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.

Publishing, postage, and prizes : classic Australian children’s literature in the public eye

2012 saw the publication of competing and complementary lines of Australian “classics”: “A&R Australian Classics” (HarperCollins) and “Text Classics” (Text Publishing). While Angus and Robertson were key in establishing a canon of Australian children’s classics in the twentieth century, it was the Text Classics line which included a selection of young people’s titles in their 2013. In turn, Penguin Australia launched a selection of “Australian Children’s Classics”. In so doing, these publishers were drawing on particular literary and visual cultural traditions in Australian children’s literature. Public assertions of a particular selection of children’s books reveals not only contemporary assumptions about desirable childhood experiences but about the operation of nostalgia therein. In encouraging Australian adults to judge books by their covers, such gestures imply that Australian children may be similarly understood. Importantly, the illusion of unity, sameness, and legibility which is promised by circumscribed canons of “classic” children’s literature may well imply a desire for similarly illusory, unified, legible, “classic” childhood. This paper attends to public attempts to materialise (and legitimise) a canon of classic Australian children’s literature. In particular, it considers the ways in which publishing, postage stamps, and book awards make visible a range of children’s books, but do so in order to either fix or efface the content or meaning of the books themselves. Moving between assertions of the best books for children from the 1980s to today, and of the social values circulated within those books, this paper considers the possibilities and problematics of an Australian children’s canon.

Literature review: Student centred schools make the difference

Student-centred schools focus on designing learning experiences that recognise and respond to the individual needs of each of their students. They encourage all members of their school community to be active learners, working to enhance the educational opportunities available at their school. This literature review seeks to address and explore the hypothesis that studentcentred schools make the difference. The review commences by defining the concept of student-centred schooling and the various learning and educational theories that underpin related research. The authors present a model comprising six core elements of learning environments that student-centred schools demonstrate, with a focus on leadership. They also link their findings to the five professional practices in AITSL’s Australian Professional Standard for Principals to illustrate how these leadership practices drive and sustain studentcentred schools. Drawing from Viviane Robinson’s work on the dimensions of student-centred school leadership, together with several further dimensions identified through an environmental scan of literature, the authors consider how and in what ways student-centred schools make the difference.

Literature review : A culture of trust enhances performance

In this environmental scan of research and policy literature, the authors consider various definitions of trust as they seek to address and inform the hypothesis that ‘a culture of trust enhances performance’ in schools. The discussion draws on the work of the Australian Institute for Teaching and School Leadership in school leadership and research by Caldwell and Harris (2008) to consider ways in which trust is linked to performance in schools and organisations. It explores the concept of trust as a form of capital available to schools, and highlights how successful school leaders work to align trust, strategy and passion in implementing effective change. At the heart of the review is the relationship between trust and school improvement. An adapted model of the elements of a culture of trust developed by Bryk and Schneider in their influential study of trust in school reform in Chicago is used to frame this aspect of the review. The authors identify four essential categories of relationships that enable schools to be described as having a culture of trust. The review concludes with a discussion of the relationship between trust and school governance.

Developing intercultural understanding through Asian-Australian children’s literature.

This PETAA paper discusses how the cross-curriculum priority concerned with developing Asia literacy, namely ‘Asia and Australia’s engagement with Asia’, can be significantly advanced through the study of children’s literature. The discussion proceeds from a brief overview of the historical development of Asia literacy to its current place within the Australian Curriculum. It then considers the potential of literature for assisting students and teachers in realising this priority through the Asian-Australian Children’s Literature and Publishing dataset, a research project on AustLit. Finally, it discusses a small selection of texts – two picture books and a novel – with suggestions or prompts for raising students’ intercultural understanding.

A critical look at cryptographic hash function literature

The cryptographic hash function literature has numerous hash function definitions and hash function requirements, and many of them disagree. This survey talks about the various definitions, and takes steps towards cleaning up the literature by explaining how the field has evolved and accurately depicting the research aims people have today.

A Survey of the 2010 Quartz Crystal Microbalance Literature

In 2010 there has again been an increase in the number of papers published involving piezoelectric acoustic sensors, or quartz crystal microbalances (QCM), when compared to the last period reviewed 2006-2009. The average number of QCM publications per annum was 124 in the period 2001-2005, 223 in the period 2006-9, and 273 in 2010. There are trends towards increasing use of QCM in the study of protein adsorption to surfaces (93% increase), homeostasis (67% increase), protein-protein interactions (40% increase), and carbohydrates (43% increase). New commercial systems have been released that are driving the uptake of the technology for characterisation of binding specificities, affinities, kinetics and conformational changes associated with a molecular recognition event. This article highlights theoretical and practical aspects of the principals that underpin acoustic analysis, then reviews exemplary papers in key application areas involving small molecular weight ligands, carbohydrates, proteins, nucleic acids, viruses, bacteria, cells, and membrane interfaces.

Irregular readers : Arthur Conan Doyle’s “six dirty scoundrels”, boyhood and literacy in contemporary Sherlockian children’s literature

Young adult (YA) literature is a socialising genre that encourages young readers to take up particular ways of relating to historical or cultural materials. The first decade of the twenty-first century witnessed a boom in Sherlockian YA fiction using the Conan Doyle canon as a context and vocabulary for stories focused on the Baker Street Irregulars as figures of identification. This paper reads YA fiction’s deployment of Conan Doyle’s fictional universe as a strategy for negotiating anxieties of adolescent masculinity, particularly in relation to literacy and social agency.

Can physical activity prevent physical and cognitive decline in postmenopausal women? A systematic review of the literature

Background Participation in regular physical activity is among the most promising and cost effective strategies to reduce physical and cognitive decline and premature death. However, confusion remains about the amount, frequency, and duration of physical activity that is likely to provide maximum benefit as well as the way in which interventions should be delivered. Aims This paper aimed to review research on the impact of leisure-time and general physical activity levels on physical and cognitive decline in postmenopausal women. In a systematic review of the literature, empirical literature from 2009-2013 is reviewed to explore the potential impact of either commencing or sustaining physical activity on older women’s health. Results All studies found that physical activity was associated with lower rates of cognitive and physical decline and a significant reduction in all-cause mortality. In this review we found that exercise interventions (or lifestyle activities) that improved cardiorespiratory exercise capacity showed the most positive impact on physical health. Conclusions Findings suggest that programs should facilitate and support women to participate in regular exercise by embedding physical activity programs in public health initiatives, by developing home-based exercise programs that require few resources and by creating interventions that can incorporate physical activity within a healthy lifestyle. The review also suggests that clinicians should consider prescribing exercise in a tailored manner for older women to ensure that it is of a high enough intensity to obtain the positive sustained effects of exercise.

Diversity or perversity?: Award-winning children's literature and the Australian curriculum

Two of the three cross-curriculum priorities for the national Australian Curriculum prescribed by the Australian Curriculum Assessment and Reporting Authority (ACARA) are focussed on what might be called diversity education: “Aboriginal and Torres Strait Islander histories and culture”, and "Asia and Australia's Engagement with Asia” (ACARA, “Cross”). One need not be versed in complex rhetorical theory to understand that, laudable and legitimate as such priorities are, their existence implies that mainstream education in Australia has been or is characterised by the marginalisation or erasure of Australia's history—the original Indigenous cultures are not only living and vibrant today, but also have tens of thousands of years’ “head start” on Australia’s settler cultures—and of its geography—Australia is, after all, located in some physical proximity to Asia. Some might even suggest that Australia is in Asia. These temporal and spatial “forgettings” constitute a kind of cultural perversity which the cross-curricular priorities both seek to address and serve to reinscribe. Even as ACARA requires Australian school students to engage with Aboriginal and Asian histories, cultures, societies, they imply that such histories, cultures, and societies are “diverse”, that they are not those of the students in Australian classrooms; producing them as objects of study rather than as lived experience. This should not necessarily be surprising. Michael W. Apple has provocatively argued that: “one of the perverse effects of a national curriculum actually will be to ‘legitimise inequality.’ It may in fact help create the illusion that whatever the massive differences in schools, they all have something in common” (18). In the Australian context, attempts to mitigate such perversity are articulated via the selection of literary texts. As educators move to resource ACARA’s cross-curricular priorities, ACARA notes that “Teachers and schools are best placed to make decisions about the selection of texts in their teaching and learning programs that address the content in the Australian Curriculum while also meeting the needs of the students in their classes” (ACARA, “Advice”). This assertion appears on a webpage called “Advice on selection of literary texts” which is notable first and foremost for its total lack of any literary texts being named, and its list of weblinks pointing to lists of texts compiled elsewhere, by other organisations, and in the main, compiled to serve agendas other than the Australian curriculum. One of the major resources referred to by ACARA for literary text selection is the Children’s Book Council of Australia (CBCA). Of course, the CBCA’s annual book awards do not share ACARA’s educational priorities, but do have a history of being drawn upon by schools as a curriculum resource. In this paper, I consider the literary texts which have been prized by the CBCA in recent years attending to their engagements with Aboriginal cultures.

Green IT segment analysis : an academic literature review

Research on Green Information Technology (IT) is becoming a prevalent research theme in Green Information Systems (IS) research. This article provides a review of 98 papers published on Green IT between 2007−2013 to facilitate future research and to provide a retrospective analysis of existing knowledge and gaps thereof. While some researchers have discussed phenomena such as Green IT, motivation of Green IT and the Green IT adoption lifecycle, others have researched the importance of Green IT implementation within the organisational and individual level. Throughout the literature, scholars are trying to portray a constructive relationship between IT and the environment. Through our analysis, we can provide an assessment of the status of information systems literature on Green IT and, we provide taxonomy of segments of Green IT publications. Future research opportunities are identified based on the review.

Investigating early childhood education for sustainability : insights from history and literature

Seemingly straightforward tasks often have a way of becoming complex. This was the case for our guest editorial team charged with creating Early Childhood Australia’s Best of Sustainability publication drawn from the the Australasian Journal of Early Childhood and Every Child. The complexities we encountered ranged from the varied terminologies and understandings of constructs such as education for sustainable development, environmental education and education for sustainability, through to the fundamental lack of published research on which to draw as the basis for a special issue. It is timely to explore these complexities as we face the global challenges of The Critical Decade (DCCEE, 2011) including rising sea levels, extreme weather events and food security. At a local level, the early childhood field in Australia is seeking to interpret sustainability with systemic support from the National Quality Standards(NQS) (ACECQA, 2011), while elsewhere environmental/sustainability education is encouraged through national curricula documents (for example, Singapore Ministry of Education, 2008; Swedish National Agency for Education,2010; Ministry of Education of Korea, 2011). Both The Critical Decade and the NQS provide imperatives to drive early childhood education’s engagement with sustainability. In other words, sustainability in early childhood education is no longer optional, but essential (Elliott, 2010). While some twenty years of advocacy has led to this somewhat subdued celebratory position, in this publication we do recognise the historical contexts that have led to early childhood education for sustainability (ECEfS), as we (Elliott & Davis) phrase it, becoming almost ‘mainstream not marginal’ (Davis, 1999)— a stitching together of the isolated ‘patches of green’, first identified a decade ago by Elliott (NSW EPA, 2003). Here we weave together, through these articles, a story of the evolving history of ECEfS from our particular perspective. In so doing, we also acknowledge that there are other perspectives or ‘paths’ for this field as identified by Edwards and Cutter-McKenzie in their concluding paper to this compilation.

Advance Care Planning in palliative care : a systematic literature review of the contextual factors influencing its uptake 2008-2012

Background: Advance Care Planning is an iterative process of discussion, decision-making and documentation about end-of-life care. Advance Care Planning is highly relevant in palliative care due to intersecting clinical needs. To enhance the implementation of Advance Care Planning, the contextual factors influencing its uptake need to be better understood. Aim: To identify the contextual factors influencing the uptake of Advance Care Planning in palliative care as published between January 2008 and December 2012. Methods: Databases were systematically searched for studies about Advance Care Planning in palliative care published between January 2008 and December 2012. This yielded 27 eligible studies, which were appraised using National Institute of Health and Care Excellence Quality Appraisal Checklists. Iterative thematic synthesis was used to group results. Results: Factors associated with greater uptake included older age, a college degree, a diagnosis of cancer, greater functional impairment, being white, greater understanding of poor prognosis and receiving or working in specialist palliative care. Barriers included having non-malignant diagnoses, having dependent children, being African American, and uncertainty about Advance Care Planning and its legal status. Individuals’ previous illness experiences, preferences and attitudes also influenced their participation. Conclusion: Factors influencing the uptake of Advance Care Planning in palliative care are complex and multifaceted reflecting the diverse and often competing needs of patients, health professionals, legislature and health systems. Large population-based studies of palliative care patients are required to develop the sound theoretical and empirical foundation needed to improve uptake of Advance Care Planning in this setting.

Integrated chronic disease management in primary-secondary care : a systematic literature review of the evidence

Introduction: Diabetes has traditionally been managed as a single chronic disease state, but it exists with co-morbidities such as depression and metabolic syndrome. Treatment is multifaceted, requiring both primary and secondary care, however, the delivery of diabetes care is often fragmented. Integrated chronic disease management is a growing model of interest, and is underpinned by the chronic care model (CCM), devised as a guide for primary care management of patients with chronic conditions. The model identifies six key elements for effective care, and has shown promise in improving the management of diabetes. Aim: To find empirical evidence of integrated care interventions targeted at co-morbidities including diabetes, across primary/secondary care. Method: A systematic review of peer reviewed literature from PubMed, CINAHL, Embase, Cochrane Library and Joanna Briggs was performed. Studies were reviewed according to inclusion criteria- studies published in English, between 2004-2014, empirical studies, studies with evidence of primary/secondary implementation, and those dealing with chronic co-morbid disease states. Results: 51 studies met the inclusion criteria. Included studies were mostly from the US (38), with five from Australia, UK (2), Canada (2), Netherlands (1), Norway (1), Ireland (1), and one multi-country study. It was found that all interventions adopted at least one (average 3-4) of the chronic care model, with the majority implementing delivery system redesign activities within the primary care practice/s. We found evidence of interventions which significantly reduced emergency department and hospital admissions, improved processes of care, patient health outcomes such as HbA1c, improved patient satisfaction, and reduced costs. Conclusion/Implications for practice: Diabetes exists as a co-morbid disease, requiring both primary and secondary care. We found that integrated care interventions adopting elements of the chronic care model positively impacted on patient outcomes, service utilisation, as well as costs. This review has highlighted that it may not be necessary to adopt all CCM elements to improve clinical outcomes, patient satisfaction and costs.