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.

Living well with diabetes: a randomized controlled trial of a telephone-delivered intervention for maintenance of weight loss, physical activity and glycaemic control in adults with type 2 diabetes

Background By 2025, it is estimated that approximately 1.8 million Australian adults (approximately 8.4% of the adult population) will have diabetes, with the majority having type 2 diabetes. Weight management via improved physical activity and diet is the cornerstone of type 2 diabetes management. However, the majority of weight loss trials in diabetes have evaluated short-term, intensive clinic-based interventions that, while producing short-term outcomes, have failed to address issues of maintenance and broad population reach. Telephone-delivered interventions have the potential to address these gaps. Methods/Design Using a two-arm randomised controlled design, this study will evaluate an 18-month, telephone-delivered, behavioural weight loss intervention focussing on physical activity, diet and behavioural therapy, versus usual care, with follow-up at 24 months. Three-hundred adult participants, aged 20-75 years, with type 2 diabetes, will be recruited from 10 general practices via electronic medical records search. The Social-Cognitive Theory driven intervention involves a six-month intensive phase (4 weekly calls and 11 fortnightly calls) and a 12-month maintenance phase (one call per month). Primary outcomes, assessed at 6, 18 and 24 months, are: weight loss, physical activity, and glycaemic control (HbA1c), with weight loss and physical activity also measured at 12 months. Incremental cost-effectiveness will also be examined. Study recruitment began in February 2009, with final data collection expected by February 2013. Discussion This is the first study to evaluate the telephone as the primary method of delivering a behavioural weight loss intervention in type 2 diabetes. The evaluation of maintenance outcomes (6 months following the end of intervention), the use of accelerometers to objectively measure physical activity, and the inclusion of a cost-effectiveness analysis will advance the science of broad reach approaches to weight control and health behaviour change, and will build the evidence base needed to advocate for the translation of this work into population health practice.

A hardware-based multi-disciplinary design optimization method for aeronautical applications

There are many applications in aeronautics where there exist strong couplings between disciplines. One practical example is within the context of Unmanned Aerial Vehicle(UAV) automation where there exists strong coupling between operation constraints, aerodynamics, vehicle dynamics, mission and path planning. UAV path planning can be done either online or offline. The current state of path planning optimisation online UAVs with high performance computation is not at the same level as its ground-based offline optimizer's counterpart, this is mainly due to the volume, power and weight limitations on the UAV; some small UAVs do not have the computational power needed for some optimisation and path planning task. In this paper, we describe an optimisation method which can be applied to Multi-disciplinary Design Optimisation problems and UAV path planning problems. Hardware-based design optimisation techniques are used. The power and physical limitations of UAV, which may not be a problem in PC-based solutions, can be approached by utilizing a Field Programmable Gate Array (FPGA) as an algorithm accelerator. The inevitable latency produced by the iterative process of an Evolutionary Algorithm (EA) is concealed by exploiting the parallelism component within the dataflow paradigm of the EA on an FPGA architecture. Results compare software PC-based solutions and the hardware-based solutions for benchmark mathematical problems as well as a simple real world engineering problem. Results also indicate the practicality of the method which can be used for more complex single and multi objective coupled problems in aeronautical applications.

A method for evaluating lean assembly process at design stage

Lean product design has the potential to reduce the overall product development time and cost and can improve the quality of a product. However, it has been found that no or little work has been carried out to provide an integrated framework of "lean design" and to quantitatively evaluate the effectiveness of lean practices/principles in product development process. This research proposed an integrated framework for lean design process and developed a dynamic decision making tool based on Methods Time Measurement (MTM) approach for assessing the impact of lean design on the assembly process. The proposed integrated lean framework demonstrates the lean processes to be followed in the product design and assembly process in order to achieve overall leanness. The decision tool consists of a central database, the lean design guidelines, and MTM analysis. Microsoft Access and C# are utilized to develop the user interface to use the MTM analysis as decision making tool. MTM based dynamic tool is capable of estimating the assembly time, costs of parts and labour of various alternatives of a design and hence is able to achieve optimum design. A case study is conducted to test and validate the functionality of the MTM Analysis as well as to verify the lean guidelines proposed for product development.

A compact interferometric sensor design using three waveguide coupling

The use of metal stripes for the guiding of plasmons is a well established technique for the infrared regime and has resulted in the development of a myriad of passive optical components and sensing devices. However, the plasmons suffer from large losses around sharp bends, making the compact design of nanoscale sensors and circuits problematic. A compact alternative would be to use evanescent coupling between two sufficiently close stripes, and thus we propose a compact interferometer design using evanescent coupling. The sensitivity of the design is compared with that achieved using a hand-held sensor based on the Kretschmann style surface plasmon resonance technique. Modeling of the new interferometric sensor is performed for various structural parameters using finite-difference time-domain and COMSOL Multiphysics. The physical mechanisms behind the coupling and propagation of plasmons in this structure are explained in terms of the allowed modes in each section of the device.

Implementing design build project delivery system in Indonesian road infrastructure projects

Design-Build (DB) project delivery systems have increasingly been adopted by many private and public sector organizations worldwide due to its many advantages. However, many Indonesian road infrastructure projects are still delivered using the traditional design-bid-build (DBB) project delivery system. This paper reviews the existing literature to explore factors that can influence the successful implementation of DB project delivery system in Indonesian road infrastructure projects. It founds the lack of clarification in existing legislations as well as the lack of experiences, knowledge and skill as the main obstacles in implementing DB systems in Indonesia. To overcome these obstacles, this paper proposes (1) A relook at existing legislation in term of providing more guidance on determining projects appropriate for the DB, procedures for implementing DB, and the structure of builder entity; (2) To develop the skills and knowledge of DB to all stakeholders through communications, knowledge sharing and training. The outcome of this review can serve as a guide to development a framework for the implementation of the design-build project delivery system in Indonesian road infrastructure projects.

An FPGA-based approach to multi-objective evolutionary algorithm for multi-disciplinary design optimisation

This paper investigates the field programmable gate array (FPGA) approach for multi-objective and multi-disciplinary design optimisation (MDO) problems. One class of optimisation method that has been well-studied and established for large and complex problems, such as those inherited in MDO, is multi-objective evolutionary algorithms (MOEAs). The MOEA, nondominated sorting genetic algorithm II (NSGA-II), is hardware implemented on an FPGA chip. The NSGA-II on FPGA application to multi-objective test problem suites has verified the designed implementation effectiveness. Results show that NSGA-II on FPGA is three orders of magnitude better than the PC based counterpart.

Coupling hybrid-game strategies with particle swarm optimisation for multi-objective high lift systems design optimisation

This paper investigates the High Lift System (HLS) application of complex aerodynamic design problem using Particle Swarm Optimisation (PSO) coupled to Game strategies. Two types of optimization methods are used; the first method is a standard PSO based on Pareto dominance and the second method hybridises PSO with a well-known Nash Game strategies named Hybrid-PSO. These optimization techniques are coupled to a pre/post processor GiD providing unstructured meshes during the optimisation procedure and a transonic analysis software PUMI. The computational efficiency and quality design obtained by PSO and Hybrid-PSO are compared. The numerical results for the multi-objective HLS design optimisation clearly shows the benefits of hybridising a PSO with the Nash game and makes promising the above methodology for solving other more complex multi-physics optimisation problems in Aeronautics.

Water sensitive urban design through the lens of urban metabolism

Stormwater pollution has been recognised as one of the main causes of aquatic ecosystem degradation and poses a significant threat to both the goal of ecological sustainable development as well as human health and wellbeing. In response, water sensitive urban design (WSUD) practices have been put forward as a strategy to mitigate the detrimental impacts of urban stormwater runoff quality and to safeguard ecosystem functions. However, despite studies that support its efficiency in urban stormwater management, the mainstreaming of WSUD remains a significant challenge. This paper proposes that viewing WSUD through the lens of the integrated urban metabolism framework which encourages an interdisciplinary approach and facilitates dialogue through knowledge transfer is a strategy in which the implementation of WSUD can be mainstreamed.

Rethinking regulatory design : The Australian National Classification Scheme review

This paper considers issues of methodological innovation in communication, media and cultural studies, that arise out of the extent to which we now live in a media environment characterised by an digital media abundance, the convergence of media platforms, content and services, and the globalisation of media content through ubiquitous computing and high-speed broadband networks. These developments have also entailed a shift in the producer-consumer relationships that characterised the 20th century mass communications paradigm, with the rapid proliferation of user-created content, accelerated innovation, the growing empowerment of media users themselves, and the blurring of distinctions between public and private, as well as age-based distinctions in terms of what media can be accessed by whom and for what purpose. It considers these issues through a case study of the Australian Law Reform Commission's National Classification Scheme Review.

A design approach to teaching new product development

The educational unit new product development, taught within the industrial design program at the Queensland University of Technology (QUT) introduces the relationship between product design and commercialisation to third year industrial design undergraduate students. In which, they are exposed for the first time to product strategy development aimed at meeting consumer expectations, whilst at the same time achieving corporate objectives. Delivered content such as intellectual property, market opportunities, competitor analysis and investor requirements are taught within the thirteen week semester timeframe. New product development theory is not a new field. However, the design approach to teaching this theory and more importantly how designers can use it in the design process is novel. This paper provides an overview of the curriculum design of this unit as well as its incremental development over the past four year duration period. Student project outcomes and more importantly the process and tools from this unit are also discussed and presented.

Livable housing design: Is it likely to work?

The need for accessible housing in Australia is acute. Both government and the community service sector recognise the importance of well designed accessible housing to optimise the integration of older people and people with disability, to encourage a prudent use of scarce health and community services and to enhance the liveability of our cities. In 2010, the housing industry, negotiated with the Australian Government and community representatives to adopt a nationally consistent voluntary code (Livable Housing Design) and a strategy to provide minimal level of accessibility in all new housing by 2020. Evidence from the implementation of such programs in the United Kingdom and USA, however, serves to question whether this aspirational goal can be achieved through voluntary codes. Minimal demand at the point of new sale, and problems in the production of housing to the required standards have raised questions regarding the application of program principles in the context of a voluntary code. In addressing the latter issue, this paper presents early findings from the analysis of qualitative interviews conducted with developers, builders and designers in various housing contexts. It identifies their “logics in use” in the production of housing in response to Livable Housing Design’s voluntary code and indicates factors that are likely to assist and impede the attainment of the 2020 aspirational goal.

The knock-on from the knock-off : recent shifts within Australian mass market fashion design practice

Australia’s mass market fashion labels have traditionally benefitted from their peripheral location to the world’s fashion centres. Operating a season behind, Australian mass market designers and buyers were well-placed to watch trends play out overseas before testing them in the Australian marketplace. For this reason, often a designer’s role was to source and oversee the manufacture of ‘knock-offs’, or close copies of Northern hemisphere mass market garments. Both Weller (2007) and Walsh (2009) have commented on this practice. The knock-on effect from this continues to be a cautious, derivative fashion sensibility within Australian mass market fashion design, where any new trend or product is first tested and proved overseas months earlier. However, there is evidence that this is changing. The rapid online dissemination of global fashion trends, coupled with the Australian consumer’s willingness to shop online, has meant that the ‘knock-off’ is less viable. For this reason, a number of mass market companies are moving away from the practice of direct sourcing and are developing product in-house under a Northern hemisphere model. This shift is also witnessed in the trend for mass market companies to develop collections in partnership with independent Australian designers. This paper explores the current and potential effects of these shifts within Australian mass market design practice, and discusses how they may impact on designers, consumers and on the wider culture of Australian fashion.

Towards participatory action design research : adapting action research and design science research methods for urban informatics

This paper proposes a new research method, Participatory Action Design Research (PADR), for studies in the Urban Informatics domain. PADR supports Urban Informatics research in developing new technological means (e.g. using mobile and ubiquitous computing) to resolve contemporary issues or support everyday life in urban environments. The paper discusses the nature, aims and inherent methodological needs of Urban Informatics research, and proposes PADR as a method to address these needs. Situated in a socio-technical context, Urban Informatics requires a close dialogue between social and design-oriented fields of research as well as their methods. PADR combines Action Research and Design Science Research, both of which are used in Information Systems, another field with a strong socio-technical emphasis, and further adapts them to the cross-disciplinary needs and research context of Urban Informatics.

Reframing the design of context-aware computing

From location-aware computing to mining the social web, representations of context have promised to make better software applications. The opportunities and challenges of context-aware computing from representational, situated and interactional perspectives have been well documented, but arguments from the perspective of design are somewhat disparate. This paper draws on both theoretical perspectives and a design framing, using the problem of designing a social mobile agile ridesharing system, in order to reflect upon and call for broader design approaches for context-aware computing and human-computer Interaction research in general.