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.

Review of refugee mental health interventions following resettlement : best practices and recommendations

There are increasing numbers of refugees worldwide, with approximately 16 million refugees in 2007 and over 2.5 million refugees resettled in the United States since the start of its humanitarian program. Psychologists and other health professionals who deliver mental health services for individuals from refugee backgrounds need to have confidence that the therapeutic interventions they employ are appropriate and effective for the clients with whom they work. The current review briefly surveys refugee research, examines empirical evaluations of therapeutic interventions in resettlement contexts, and provides recommendations for best practices and future directions in resettlement countries. The resettlement interventions found to be most effective typically target culturally homogeneous client samples and demonstrate moderate to large outcome effects on aspects of traumatic stress and anxiety reduction. Further evaluations of the array of psychotherapeutic, psychosocial, pharmacological, and other therapeutic approaches, including psychoeducational and community-based interventions that facilitate personal and community growth and change, are encouraged. There is a need for increased awareness, training and funding to implement longitudinal interventions that work collaboratively with clients from refugee backgrounds through the stages of resettlement.

Review of refugee mental health assessment: Best practices and recommendations

This article focuses on mental health assessment of refugees in clinical, educational and administrative-legal settings in order to synthesise research and practice designed to enhance and promote further development of culturally appropriate clinical assessment services during the refugee resettlement process. It specifically surveys research published over the last 25 years into the development, reliability measurement and validity testing of assessment instruments, which have been used with children, adolescents and adults from refugee backgrounds, prior to or following their arrival in a resettlement country, to determine whether the instruments meet established crosscultural standards of conceptual, functional, linguistic, technical and normative equivalence. The findings suggest that, although attempts have been made to develop internally reliable, appropriately normed tests for use with refugees from diverse cultural and linguistic backgrounds, matters of conceptual and linguistic equivalence and test–retest reliability are often overlooked. Implications of these oversights for underreporting refugees' mental health needs are considered. Efforts should also be directed towards development of culturally comparable, valid and reliable measures of refugee children's mental health and of refugee children's and adults' psychoeducational, neuropsychological and applied memory capabilities.

Examination of process to develop a framework for better implementation of quality practices in building projects

Quality, as well as project success, in construction projects should be capable of being regarded as the fulfillment of expectation of those contributors and stakeholders involved in such projects. Although a significant amount of quality practices have been introduced within the industry, establishment and attainment of reasonable levels of quality internationally in construction projects continues to be an ongoing problem. To date, some investigation into the introduction and improvement of quality practices and stakeholder management in the construction industry has been accomplished independently, but so far no major studies have been completed that examine comprehensively how quality management practices that particularly concentrate on the stakeholders’ perspective of quality can be used to contribute to final project quality outcomes. This paper aims to examine the process for development of a framework for better involvement of stakeholders in quality planning and practices and subsequently to contribute to higher quality outcomes within construction projects. Through extensive literature review it highlights various perceptions of quality, categorizes quality issues with particular focus on benefits and shortcomings and also examines stakeholders’ viewpoint of project quality in order to promote the improvement of outcomes throughout a project’s lifecycle. It proposes a set of arranged information as a basis for development of prospective framework which ultimately aims to improve project quality outcomes. The subsequent framework that will be developed from this research will provide project managers and owners with the required information and strategic direction to achieve their own and their stakeholders’ targets for implementation of quality practices and achievement of high quality outcomes on their future projects.

Diffusion of corporate governance practices : the Dutch response to pressures for shareholder value

As part of a larger literature focused on identifying and relating the antecedents and consequences of diffusing organizational practices/ideas, recent research has debated the international adoption of a shareholder-value-orientation (SVO). The debate has financial economists characterizing the adoption of an SVO as performance-enhancing and thus inevitable, with behavioral scientists disputing both claims, invoking institutional differences. This study seeks to provide some resolution to the debate (and advance current understanding on the diffusion of practices/ideas) by developing a socio-political perspective that links the antecedents and consequences of an SVO. In particular, we introduce the notion of misaligned elites and misfitted practices in our analysis of how and why differences in the technical and cultural preferences of major owners will influence a firm’s adoption and (un)successful implementation of an SVO among the largest 100 corporations in the Netherlands from 1992-2006. We conclude with a discussion of the implications of our perspective and our findings for future research on corporate governance and the diffusion of organizational practices/ideas.

Developing shared understandings of standards-based assessment : online moderation practices across geographically diverse contexts

This thesis investigates the place of online moderation in supporting teachers to work in a system of standards-based assessment. The participants of the study were fifty middle school teachers who met online with the aim of developing consistency in their judgement decisions. Data were gathered through observation of the online meetings, interviews, surveys and the collection of artefacts. The data were viewed and analysed through sociocultural theories of learning and sociocultural theories of technology, and demonstrates how utilising these theories can add depth to understanding the added complexity of developing shared meaning of standards in an online context. The findings contribute to current understanding of standards-based assessment by examining the social moderation process as it acts to increase the reliability of judgements that are made within a standards framework. Specifically, the study investigates the opportunities afforded by conducting social moderation practices in a synchronous online context. The study explicates how the technology affects the negotiation of judgements and the development of shared meanings of assessment standards, while demonstrating how involvement in online moderation discussions can support teachers to become and belong within a practice of standards-based assessment. This research responds to a growing international interest in standards-based assessment and the use of social moderation to develop consistency in judgement decisions. Online moderation is a new practice to address these concerns on a systemic basis.

Moderation and consistency of teacher judgement : teachers’ views

Major curriculum and assessment reforms in Australia have generated research interest in issues related to standards, teacher judgement and moderation. This article is based on one related inquiry of a large-scale Australian Research Council Linkage project conducted in Queensland. This qualitative study analysed interview data to identify teachers’ views on standards and moderation as a means to achieving consistency of teacher judgement. A complementary aspect of the research involved a blind review that was conducted to determine the degree of teacher consistency without the experience of moderation. Empirical evidence was gained that most teachers, of the total interviewed, articulated a positive attitude towards the use of standards in moderation and perceived that this process produces consistency in teachers’ judgements. Context was identified as an important influential factor in teachers’ judgements and it was concluded that teachers’ assessment beliefs, attitudes and practices impact on their perceptions of the value of moderation practice and the extent to which consistency can be achieved.

Home literacy education of Taiwanese Australian families : a sociological analysis

This research investigates home literacy education practices of Taiwanese families in Australia. As Taiwanese immigrants represent the largest ¡°Chinese Australian¡± subgroup to have settled in the state of Queensland, teachers in this state often face the challenges of cultural differences between Australian schools and Taiwanese homes. Extensive work by previous researchers suggests that understanding the cultural and linguistic differences that influence how an immigrant child views and interacts with his/her environment is a possible way to minimise the challenges. Cultural practices start from infancy and at home. Therefore, this study is focused on young children who are around the age of four to five. It is a study that examines the form of literacy education that is enacted and valued by Taiwanese parents in Australia. Specifically, this study analyses ¡°what literacy knowledge and skill is taught at home?¡±, ¡°how is it taught?¡± and ¡°why is it taught?¡± The study is framed in Pierre Bourdieu.s theory of social practice that defines literacy from a sociological perspective. The aim is to understand the practices through which literacy is taught in the Taiwanese homes. Practices of literacy education are culturally embedded. Accordingly, the study shows the culturally specialised ways of learning and knowing that are enacted in the study homes. The study entailed four case studies that draw on: observations and recording of the interactions between the study parent and child in their literacy events; interviews and dialogues with the parents involved; and a collection of photographs of the children.s linguistic resources and artefacts. The methodological arguments and design addressed the complexity of home literacy education where Taiwanese parents raise children in their own cultural ways while adapting to a new country in an immigrant context. In other words, the methodology not only involves cultural practices, but also involves change and continuity in home literacy practices. Bernstein.s theory of pedagogic discourse was used to undertake a detailed analysis of parents. selection and organisation of content for home literacy education, and the evaluative criteria they established for the selected literacy knowledge and skill. This analysis showed how parents selected and controlled the interactions in their child.s literacy learning. Bernstein.s theory of pedagogic discourse was used also to analyse change and continuity in home literacy practice, specifically, the concepts of ¡°classification¡± and ¡°framing¡±. The design of this study aimed to gain an understanding of parents. literacy teaching in an immigrant context. The study found that parents tended to value and enact traditional practices, yet most of the parents were also searching for innovative ideas for their adult-structured learning. Home literacy education of Taiwanese families in this study was found to be complex, multi-faceted and influenced in an ongoing way by external factors. Implications for educators and recommendations for future study are provided. The findings of this study offer early childhood teachers in Australia understandings that will help them build knowledge about home literacy education of Taiwanese Australian families.

Consumer misbehaviour during professional service encounters

To date, consumer behaviour research is still over-focused on the functional rather than the dysfunctional. Both empirical and anecdotal evidence suggest that service organisations are burdened with the concept of consumer sovereignty, while consumers freely flout the ‘rules’ of social exchange and behave in deviant and dysfunctional ways. Further, the current scope of consumer misbehaviour research suggests that the phenomenon has principally been studied in the context of economically-focused exchange. This limits our current understanding of consumer misbehaviour to service encounters that are more transactional than relational in nature. Consequently, this thesis takes a Social Exchange approach to consumer misbehaviour and reports a three-stage multi-method study that examined the nature and antecedents of consumer misbehaviour in professional services. It addresses the following broad research question: What is the nature of consumer misbehaviour during professional service encounters? Study One initially explored the nature of consumer misbehaviour in professional service encounters using critical incident technique (CIT) within 38 semi-structured in-depth interviews. The study was designed to develop a better understanding of what constitutes consumer misbehaviour from a service provider’s perspective. Once the nature of consumer misbehaviour had been qualified, Study Two focused on developing and refining calibrated items that formed Guttman-like scales for two consumer misbehaviour constructs: one for the most theoretically-central type of consumer misbehaviour identified in Study One (i.e. refusal to participate) and one for the most well-theorised and salient type of consumer misbehaviour (i.e. verbal abuse) identified in Study One to afford a comparison. This study used Rasch modelling to investigate whether it was possible to calibrate the escalating severity of a series of decontextualised behavioural descriptors in a valid and reliable manner. Creating scales of calibrated items that capture the variation in severity of different types of consumer misbehaviour identified in Study One allowed for a more valid and reliable investigation of the antecedents of such behaviour. Lastly, Study Three utilised an experimental design to investigate three key antecedents of consumer misbehaviour: (1) the perceived quality of the service encounter [drawn from Fullerton and Punj’s (1993) model of aberrant consumer behaviour], (2) the violation of consumers’ perceptions of justice and equity [drawn from Rousseau’s (1989) Psychological Contract Theory], and (3) consumers’ affective responses to exchange [drawn from Weiss and Cropanzano’s (1996) Affective Events Theory]. Investigating three key antecedents of consumer misbehaviour confirmed the newly-developed understanding of the nature of consumer misbehaviour during professional service encounters. Combined, the results of the three studies suggest that consumer misbehaviour is characteristically different within professional services. The most salient and theoretically-central behaviours can be measured using increasingly severe decontextualised behavioural descriptors. Further, increasingly severe forms of consumer misbehaviour are likely to occur as a response to consumer anger at low levels of interpersonal service quality. These findings have a range of key implications for both marketing theory and practice.

Cosmetic surgery on children : professional and legal obligations in Australia

Public awareness and concern about cosmetic surgery on children is increasing. Nationally and internationally questions have been raised by the media and government bodies about the appropriateness of children undergoing cosmetic surgery. Considering the rates of cosmetic surgery in comparable Western societies, it seems likely that the number of physicians in Australia who will deal with a request for cosmetic surgery for a child will continue to increase. This is a sensitive issue and it is essential that physicians understand the professional and legal obligations that arise when cosmetic surgery is proposed for a child.

What information counts at the moment of practice? Information practices of renal nurses

Aims. This article is a report of a study done to identify how renal nurses experience information about renal care and the information practices that they used to support everyday practice. Background. What counts as nursing knowledge remains a contested area in the discipline yet little research has been undertaken. Information practice encompasses a range of activities such as seeking, evaluation and sharing of information. The ability to make informed judgement is dependent on nurses being able to identify relevant sources of information that inform their practice and those sources of information may enable the identification of what knowledge is important to nursing practice. Method. The study was philosophically framed from a practice perspective and informed by Habermas and Schatzki; it employed qualitative research techniques. Using purposive sampling six registered nurses working in two regional renal units were interviewed during 2009 and data was thematically analysed. Findings. The information practices of renal nurses involved mapping an information landscape in which they drew on information obtained from epistemic, social and corporeal sources. They also used coupling, a process of drawing together information from a range of sources, to enable them to practice. Conclusion. Exploring how nurses engage with information, and the role the information plays in situating and enacting epistemic, social and corporeal knowledge into everyday nursing practice is instructive because it indicates that nurses must engage with all three modalities in order to perform effectively, efficiently and holistically in the context of patient care. © 2011 The Authors. Journal of Advanced Nursing © 2011 Blackwell Publishing Ltd.