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.

A framework for conceptualising traffic safety culture

Traffic safety culture is a relatively new concept which has recently gained attention in the field of traffic safety. There is currently little known regarding the nature of the concept, nor how it should be defined. Preliminary definitions have tended to focus on specific road safety problems and the anticipated effect of a strong traffic safety culture. The literature to date has tended to emphasise how traffic safety culture might be created or shaped. However, without a better understanding of the nature and structure of traffic safety culture, discussions regarding changes to traffic safety culture are restricted. An examination of different conceptualisations and definitions of organisational safety culture provides a preliminary theoretical framework for traffic safety culture. Two high risk driving behaviours within the Australian context are compared to illustrate how key factors within this framework can be used to understand and improve road safety outcomes.

Challenges of knowledge integration in small and medium enterprises

This study attempts to develop a better understanding of the challenges of knowledge integration (KI) within the innovation process in Small and Medium Enterprises (SMEs). Using several case studies, this study investigates how knowledge integration may be managed within the context of innovation in SMEs. The research places particular focus on identifying the challenges of knowledge integration in SMEs in relation to three aspects of knowledge integration activities, namely knowledge identification, knowledge acquisition, and knowledge sharing. Four distinct tasks emerged in the knowledge integration process, namely team building capability, capturing tacit knowledge, role of knowledge management (KM) systems, and technological systemic integration. The paper suggests that managing knowledge integration in SMEs can be best managed by focusing on these four tasks, which in turn will lead to innovation.

School-based youth health nurses and adolescent decision-making concerning reproductive and sexual health advice : how can the law guide healthcare practitioners in this context?

This paper outlines some of the issues faced by School-Based Youth Health Nurses working in Queensland, in relation to the legal principles surrounding the provision of reproductive and sexual health advice. The paper outlines a number of specific issues faced by nurses working within this setting and considers the legal principles underpinning the issues concerning consent and confidentiality. The discussion in this paper demonstrates how the legal principles – which are often viewed as complex and uncertain by nurses working within this field – may be used as a guide to underpin good practice and compliance with the law. Although this paper is considered in the context of nurses working within Queensland, the principles and factors outlined are relevant to healthcare practitioners working within all Australian jurisdictions.

Advancing nursing practice : redefining the theoretical and practical integration of knowledge

Aim The aim of this paper is to offer an alternative knowing-how knowing-that framework of nursing knowledge, which in the past has been accepted as the provenance of advanced practice. Background The concept of advancing practice is central to the development of nursing practice and has been seen to take on many different forms depending on its use in context. To many it has become synonymous with the work of the advanced or expert practitioner; others have viewed it as a process of continuing professional development and skills acquisition. Moreover, it is becoming closely linked with practice development. However, there is much discussion as to what constitutes the knowledge necessary for advancing and advanced practice, and it has been suggested that theoretical and practical knowledge form the cornerstone of advanced knowledge. Design The design of this article takes a discursive approach as to the meaning and integration of knowledge within the context of advancing nursing practice. Method A thematic analysis of the current discourse relating to knowledge integration models in an advancing and advanced practice arena was used to identify concurrent themes relating to the knowing-how knowing-that framework which commonly used to classify the knowledge necessary for advanced nursing practice. Conclusion There is a dichotomy as to what constitutes knowledge for advanced and advancing practice. Several authors have offered a variety of differing models, yet it is the application and integration of theoretical and practical knowledge that defines and develops the advancement of nursing practice. An alternative framework offered here may allow differences in the way that nursing knowledge important for advancing practice is perceived, developed and coordinated. Relevance to clinical practice What has inevitably been neglected is that there are various other variables which when transposed into the existing knowing-how knowing-that framework allows for advanced knowledge to be better defined. One of the more notable variables is pattern recognition, which became the focus of Benner’s work on expert practice. Therefore, if this is included into the knowing-how knowing-that framework, the knowing-how becomes the knowledge that contributes to advancing and advanced practice and the knowing-that becomes the governing action based on a deeper understanding of the problem or issue.

Circles of care : should community development redefine the practice of palliative care?

Specialist palliative care, within hospices in particular, has historically led and set the standard for caring for patients at end of life. The focus of this care has been mostly for patients with cancer. More recently, health and social care services have been developing equality of care for all patients approaching end of life. This has mostly been done in the context of a service delivery approach to care whereby services have become increasingly expert in identifying health and social care need and meeting this need with professional services. This model of patient centred care, with the impeccable assessment and treatment of physical, social, psychological and spiritual need, predominantly worked very well for the latter part of the 20th century. Over the last 13 years, however, there have been several international examples of community development approaches to end of life care. The patient centred model of care has limitations when there is a fundamental lack of integrated community policy, development and resourcing. Within this article, we propose a model of care which identifies a person with an illness at the centre of a network which includes inner and outer networks, communities and service delivery organisations. All of these are underpinned by policy development, supporting the overall structure. Adoption of this model would allow individuals, communities, service delivery organisations and policy makers to work together to provide end of life care that enhances value and meaning for people at end of life, both patients and communities alike.

Domestic artefacts: Sustainability in the context of Indian middle class

Sustainability has become one of the important research topics in the field of Human Computer Interaction (HCI). However, the majority of work has focused on the Western culture. In this paper, we explore sustainable household practices in the developing world. Our research draws on the results from an ethnographic field study of household women belonging to the so-called middle class in India. We analyze our results in the context of Blevis' [4] principles of sustainable interaction design (established within the Western culture), to extract the intercultural aspects that need to be considered for designing technologies. We present examples from the field that we term "domestic artefacts". Domestic artefacts represent creative and sustainable ways household women appropriate and adapt used objects to create more useful and enriching objects that support household members' everyday activities. Our results show that the rationale behind creating domestic artefacts is not limited to the practicality and usefulness, but it shows how religious beliefs, traditions, family intimacy, personal interests and health issues are incorporated into them.

Building and sustaining a culture to support peer review of teaching

1. Background/context This presentation will report on emerging results from a two phase project funded by the Australian Learning and Teaching Council (ALTC). The project was designed in partnership with five universities and aimed to embed peer review within the local teaching and learning culture by using a distributive leadership framework. 2. The initiative/practice The presentation will highlight research outcomes that bring together both the fundamentals of peer review of teaching with the broader contextual elements of Integration, Leadership and Development. It will be demonstrated that peer review of teaching can be implemented and have advantages for academic staff, teaching evaluation and an organisation if attention is given to strategies that influence the contexts and cultures of teaching. Peer review as a strategy to develop excellence in teaching is considered from a holistic perspective that by necessity encompasses all elements of an educational environment. Results demonstrate achievements that can be obtained through working to foster conditions needed for sustainable leadership and change. The work has implications for policy, research, teaching development and student outcomes and has potential application world-wide. 3. Method(s) of evaluative data collection and analysis The 2 phase project collected focus group and questionnaire data to inform research results that were analysed using a thematic qualitative approach and statistical exploration. 4. Evidence of effectiveness The presentation will demonstrate the effectiveness of distributive leadership and strategic approaches to working for cultural change through the presentation of project findings.

Toward a sustainable culture of peer partnership

This project is a two phase design working in partnership with five universities to develop, implement and systematically embed a distributive leadership model that aims to embed peer partnership (review, development) within the culture of teaching and learning excellence. This presentation will posit a ‘prototype’ peer review leadership model based on ongoing research that brings together both the fundamentals of peer review with the broader importance of context and persons. It will be argued that essential to teaching development is a need to address not only the implementation of peer partnership programs but also strategies to influence and change both the contexts of teaching and the advantages for colleagues. Peer review as a strategy to develop excellence in teaching needs to be considered from a holistic perspective encompassing all elements of the teaching environment. The emphasis is on working to foster the type of conditions needed for leadership and change to begin and be sustained. The work has implications for policy, research, leadership development and student outcomes and has potential application world-wide. Phase 1 has collected focus interview and questionnaire data to inform the research and is being analysed using a thematic qualitative approach and statistical analysis. Evidence is emerging currently as the project is ongoing.

Identifying the Events That Connect Social Media Users : Charting Follower Accession on Twitter

Twitter is the focus of much research attention, both in traditional academic circles and in commercial market and media research, as analytics give increasing insight into the performance of the platform in areas as diverse as political communication, crisis management, television audiencing and other industries. While methods for tracking Twitter keywords and hashtags have developed apace and are well documented, the make-up of the Twitter user base and its evolution over time have been less understood to date. Recent research efforts have taken advantage of functionality provided by Twitter's Application Programming Interface to develop methodologies to extract information that allows us to understand the growth of Twitter, its geographic spread and the processes by which particular Twitter users have attracted followers. From politicians to sporting teams, and from YouTube personalities to reality television stars, this technique enables us to gain an understanding of what prompts users to follow others on Twitter. This article outlines how we came upon this approach, describes the method we adopted to produce accession graphs and discusses their use in Twitter research. It also addresses the wider ethical implications of social network analytics, particularly in the context of a detailed study of the Twitter user base.

A threshold concepts focus to curriculum design: supporting student learning through application of variation theory

This project develops and evaluates a model of curriculum design that aims to assist student learning of foundational disciplinary ‘Threshold Concepts’. The project uses phenomenographic action research, cross-institutional peer collaboration and the Variation Theory of Learning to develop and trial the model. Two contrasting disciplines (Physics and Law) and four institutions (two research-intensive and two universities of technology) were involved in the project, to ensure broad applicability of the model across different disciplines and contexts. The Threshold Concepts that were selected for curriculum design attention were measurement uncertainty in Physics and legal reasoning in Law. Threshold Concepts are key disciplinary concepts that are inherently troublesome, transformative and integrative in nature. Once understood, such concepts transform students’ views of the discipline because they enable students to coherently integrate what were previously seen as unrelated aspects of the subject, providing new ways of thinking about it (Meyer & Land 2003, 2005, 2006; Land et al. 2008). However, the integrative and transformative nature of such threshold concepts make them inherently difficult for students to learn, with resulting misunderstandings of concepts being prevalent...

Sustainable development as a meta-context for engineering education

At the end of the first decade of the twenty-first century, there is unprecedented awareness of the need for a transformation in development, to meet the needs of the present while also preserving the ability of future generations to meet their own needs. However, within engineering, educators still tend to regard such development as an ‘aspect’ of engineering rather than an overarching meta-context, with ad hoc and highly variable references to topics. Furthermore, within a milieu of interpretations there can appear to be conflicting needs for achieving sustainable development, which can be confusing for students and educators alike. Different articulations of sustainable development can create dilemmas around conflicting needs for designers and researchers, at the level of specific designs and (sub-) disciplinary analysis. Hence sustainability issues need to be addressed at a meta-level using a whole of system approach, so that decisions regarding these dilemmas can be made. With this appreciation, and in light of curriculum renewal challenges that also exist in engineering education, this paper considers how educators might take the next step to move from sustainable development being an interesting ‘aspect’ of the curriculum, to sustainable development as a meta-context for curriculum renewal. It is concluded that capacity building for such strategic considerations is critical in engineering education.

Sustainable development as a meta-context for engineering education

At the end of the first decade of the twenty-first century, there is unprecedented awareness of the need for a transformation in development, to meet the needs of the present while also preserving the ability of future generations to meet their own needs. However, within engineering, educators still tend to regard such development as an ‘aspect’ of engineering rather than an overarching meta-context, with ad hoc and highly variable references to topics. Furthermore, within a milieu of interpretations there can appear to be conflicting needs for achieving sustainable development, which can be confusing for students and educators alike. Different articulations of sustainable development can create dilemmas around conflicting needs for designers and researchers, at the level of specific designs and (sub-) disciplinary analysis. Hence sustainability issues need to be addressed at a meta-level using a whole of system approach, so that decisions regarding these dilemmas can be made. With this appreciation, and in light of curriculum renewal challenges that also exist in engineering education, this paper considers how educators might take the next step to move from sustainable development being an interesting ‘aspect’ of the curriculum, to sustainable development as a meta-context for curriculum renewal. It is concluded that capacity building for such strategic considerations is critical in engineering education.

Cents and Sustainability : Securing Our Common Future by Decoupling Economic Growth from Environmental Pressures

The focus of Cents and Sustainability is to respond to the call by Dr Gro Brundtland in the seminal book Our Common Future to achieve, 'a new era of economic growth - growth that is forceful and at the same time socially and environmentally sustainable'. With the 20th anniversary of Our Common Future in 2007, it is clearly time to re-examine this important work in a modern global context. Using the framework of ‘Decoupling Economic Growth from Environmental Pressures’, Cents and Sustainability investigates a range of new evidence and research in order to develop a deeper understanding of how, and under what conditions, this 'forceful sustainable growth' is possible. With an introduction by Dr Jim MacNeill (former Secretary General to the Brundtland Commission, and former Director, OECD Environment Directorate 1978 -1984), the book will carry forewords from Dr Gro Brundtland (former Chair of the World Commission on Environment and Development), Dr Rajendra Pachauri (Chief, Intergovernmental Panel on Climate Change (IPCC), and joint recipient of the 2007 Nobel Peace Prize on behalf of the IPCC), and Dr Kenneth Ruffing (former Deputy Director and Chief Economist of the OECD Environment Directorate 2000 - 2005). Beginning with a detailed explanation of decoupling theory, along with investigation into a range of issues and barriers to its achievement, the book then focuses on informing national strategies for decoupling. Then putting this into action the book focuses on five key areas of decoupling, namely greenhouse gas emissions, biodiversity, freshwater extraction, waste production, and air pollution, and in each case showing compelling evidence for significant cost effective reductions in environmental pressures. The book concludes with a detailed case study of the groundbreaking application of public interest litigation to combat air pollution in Delhi, India.

“Scary” heterosexualities in a rural Australian mining town

This paper draws upon Hubbard's (1999, p. 57) term ‘scary heterosexualities,’ that is non-normative heterosexuality, in the context of the rural drawing on data from fieldwork in the remote Western Australian mining town of Kalgoorlie. Our focus is ‘the skimpie’ – a female barmaid who serves in her underwear and who, in both historical and contemporary times, is strongly associated with rural mining communities. Interviews with skimpies and local residents as well as participant observation reveal how potential fears and anxieties about skimpies are managed. We identify the discursive and spatial processes by which skimpie work is contained in Kalgoorlie so that the potential scariness ‘the skimpie’ represents to the rural is muted and buttressed in terms of a more conventional and less threatening rural heterosexuality.