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.

Mental health issues and resources in rural and regional communities : an exploration of perceptions of service providers

Objective: To identify service providers’ and community organisations’ perceptions of the resources available to support people with mental illness and the unmet needs of this client group in rural Queensland. Design: An exploratory study was undertaken involving focus group interviews across the study sites. Setting: Five regional towns in rural Queensland. Participants: Ten to 14 members were recruited for each of the five focus groups. The groups represented a diverse mix of participants including health and community service providers and representatives from community organisations. Results: Participants identified gaps in services in relation to health, employment and education, housing and accommodation, transport and social inclusion and health promotion. Inter-service communication and inappropriate funding models were themes affecting service delivery. Conclusions: Specific service issues of housing and transport were identified to be particularly problematic for people with mental illness across all towns. Intersectoral communication and funding models require further research.

Film, cinema, screen

Screen industries around the globe are evolving. While technological change has been slower to take effect upon the Australian film industry than other creative sectors such as music and publishing, all indications suggest that local screen practices are in a process of fundamental change. Fragmenting audiences, the growth of digital video, distribution and exhibition, the potential for entirely new forms of cultural expression, the proliferation of multi-platforms, and the importance of social networking and viral marketing in promoting products, are challenging traditional approaches to ‘film making’. Moreover, there has been a marked transition in government policy rationales and funding models in recent years, resulting in the most significant overhaul of public finance structures for the film industry in almost 20 years. Film, Cinema, Screen evaluates the Australian film industry’s recent development – particularly in terms of Australian feature film and television series production; it also advocates new approaches to Australian film, and address critical issues around how screen production globally is changing, with implications for local screen industries.

The impact of managers' characteristics on the use of public relations strategy : an exploratory study in Queensland schools

While previous positive and normative studies have focused on the role public relations should play in organisations and the need for management in all organisations to attend to public relations (Cutlip et al., 2006), there has been little discussion in the public relations literature on why or how managers choose to enact public relations strategies for their organisations. If the discipline of public relations is to cement itself as a management function, then researchers must gain a better understanding of managers themselves given that they are the ones who decide if and how public relations strategies should be employed in the organisation. This study has sought to explore evidence of a relationship between management characteristics and their impact on decisions managers make when choosing which public relations strategies to adopt in response to changes in the organisation’s operating environment. This exploratory research study has been conducted within a specific context of schools in Queensland, Australia. Queensland schools have been facing a number of changes within their operating environment due to changes in Federal funding models in Australia’s education system. This study used an exploratory, qualitative approach to understand the management characteristics demonstrated by managers in schools and how these have impacted on the selection of public relations strategies for responding to their changing and increasingly competitive environment. The unit of analysis for this research study was principals in State (government) schools and in non-government schools. Ten principals were interviewed from four different types of schools in Queensland – the more traditional, elite, private schools (GPS Schools); other Independent Schools; Catholic Schools; and State (or public) schools. These interviews were analysed for quantitative comparisons of the managers’ characteristics across the different schools (in terms of the number of principals in each age bracket, those holding postgraduate qualifications, years of experience etc.); and for qualitative data to provide a greater sense of their understanding of public relations. The 10 schools were selected within a geographic area from Brisbane’s inner city to its outer western suburbs to include an element of competition amongst those managers being interviewed. A detailed review of government, school and other public documents was also conducted to gain an insight into the environment in which principals made decisions about public relations strategy to respond to increasing competition. This study found support for the literature on the relationship between management characteristics and strategy. However, there was also variation in findings warranting further investigation of the literature on the relationship between management characteristics and strategy in a school setting. Key relationships found in this study were between: management characteristics themselves; age and the use of public relations strategies; and gender and the use of public relations strategies. There was also evidence of support for the literature linking the impact that the combination of managers’ age, education and experience had on the use of public relations strategies. While this study was exploratory in nature, it did reveal a number of areas that require further investigation to gain a deeper understanding of how and why managers choose public relations strategies as a response to changes in their operating environment. It also provided a different framework to gain a better understanding of managers’ understanding and support of public relations in schools, which, in conjunction with an analysis of their management characteristics, will hopefully allow public relations scholars and practitioners alike gain an understanding of how and why managers use public relations strategies.

Risky strategic behaviour : unintended consequences of good intentions in the homelessness service system

The delivery of human services occurs through a complex and often volatile system characterised by both competing and cooperating efforts. A recent strategic intention of government has been to integrate disparate service providers and programs into a more effective and efficient system using competitive funding regimes. A program of amalgamation has also been forecast and promoted as a further mechanism by which to link up smaller agencies thus creating economy and efficiency in the scale and scope of their service modes. Despite the current reliance on competitive funding models and amalgamation as the preferred ways forward for the sector little is known about their integrative capacity including their ability to predict outcomes and their consequences : the ‘unknown unknowns’. Drawing on an extensive data set of human services integration initiatives in Queensland, Australia, this paper examines the impact of government policy and service models and the risks arising from the tensions between competition and accountability on the one hand and the established good will and trust on the other. It is argued that unresolved, these tensions can lead to a weakening of the social infrastructure and make the system more vulnerable to inherent systemic risks. The paper finds that government’s efforts to externalise risk to the non-government sector leads to fragmentation of the service system and fractured collaborative capability. These unintended outcomes themselves have the unintended consequence of leaving governments disconnected from the service system and unable to provide the leadership role and direction necessary for sustained integration. Moreover, facilitating such a leadership role is undermined by behaviours that are directly contrary to collective integration models.

Refining animal models in fracture research: Seeking consensus in optimising both animal welfare and scientific validity for appropriate biomedical use

Background In an attempt to establish some consensus on the proper use and design of experimental animal models in musculoskeletal research, AOVET (the veterinary specialty group of the AO Foundation) in concert with the AO Research Institute (ARI), and the European Academy for the Study of Scientific and Technological Advance, convened a group of musculoskeletal researchers, veterinarians, legal experts, and ethicists to discuss, in a frank and open forum, the use of animals in musculoskeletal research. Methods The group narrowed the field to fracture research. The consensus opinion resulting from this workshop can be summarized as follows: Results & Conclusion Anaesthesia and pain management protocols for research animals should follow standard protocols applied in clinical work for the species involved. This will improve morbidity and mortality outcomes. A database should be established to facilitate selection of anaesthesia and pain management protocols for specific experimental surgical procedures and adopted as an International Standard (IS) according to animal species selected. A list of 10 golden rules and requirements for conduction of animal experiments in musculoskeletal research was drawn up comprising 1) Intelligent study designs to receive appropriate answers; 2) Minimal complication rates (5 to max. 10%); 3) Defined end-points for both welfare and scientific outputs analogous to quality assessment (QA) audit of protocols in GLP studies; 4) Sufficient details for materials and methods applied; 5) Potentially confounding variables (genetic background, seasonal, hormonal, size, histological, and biomechanical differences); 6) Post-operative management with emphasis on analgesia and follow-up examinations; 7) Study protocols to satisfy criteria established for a "justified animal study"; 8) Surgical expertise to conduct surgery on animals; 9) Pilot studies as a critical part of model validation and powering of the definitive study design; 10) Criteria for funding agencies to include requirements related to animal experiments as part of the overall scientific proposal review protocols. Such agencies are also encouraged to seriously consider and adopt the recommendations described here when awarding funds for specific projects. Specific new requirements and mandates related both to improving the welfare and scientific rigour of animal-based research models are urgently needed as part of international harmonization of standards.

Infrastructure charges and increases to new house prices : a preliminary analysis of the US empirical models

Sourcing appropriate funding for the provision of new urban infrastructure has been a policy dilemma for governments around the world for decades. This is particularly relevant in high growth areas where new services are required to support swelling populations. The Australian infrastructure funding policy dilemmas are reflective of similar matters in many countries, particularly the United States of America, where infrastructure cost recovery policies have been in place since the 1970’s. There is an extensive body of both theoretical and empirical literature from these countries that discusses the passing on (to home buyers) of these infrastructure charges, and the corresponding impact on housing prices. The theoretical evidence is consistent in its findings that infrastructure charges are passed on to home buyers by way of higher house prices. The empirical evidence is also consistent in its findings, with “overshifting” of these charges evident in all models since the 1980’s, i.e. $1 infrastructure charge results in greater than $1 increase in house prices. However, despite over a dozen separate studies over two decades in the US on this topic, no empirical works have been carried out in Australia to test if similar shifting or overshifting occurs here. The purpose of this research is to conduct a preliminary analysis of the more recent models used in these US empirical studies in order to identify the key study area selection criteria and success factors. The paper concludes that many of the study area selection criteria are implicit rather than explicit. By collecting data across the models, some implicit criteria become apparent, whilst others remain elusive. This data will inform future research on whether an existing model can be adopted or adapted for use in Australia.

Moving beyond transition pedagogy: Maturity models and student engagement

Australian higher education institutions (HEIs) have entered a new phase of regulation and accreditation which includes performance-based funding relating to the participation and retention of students from social and cultural groups previously underrepresented in higher education. However, in addressing these priorities, it is critical that HEIs do not further disadvantage students from certain groups by identifying them for attention because of their social or cultural backgrounds, circumstances which are largely beyond the control of students. In response, many HEIs are focusing effort on university-wide approaches to enhancing the student experience because such approaches will enhance the engagement, success and retention of all students, and in doing so, particularly benefit those students who come from underrepresented groups. Measuring and benchmarking student experiences and engagement that arise from these efforts is well supported by extensive collections of student experience survey data. However no comparable instrument exists that measures the capability of institutions to influence and/or enhance student experiences where capability is an indication of how well an organisational process does what it is designed to do (Rosemann & de Bruin, 2005). This paper proposes that the concept of a maturity model (Marshall, 2010; Paulk, 1999) may be useful as a way of assessing the capability of HEIs to provide and implement student engagement, success and retention activities. We will describe the Student Engagement, Success and Retention Maturity Model (SESR-MM), (Clarke, Nelson & Stoodley, 2012; Nelson, Clarke & Stoodley, 2012) we are currently investigating. We will discuss if our research may address the current gap by facilitating the development of an SESR-MM instrument that aims (i) to enable institutions to assess the capability of their current student engagement and retention programs and strategies to influence and respond to student experiences within the institution; and (ii) to provide institutions with the opportunity to understand various practices across the sector with a view to further improving programs and practices relevant to their context. The first aim of our research is to extend the generational approach which has been useful in considering the evolutionary nature of the first year experience (FYE) (Wilson, 2009). Three generations have been identified and explored: First generation approaches that focus on co-curricular strategies (e.g. orientation and peer programs); Second generation approaches that focus on curriculum (e.g. pedagogy, curriculum design, and learning and teaching practice); and third generation approaches—also referred to as transition pedagogy—that focus on the production of an institution-wide integrated holistic intentional blend of curricular and co-curricular activities (Kift, Nelson & Clarke, 2010). The second aim of this research is to move beyond assessments of students’ experiences to focus on assessing institutional processes and their capability to influence student engagement. In essence, we propose to develop and use the maturity model concept to produce an instrument that will indicate the capability of HEIs to manage and improve student engagement, success and retention programs and strategies. References Australian Council for Educational Research. (n.d.). Australasian Survey of Student Engagement. Retrieved from http://www.acer.edu.au/research/ausse/background Clarke, J., Nelson, K., & Stoodley, I. (2012, July). The Maturity Model concept as framework for assessing the capability of higher education institutions to address student engagement, success and retention: New horizon or false dawn? A Nuts & Bolts presentation at the 15th International Conference on the First Year in Higher Education, “New Horizons,” Brisbane, Australia. Kift, S., Nelson, K., & Clarke, J. (2010) Transition pedagogy - a third generation approach to FYE: A case study of policy and practice for the higher education sector. The International Journal of the First Year in Higher Education, 1(1), pp. 1-20. Department of Education, Employment and Workplace Relations. (n.d.). The University Experience Survey. Advancing quality in higher education information sheet. Retrieved from http://www.deewr.gov.au/HigherEducation/Policy/Documents/University_Experience_Survey.pdf Marshall, S. (2010). A quality framework for continuous improvement of e-Learning: The e-Learning Maturity Model. Journal of Distance Education, 24(1), 143-166. Nelson, K., Clarke, J., & Stoodley, I. (2012). An exploration of the Maturity Model concept as a vehicle for higher education institutions to assess their capability to address student engagement. A work in progress. Submitted for publication. Paulk, M. (1999). Using the Software CMM with good judgment, ASQ Software Quality Professional, 1(3), 19-29. Wilson, K. (2009, June–July). The impact of institutional, programmatic and personal interventions on an effective and sustainable first-year student experience. Keynote address presented at the 12th Pacific Rim First Year in Higher Education Conference, “Preparing for Tomorrow Today: The First Year as Foundation,” Townsville, Australia. Retrieved from http://www.fyhe.com.au/past_papers/papers09/ppts/Keithia_Wilson_paper.pdf

Impact fees and new housing cost: A comparative analysis of the empirical models

Developers and policy makers are consistently at odds over the debate as to whether impact fees increase house prices. This debate continues despite the extensive body of theoretical and empirical international literature that discusses the passing on to home buyers of impact fees, and the corresponding increase to housing prices. In attempting to quantify this impact, over a dozen empirical studies have been carried out in the US and Canada since the 1980’s. However the methodologies used vary greatly, as do the results. Despite similar infrastructure funding policies in numerous developed countries, no such empirical works exist outside of the US/Canada. The purpose of this research is to analyse the existing econometric models in order to identify, compare and contrast the theoretical bases, methodologies, key assumptions and findings of each. This research will assist in identifying if further model development is required and/or whether any of these models have external validity and are readily transferable outside of the US. The findings conclude that there is very little explicit rationale behind the various model selections and that significant model deficiencies appear still to exist.

Examining workload models in online and blended teaching

Over the past decade, most Australian universities have moved increasingly towards online course delivery for both undergraduate and graduate programs. In almost all cases, elements of online teaching are part of routine teaching loads. Yet detailed and accurate workload data are not readily available. As a result, institutional policies on academic staff workload are often guided more by untested assumptions about reduction of costs per student unit, rather than being evidence-based, with the result that implementation of new technologies for online teaching has resulted in poorly defined workload expectations. While the academics in this study often revealed a limited understanding of their institutional workload formulas, which in Australia are negotiated between management and the national union through their local branches, the costs of various types of teaching delivery have become a critical issue in a time of increasing student numbers, declining funding, pressures to increase quality and introduce minimum standards of teaching and curriculum, and substantial expenditure on technologies to support e-learning. There have been relatively few studies on the costs associated with workload for online teaching, and even fewer on the more ubiquitous ‘blended’, ‘hybrid’ or ‘flexible’ modes, in which face-to-face teaching is supplemented by online resources and activities. With this in mind the research reported here has attempted to answer the following question: What insights currently inform Australian universities about staff workload when teaching online?

Funding emergency care : Australian style

The ongoing challenge for ED leaders is to remain abreast of system-wide changes that impact on the day-to-day management of their departments. Changes to the funding model creates another layer of complexity and this introductory paper serves as the beginning of a discussion about the way in which EDs are funded and how this can and will impact on business decisions, models of care and resource allocation within Australian EDs. Furthermore it is evident that any funding model today will mature and change with time, and moves are afoot to refine and contextualise ED funding over the medium term. This perspective seeks to provide a basis of understanding for our current and future funding arrangements in Australian EDs.

The Fleet Store : devising a public retail exhibition to promote creative, innovative and sustainable business models for emerging fashion designers

1.Description of the Work The Fleet Store was devised as a creative output to establish an exhibition linked to a fashion business model where emerging designers were encouraged to research new and innovative strategies for creating design-driven and commercial collections for a public consumer. This was a project that was devised to break down the perceptions of emerging fashion designers that designing commercial collections linked to a sustainable business model is a boring and unnecessary process. The focus was to demystify the business of fashion and to link its importance to a design-driven and public outcome that is more familiar to fashion designers. The criterion for participation was that all designers had to be registered as a business with the Australian Taxation Office. Designers were chosen from the Creative Enterprise Australia Fashion Business Incubator, the QUT fashion graduate alumni and current QUT fashion design and double degree (fashion and business) students with existing businesses. The project evolved from a series of collaborative workshops where designers were introduced to new and innovative creative industries’ business models and the processes, costings and timings involved to create a niche, sustainable business for a public exhibition of design-driven commercial collections. All designers initiated their own business infra-structure but were then introduced to the concept of collaboration for successful and profitable exhibition and business outcomes. Collaborative strategies such as crowd funding, crowd sourcing, peer to peer mentoring and manufacturing were all researched, and strategies for the establishment of the retail exhibition were all devised in a collaborative environment. All participants also took on roles outside their ‘designer’ background to create a retail exhibition that was creative but also had critical mass and aesthetic for the consumer. The Fleet Store ‘popped up’ for 2 weeks (10 days), in a heritage-listed building in an inner city location. Passers-by were important, but the main consumer was enlisted by the use of interest and investment from crowd sourcing, crowd funding, ethical marketing, corporate social responsibility projects and collaborative public relations and social media strategies. The research has furthered discussion on innovative strategies for emerging fashion designers to initiate and maintain sustainable businesses and suggests that collaboration combined with a design-driven and business focus can create a sustainable and economically viable retail exhibition. 2. Research Statement Research Background The research field involved developing a new ethical, design-driven, collaborative and sustainable model for fashion design practice and management. The research asked can a public, design-driven, collaborative retail exhibition create a platform for promoting creative, innovative and sustainable business models for emerging fashion designers. The methodology was primarily practice-led as all participants were designers in their own right and the project manager acted as a mentor and curator to guide the process and analyse the potential of the research question. The Fleet Store offers new knowledge in design practice and management; with the creation of a model where design outcomes and business models are inextricably linked to the success of the creative output. Key innovations include extending the commercialisation of emerging fashion businesses by creating a curated retail gallery for collaborative and sustainable strategies to support niche fashion designer labels. This has contributed to a broader conversation on how to nurture and sustain competitive Australian fashion designers/labels. Research Contribution and Significance The Fleet Store has contributed to a growing body of research into innovative and sustainable business models for niche fashion and creative industries’ practitioners. All participants have maintained their business infra-structure and many are currently growing their businesses, using the strategies tested for the Fleet Store. The exhibition space was visited by over 1,000 people and sales of $27,000 were made in 10 days of opening. (Follow up sales of $3,000 has also been reported.) Three of the designers were ‘discovered’ from the exhibition and have received substantial orders from high profile national buyers and retailers for next season delivery. Several participants have since collaborated to create other pop up retail environments and are now mentoring other emerging designers on the significance of a collaborative retail exhibition to consolidate niche business models for emerging fashion designers.