are convenient, setting aside time to do PA, and setting goals to do PA. Less than 10% reported rewarding oneself for PA, writing planned activities in a book or calendar, and keeping charts of PA. SMS use was associated with increased self-efficacy (r = 0.47, P < .001) and higher levels of PA (r = 0.34 P < .001). A one unit difference in SMS scores was associated with a ~ 4-fold increase in the probability of being active (OR = 3.7, 95% CI = 1.8-7.4). Although strongly associated with PA, a relatively small percentage of adolescents routinely use SMS's.

Mitigating undesirable impacts in the marine environment: A review of market-based management measures

Internationally, marine biodiversity conservation objectives are having an increasing influence on the management of commercial fisheries. While this is largely being implemented through Marine Protected Areas (MPAs) other management measures, such as market based instruments (MBIs), have proved to be effective at managing target species catch in fisheries and reducing environmental impacts in industries such as mining and tourism. Market-based management measures aim to mitigate the impacts of activities by better aligning the incentives their participants face with the objectives of management, changing their behavior as a consequence. In this paper, we review the potential of MBIs as management tools to mitigate undesirable environmental impacts associated with commercial fishing. Where they exist, examples of previous applications are described and the factors that influence their applicability and effectiveness are discussed. Several fishing methods and impacts are considered and suggest that whilst no single approach is most appropriate in all circumstances either replacing or complementing existing management arrangements with MBIs has the potential to improve environmental performance. This has a number of implications. From the environmental perspective they should enable levels of undesirable impacts such as damage to sensitive habitat or the bycatch of protected species of turtles, marine mammals, and seabirds to be reduced. The increased flexibility MBIs allow industry when developing solutions also has the potential to reduce costs to both the industry and managers, improving the cost-effectiveness of regulation as a result. Further, in the increasingly relevant case of MPAs the need for publicly funded compensation, often paid to industry when vessels are excluded from grounds, may also be significantly reduced if improved environmental performance makes it possible for some industry members to continue operating.

Systems-based accident analysis in the led outdoor activity domain : application and evaluation of a risk management framework

Safety-compromising accidents occur regularly in the led outdoor activity domain. Formal accident analysis is an accepted means of understanding such events and improving safety. Despite this, there remains no universally accepted framework for collecting and analysing accident data in the led outdoor activity domain. This article presents an application of Rasmussen's risk management framework to the analysis of the Lyme Bay sea canoeing incident. This involved the development of an Accimap, the outputs of which were used to evaluate seven predictions made by the framework. The Accimap output was also compared to an analysis using an existing model from the led outdoor activity domain. In conclusion, the Accimap output was found to be more comprehensive and supported all seven of the risk management framework's predictions, suggesting that it shows promise as a theoretically underpinned approach for analysing, and learning from, accidents in the led outdoor activity domain.

Value creation and value capture fro open source software publisher : a new business model based on mutualisation

Key topics: Since the birth of the Open Source movement in the mid-80's, open source software has become more and more widespread. Amongst others, the Linux operating system, the Apache web server and the Firefox internet explorer have taken substantial market shares to their proprietary competitors. Open source software is governed by particular types of licenses. As proprietary licenses only allow the software's use in exchange for a fee, open source licenses grant users more rights like the free use, free copy, free modification and free distribution of the software, as well as free access to the source code. This new phenomenon has raised many managerial questions: organizational issues related to the system of governance that underlie such open source communities (Raymond, 1999a; Lerner and Tirole, 2002; Lee and Cole 2003; Mockus et al. 2000; Tuomi, 2000; Demil and Lecocq, 2006; O'Mahony and Ferraro, 2007;Fleming and Waguespack, 2007), collaborative innovation issues (Von Hippel, 2003; Von Krogh et al., 2003; Von Hippel and Von Krogh, 2003; Dahlander, 2005; Osterloh, 2007; David, 2008), issues related to the nature as well as the motivations of developers (Lerner and Tirole, 2002; Hertel, 2003; Dahlander and McKelvey, 2005; Jeppesen and Frederiksen, 2006), public policy and innovation issues (Jullien and Zimmermann, 2005; Lee, 2006), technological competitions issues related to standard battles between proprietary and open source software (Bonaccorsi and Rossi, 2003; Bonaccorsi et al. 2004, Economides and Katsamakas, 2005; Chen, 2007), intellectual property rights and licensing issues (Laat 2005; Lerner and Tirole, 2005; Gambardella, 2006; Determann et al., 2007). A major unresolved issue concerns open source business models and revenue capture, given that open source licenses imply no fee for users. On this topic, articles show that a commercial activity based on open source software is possible, as they describe different possible ways of doing business around open source (Raymond, 1999; Dahlander, 2004; Daffara, 2007; Bonaccorsi and Merito, 2007). These studies usually look at open source-based companies. Open source-based companies encompass a wide range of firms with different categories of activities: providers of packaged open source solutions, IT Services&Software Engineering firms and open source software publishers. However, business models implications are different for each of these categories: providers of packaged solutions and IT Services&Software Engineering firms' activities are based on software developed outside their boundaries, whereas commercial software publishers sponsor the development of the open source software. This paper focuses on open source software publishers' business models as this issue is even more crucial for this category of firms which take the risk of investing in the development of the software. Literature at last identifies and depicts only two generic types of business models for open source software publishers: the business models of ''bundling'' (Pal and Madanmohan, 2002; Dahlander 2004) and the dual licensing business models (Välimäki, 2003; Comino and Manenti, 2007). Nevertheless, these business models are not applicable in all circumstances. Methodology: The objectives of this paper are: (1) to explore in which contexts the two generic business models described in literature can be implemented successfully and (2) to depict an additional business model for open source software publishers which can be used in a different context. To do so, this paper draws upon an explorative case study of IdealX, a French open source security software publisher. This case study consists in a series of 3 interviews conducted between February 2005 and April 2006 with the co-founder and the business manager. It aims at depicting the process of IdealX's search for the appropriate business model between its creation in 2000 and 2006. This software publisher has tried both generic types of open source software publishers' business models before designing its own. Consequently, through IdealX's trials and errors, I investigate the conditions under which such generic business models can be effective. Moreover, this study describes the business model finally designed and adopted by IdealX: an additional open source software publisher's business model based on the principle of ''mutualisation'', which is applicable in a different context. Results and implications: Finally, this article contributes to ongoing empirical work within entrepreneurship and strategic management on open source software publishers' business models: it provides the characteristics of three generic business models (the business model of bundling, the dual licensing business model and the business model of mutualisation) as well as conditions under which they can be successfully implemented (regarding the type of product developed and the competencies of the firm). This paper also goes further into the traditional concept of business model used by scholars in the open source related literature. In this article, a business model is not only considered as a way of generating incomes (''revenue model'' (Amit and Zott, 2001)), but rather as the necessary conjunction of value creation and value capture, according to the recent literature about business models (Amit and Zott, 2001; Chresbrough and Rosenblum, 2002; Teece, 2007). Consequently, this paper analyses the business models from these two components' point of view.

Building adaptable agent-based models – application to the electricity distribution network

Agent-based modelling (ABM), like other modelling techniques, is used to answer specific questions from real world systems that could otherwise be expensive or impractical. Its recent gain in popularity can be attributed to some degree to its capacity to use information at a fine level of detail of the system, both geographically and temporally, and generate information at a higher level, where emerging patterns can be observed. This technique is data-intensive, as explicit data at a fine level of detail is used and it is computer-intensive as many interactions between agents, which can learn and have a goal, are required. With the growing availability of data and the increase in computer power, these concerns are however fading. Nonetheless, being able to update or extend the model as more information becomes available can become problematic, because of the tight coupling of the agents and their dependence on the data, especially when modelling very large systems. One large system to which ABM is currently applied is the electricity distribution where thousands of agents representing the network and the consumers’ behaviours are interacting with one another. A framework that aims at answering a range of questions regarding the potential evolution of the grid has been developed and is presented here. It uses agent-based modelling to represent the engineering infrastructure of the distribution network and has been built with flexibility and extensibility in mind. What distinguishes the method presented here from the usual ABMs is that this ABM has been developed in a compositional manner. This encompasses not only the software tool, which core is named MODAM (MODular Agent-based Model) but the model itself. Using such approach enables the model to be extended as more information becomes available or modified as the electricity system evolves, leading to an adaptable model. Two well-known modularity principles in the software engineering domain are information hiding and separation of concerns. These principles were used to develop the agent-based model on top of OSGi and Eclipse plugins which have good support for modularity. Information regarding the model entities was separated into a) assets which describe the entities’ physical characteristics, and b) agents which describe their behaviour according to their goal and previous learning experiences. This approach diverges from the traditional approach where both aspects are often conflated. It has many advantages in terms of reusability of one or the other aspect for different purposes as well as composability when building simulations. For example, the way an asset is used on a network can greatly vary while its physical characteristics are the same – this is the case for two identical battery systems which usage will vary depending on the purpose of their installation. While any battery can be described by its physical properties (e.g. capacity, lifetime, and depth of discharge), its behaviour will vary depending on who is using it and what their aim is. The model is populated using data describing both aspects (physical characteristics and behaviour) and can be updated as required depending on what simulation is to be run. For example, data can be used to describe the environment to which the agents respond to – e.g. weather for solar panels, or to describe the assets and their relation to one another – e.g. the network assets. Finally, when running a simulation, MODAM calls on its module manager that coordinates the different plugins, automates the creation of the assets and agents using factories, and schedules their execution which can be done sequentially or in parallel for faster execution. Building agent-based models in this way has proven fast when adding new complex behaviours, as well as new types of assets. Simulations have been run to understand the potential impact of changes on the network in terms of assets (e.g. installation of decentralised generators) or behaviours (e.g. response to different management aims). While this platform has been developed within the context of a project focussing on the electricity domain, the core of the software, MODAM, can be extended to other domains such as transport which is part of future work with the addition of electric vehicles.

Management based on exhaled nitric oxidelevels adjusted for atopy reduces asthma exacerbations in children : A dual centre randomised controlled trial

While several randomised control trials (RCTs) have evaluated the use of fractional exhaled nitric oxide (FeNO) to improve asthma outcomes, none used FeNO cut-offs adjusted for atopy, a determinant of FeNO levels. In a dual centre RCT, we assessed whether a treatment strategy based on FeNO levels, adjusted for atopy, reduces asthma exacerbations compared with the symptoms-based management (controls). Children with asthma from hospital clinics of two hospitals were randomly allocated to receive an a-priori determined treatment hierarchy based on symptoms or FeNO levels. There was a 2-week run-in period and they were then reviewed ten times over 12-months. The primary outcome was the number of children with exacerbations over 12-months. Sixty-three children were randomised (FeNO=31, controls=32); 55 (86%) completed the study. Although we did achieve our planned sample size, significantly fewer children in the FeNO group (6 of 27) had an asthma exacerbation compared to controls (15 of 28), p=0.021; number to treat for benefit=4 (95%CI 3-24). There was no difference between groups for any secondary outcomes (quality of life, symptoms, FEV1). The final daily inhaled corticosteroids (ICS) dose was significantly (p=0.037) higher in the FeNO group (median 400µg, IQR 250-600) compared to the controls (200, IQR100-400). Taking atopy into account when using FeNO to tailor asthma medications is likely beneficial in reducing the number of children with severe exacerbations at the expense of increased ICS use. However, the strategy is unlikely beneficial for improving asthma control. A larger study is required to confirm or refute our findings.