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

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

Developing an IS-Impact decision tool : a literature based design science roadmap

This paper derives from research-in-progress intending both Design Research (DR) and Design Science (DS) outputs; the former a management decision tool based in IS-Impact (Gable et al. 2008) kernel theory; the latter being methodological learnings deriving from synthesis of the literature and reflection on the DR ‘case study’ experience. The paper introduces a generic, detailed and pragmatic DS ‘Research Roadmap’ or methodology, deriving at this stage primarily from synthesis and harmonization of relevant concepts identified through systematic archival analysis of related literature. The scope of the Roadmap too has been influenced by the parallel study aim to undertake DR applying and further evolving the Roadmap. The Roadmap is presented in attention to the dearth of detailed guidance available to novice Researchers in Design Science Research (DSR), and though preliminary, is expected to evolve and gradually be substantiated through experience of its application. A key distinction of the Roadmap from other DSR methods is its breadth of coverage of published DSR concepts and activities; its detail and scope. It represents a useful synthesis and integration of otherwise highly disparate DSR-related concepts.

A design science research roadmap

This paper proposes and synthesizes from previous design science(DS) methodological literature a structured and detailed DS Roadmap for the conduct of DS research. The Roadmap is a general guide for researchers to carry out DS research by suggesting reasonably detailed activities.Though highly tentative, it is believed the Roadmap usefully inter-relates many otherwise seemingly disparate, overlapping or conflicting concepts. It is hoped the DS Roadmap will aid in the planning, execution and communication of DS research,while also attracting constructive criticism, improvements and extensions. A key distinction of the Roadmap from other DS research methods is its breadth of coverage of DS research aspects and activities; its detail and scope. We demonstrate and evaluate the Roadmap by presenting two case studies in terms of the DS Roadmap.

Included by design : a case for regulation for accessible housing in Australia

Accessible housing is a scarce yet much needed commodity in Australia. A national agreement between industry and advocacy groups to a voluntary approach, called the Livable Design program, aims to provide access features in all new housing by 2020. Through a range of awareness raising initiatives, the program is anticipating increased supply by builders and increased demand by home-buyers. However the people who need accessible housing are the least likely and least able to buy it at the point of new sale and average homebuyers do not consider access features as a priority. This approach has not been successful overseas or in Australia in the past. Regulation with incentives supported by education and awareness has provided the best results, yet, regulation typically comes with controversy and resistance from the housing industry. A study is planned to identify how effective the Livable Design program is likely to be, what is likely to hinder it and why regulation is likely to be needed.

Designing disruption : linking participatory design and design thinking in technology orientated industries

A vast proportion of companies nowadays are looking to design and are focusing on the end users as a means of driving new projects. However still many companies are drawn to technological improvements which drive innovation within their industry context. The Australian livestock industry is no different. To date the adoption of new products and services within the livestock industry has been documented as being quite slow. This paper investigates how disruptive innovation should be a priority for these technologically focused companies and demonstrates how the use of design led innovation can bring about a higher quality engagement between end user and company alike. A case study linking participatory design and design thinking is presented. Within this, a conceptual model of presenting future scenarios to internal and external stakeholders is applied to the livestock industry; assisting companies to apply strategy, culture and advancement in meaningful product offerings to consumers.

Teaching design led innovation : the future of industrial design

The profession of industrial design is changing and with that so must industrial design education. The newly derived final year industrial design unit at the Queensland University of Technology (QUT) was created to initiate such a change. A designers’ role in industry is no longer limited to the invention process surrounding human cantered design but has now evolved into design led innovation. This paper reflects upon the teaching methods employed over a two-year period and improvements made over that time to the unit. The student project outcome is to produce a design solution that integrates an underlying novel technology into a new product and or service, with business strategies and manufacturing details being fully integrated into the design process. It is this integrated approach to industrial design teaching that will foster a more grounded and resourceful future designer.

Design and development of automatic visual inspection system for PCB manufacturing

Inspection of solder joints has been a critical process in the electronic manufacturing industry to reduce manufacturing cost, improve yield, and ensure product quality and reliability. This paper proposes two inspection modules for an automatic solder joint classification system. The “front-end” inspection system includes illumination normalisation, localisation and segmentation. The “back-end” inspection involves the classification of solder joints using the Log Gabor filter and classifier fusion. Five different levels of solder quality with respect to the amount of solder paste have been defined. The Log Gabor filter has been demonstrated to achieve high recognition rates and is resistant to misalignment. This proposed system does not need any special illumination system, and the images are acquired by an ordinary digital camera. This system could contribute to the development of automated non-contact, non-destructive and low cost solder joint quality inspection systems.

Design of experiments for bivariate binary responses modelled by Copula functions

Optimal design for generalized linear models has primarily focused on univariate data. Often experiments are performed that have multiple dependent responses described by regression type models, and it is of interest and of value to design the experiment for all these responses. This requires a multivariate distribution underlying a pre-chosen model for the data. Here, we consider the design of experiments for bivariate binary data which are dependent. We explore Copula functions which provide a rich and flexible class of structures to derive joint distributions for bivariate binary data. We present methods for deriving optimal experimental designs for dependent bivariate binary data using Copulas, and demonstrate that, by including the dependence between responses in the design process, more efficient parameter estimates are obtained than by the usual practice of simply designing for a single variable only. Further, we investigate the robustness of designs with respect to initial parameter estimates and Copula function, and also show the performance of compound criteria within this bivariate binary setting.

Design of decoupling networks for circulant symmetric antenna arrays

Small element spacing in compact arrays results in strong mutual coupling between array elements. Performance degradation associated with the strong coupling can be avoided through the introduction of a decoupling network consisting of interconnected reactive elements. We present a systematic design procedure for decoupling networks of symmetrical arrays with more than three elements and characterized by circulant scattering parameter matrices. The elements of the decoupling network are obtained through repeated decoupling of the characteristic eigenmodes of the array, which allows the calculation of element values using closed-form expressions.