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.

Collaborative destination branding : planning for tourism development through design in the Waterfall Way, NSW, Australia

This thesis develops, applies and analyses a collaborative design methodology for branding a tourism destination. The area between the Northern Tablelands and the Mid-North Coast of New South Wales, Australia, was used as a case study for this research. The study applies theoretical concepts of systems thinking and complexity to the real world, and tests the use of design as a social tool to engage multiple stakeholders in planning. In this research I acknowledge that places (and destinations) are socially constructed through people's interactions with their physical and social environments. This study explores a methodology that is explicit about the uncertainties of the destination’s system, and that helps to elicit knowledge and system trends. The collective design process used the creation of brand concepts, elements and strategies as instruments to directly engage stakeholders in the process of reflecting about their places and the issues related to tourism activity in the region. The methods applied included individual conversations and collaborative design sessions to elicit knowledge from local stakeholders. Concept maps were used to register and interpret information released throughout the process. An important aspect of the methodology was to bring together different stakeholder groups and translate the information into a common language that was understandable by all participants. This work helped release significant information as to what kind of tourism activity local stakeholders are prepared to receive and support. It also helped the emergence of a more unified regional identity. The outcomes delivered by the project (brand, communication material and strategies) were of high quality and in line with the desires and expectation of the local hosts. The process also reinforced local sense of pride, belonging and conservation. Furthermore, interaction between participants from different parts of the region triggered some self organising activity around the brand they created together. A major contribution of the present work is the articulation of an inclusive methodology to facilitate the involvement of locals into the decision-making process related to tourism planning. Of particular significance is the focus on the social construction of meaning in and through design, showing that design exercises can have significant social impact – not only on the final product, but also on the realities of the people involved in the creative process.

Active transonic aerofoil design optimization using robust multiobjective evolutionary algorithms

The use of adaptive wing/aerofoil designs is being considered, as they are promising techniques in aeronautic/ aerospace since they can reduce aircraft emissions and improve aerodynamic performance of manned or unmanned aircraft. This paper investigates the robust design and optimization for one type of adaptive techniques: active flow control bump at transonic flow conditions on a natural laminar flow aerofoil. The concept of using shock control bump is to control supersonic flow on the suction/pressure side of natural laminar flow aerofoil that leads to delaying shock occurrence (weakening its strength) or boundary layer separation. Such an active flow control technique reduces total drag at transonic speeds due to reduction of wave drag. The location of boundary-layer transition can influence the position and structure of the supersonic shock on the suction/pressure side of aerofoil. The boundarylayer transition position is considered as an uncertainty design parameter in aerodynamic design due to the many factors, such as surface contamination or surface erosion. This paper studies the shock-control-bump shape design optimization using robust evolutionary algorithms with uncertainty in boundary-layer transition locations. The optimization method is based on a canonical evolution strategy and incorporates the concepts of hierarchical topology, parallel computing, and asynchronous evaluation. The use of adaptive wing/aerofoil designs is being considered, as they are promising techniques in aeronautic/ aerospace since they can reduce aircraft emissions and improve aerodynamic performance of manned or unmanned aircraft. This paper investigates the robust design and optimization for one type of adaptive techniques: active flow control bump at transonic flow conditions on a natural laminar flow aerofoil. The concept of using shock control bump is to control supersonic flow on the suction/pressure side of natural laminar flow aerofoil that leads to delaying shock occurrence (weakening its strength) or boundary-layer separation. Such an active flow control technique reduces total drag at transonic speeds due to reduction of wave drag. The location of boundary-layer transition can influence the position and structure of the supersonic shock on the suction/pressure side of aerofoil. The boundarylayer transition position is considered as an uncertainty design parameter in aerodynamic design due to the many factors, such as surface contamination or surface erosion. This paper studies the shock-control-bump shape design optimization using robust evolutionary algorithms with uncertainty in boundary-layer transition locations. The optimization method is based on a canonical evolution strategy and incorporates the concepts of hierarchical topology, parallel computing, and asynchronous evaluation. Two test cases are conducted: the first test assumes the boundary-layer transition position is at 45% of chord from the leading edge, and the second test considers robust design optimization for the shock control bump at the variability of boundary-layer transition positions. The numerical result shows that the optimization method coupled to uncertainty design techniques produces Pareto optimal shock-control-bump shapes, which have low sensitivity and high aerodynamic performance while having significant total drag reduction.

Double-shock control bump design optimization using hybridized evolutionary algorithms

This study investigates the application of two advanced optimization methods for solving active flow control (AFC) device shape design problem and compares their optimization efficiency in terms of computational cost and design quality. The first optimization method uses hierarchical asynchronous parallel multi-objective evolutionary algorithm and the second uses hybridized evolutionary algorithm with Nash-Game strategies (Hybrid-Game). Both optimization methods are based on a canonical evolution strategy and incorporate the concepts of parallel computing and asynchronous evaluation. One type of AFC device named shock control bump (SCB) is considered and applied to a natural laminar flow (NLF) aerofoil. The concept of SCB is used to decelerate supersonic flow on suction/pressure side of transonic aerofoil that leads to a delay of shock occurrence. Such active flow technique reduces total drag at transonic speeds which is of special interest to commercial aircraft. Numerical results show that the Hybrid-Game helps an EA to accelerate optimization process. From the practical point of view, applying a SCB on the suction and pressure sides significantly reduces transonic total drag and improves lift-to-drag (L/D) value when compared to the baseline design.

Robust multidisciplinary UAS design optimisation

There are many applications in aeronautical/aerospace engineering where some values of the design parameters states cannot be provided or determined accurately. These values can be related to the geometry(wingspan, length, angles) and or to operational flight conditions that vary due to the presence of uncertainty parameters (Mach, angle of attack, air density and temperature, etc.). These uncertainty design parameters cannot be ignored in engineering design and must be taken into the optimisation task to produce more realistic and reliable solutions. In this paper, a robust/uncertainty design method with statistical constraints is introduced to produce a set of reliable solutions which have high performance and low sensitivity. Robust design concept coupled with Multi Objective Evolutionary Algorithms (MOEAs) is defined by applying two statistical sampling formulas; mean and variance/standard deviation associated with the optimisation fitness/objective functions. The methodology is based on a canonical evolution strategy and incorporates the concepts of hierarchical topology, parallel computing and asynchronous evaluation. It is implemented for two practical Unmanned Aerial System (UAS) design problems; the flrst case considers robust multi-objective (single disciplinary: aerodynamics) design optimisation and the second considers a robust multidisciplinary (aero structures) design optimisation. Numerical results show that the solutions obtained by the robust design method with statistical constraints have a more reliable performance and sensitivity in both aerodynamics and structures when compared to the baseline design.

Adaptive wing/aerofoil design optimisation using MOEA coupled to uncertainty design method

The use of adaptive wing/aerofoil designs is being considered as promising techniques in aeronautic/aerospace since they can reduce aircraft emissions, improve aerodynamic performance of manned or unmanned aircraft. The paper investigates the robust design and optimisation for one type of adaptive techniques; Active Flow Control (AFC) bump at transonic flow conditions on a Natural Laminar Flow (NLF) aerofoil designed to increase aerodynamic efficiency (especially high lift to drag ratio). The concept of using Shock Control Bump (SCB) is to control supersonic flow on the suction/pressure side of NLF aerofoil: RAE 5243 that leads to delaying shock occurrence or weakening its strength. Such AFC technique reduces total drag at transonic speeds due to reduction of wave drag. The location of Boundary Layer Transition (BLT) can influence the position the supersonic shock occurrence. The BLT position is an uncertainty in aerodynamic design due to the many factors, such as surface contamination or surface erosion. The paper studies the SCB shape design optimisation using robust Evolutionary Algorithms (EAs) with uncertainty in BLT positions. The optimisation method is based on a canonical evolution strategy and incorporates the concepts of hierarchical topology, parallel computing and asynchronous evaluation. Two test cases are conducted; the first test assumes the BLT is at 45% of chord from the leading edge and the second test considers robust design optimisation for SCB at the variability of BLT positions and lift coefficient. Numerical result shows that the optimisation method coupled to uncertainty design techniques produces Pareto optimal SCB shapes which have low sensitivity and high aerodynamic performance while having significant total drag reduction.

Representative learning design and functionality of research and practice in sport

Egon Brunswik proposed the concept of “representative design” for psychological experimentation, which has historically been overlooked or confused with another of Brunswik’s terms, ecological validity. In this article, we reiterate the distinc­tion between these two important concepts and highlight the relevance of the term representative design for sports psychology, practice, and experimental design. We draw links with ideas on learning design in the constraints-led approach to motor learning and nonlinear pedagogy. We propose the adoption of a new term, repre­sentative learning design, to help sport scientists, experimental psychologists, and pedagogues recognize the potential application of Brunswik’s original concepts, and to ensure functionality and action fidelity in training and learning environments.

A classification framework for design-build variants from an operational perspective

Design-build (DB) is a generic form of construction procurement, and, rather than simply representing a single system, it has evolved in practice into a variety of forms, each of which is similar to, and yet different from each other. Although the importance of selecting an appropriate DB variant has been widely accepted, difficulties occur in practice due to the multiplicity of terms and concepts used. What is needed is some kind of taxonomy or framework within which the individual variants can be placed and their relative attributes identified and understood. Through a comprehensive literature review and content analysis, this paper establishes a systematic classification framework for DB variants based on their operational attributes. In addition to providing much needed support for decision-making, this classification framework provides client/owners with perspectives to understand and examine different categories of DB variants from an operational perspective.

The unfinished landscape fractal geometry and the aesthetics of ecological design

During the late 20th century it was proposed that a design aesthetic reflecting current ecological concerns was required within the overall domain of the built environment and specifically within landscape design. To address this, some authors suggested various theoretical frameworks upon which such an aesthetic could be based. Within these frameworks there was an underlying theme that the patterns and processes of Nature may have the potential to form this aesthetic — an aesthetic based on fractal rather than Euclidean geometry. In order to understand how fractal geometry, described as the geometry of Nature, could become the referent for a design aesthetic, this research examines the mathematical concepts of fractal Geometry, and the underlying philosophical concepts behind the terms ‘Nature’ and ‘aesthetics’. The findings of this initial research meant that a new definition of Nature was required in order to overcome the barrier presented by the western philosophical Nature¯culture duality. This new definition of Nature is based on the type and use of energy. Similarly, it became clear that current usage of the term aesthetics has more in common with the term ‘style’ than with its correct philosophical meaning. The aesthetic philosophy of both art and the environment recognises different aesthetic criteria related to either the subject or the object, such as: aesthetic experience; aesthetic attitude; aesthetic value; aesthetic object; and aesthetic properties. Given these criteria, and the fact that the concept of aesthetics is still an active and ongoing philosophical discussion, this work focuses on the criteria of aesthetic properties and the aesthetic experience or response they engender. The examination of fractal geometry revealed that it is a geometry based on scale rather than on the location of a point within a three-dimensional space. This enables fractal geometry to describe the complex forms and patterns created through the processes of Wild Nature. Although fractal geometry has been used to analyse the patterns of built environments from a plan perspective, it became clear from the initial review of the literature that there was a total knowledge vacuum about the fractal properties of environments experienced every day by people as they move through them. To overcome this, 21 different landscapes that ranged from highly developed city centres to relatively untouched landscapes of Wild Nature have been analysed. Although this work shows that the fractal dimension can be used to differentiate between overall landscape forms, it also shows that by itself it cannot differentiate between all images analysed. To overcome this two further parameters based on the underlying structural geometry embedded within the landscape are discussed. These parameters are the Power Spectrum Median Amplitude and the Level of Isotropy within the Fourier Power Spectrum. Based on the detailed analysis of these parameters a greater understanding of the structural properties of landscapes has been gained. With this understanding, this research has moved the field of landscape design a step close to being able to articulate a new aesthetic for ecological design.

Decision support for the safe design and operation of unmanned aircraft systems

Unmanned Aircraft Systems (UAS) describe a diverse range of aircraft that are operated without a human pilot on-board. Unmanned aircraft range from small rotorcraft, which can fit in the palm of your hand, through to fixed wing aircraft comparable in size to that of a commercial passenger jet. The absence of a pilot on-board allows these aircraft to be developed with unique performance capabilities facilitating a wide range of applications in surveillance, environmental management, agriculture, defence, and search and rescue. However, regulations relating to the safe design and operation of UAS first need to be developed before the many potential benefits from these applications can be realised. According to the International Civil Aviation Organization (ICAO), a Risk Management Process (RMP) should support all civil aviation policy and rulemaking activities (ICAO 2009). The RMP is described in International standard, ISO 31000:2009 (ISO, 2009a). This standard is intentionally generic and high-level, providing limited guidance on how it can be effectively applied to complex socio-technical decision problems such as the development of regulations for UAS. Through the application of principles and tools drawn from systems philosophy and systems engineering, this thesis explores how the RMP can be effectively applied to support the development of safety regulations for UAS. A sound systems-theoretic foundation for the RMP is presented in this thesis. Using the case-study scenario of a UAS operation over an inhabited area and through the novel application of principles drawn from general systems modelling philosophy, a consolidated framework of the definitions of the concepts of: safe, risk and hazard is made. The framework is novel in that it facilitates the representation of broader subjective factors in an assessment of the safety of a system; describes the issues associated with the specification of a system-boundary; makes explicit the hierarchical nature of the relationship between the concepts and the subsequent constraints that exist between them; and can be evaluated using a range of analytic or deliberative modelling techniques. Following the general sequence of the RMP, the thesis explores the issues associated with the quantified specification of safety criteria for UAS. A novel risk analysis tool is presented. In contrast to existing risk tools, the analysis tool presented in this thesis quantifiably characterises both the societal and individual risk of UAS operations as a function of the flight path of the aircraft. A novel structuring of the risk evaluation and risk treatment decision processes is then proposed. The structuring is achieved through the application of the Decision Support Problem Technique; a modelling approach that has been previously used to effectively model complex engineering design processes and to support decision-making in relation to airspace design. The final contribution made by this thesis is in the development of an airworthiness regulatory framework for civil UAS. A novel "airworthiness certification matrix" is proposed as a basis for the definition of UAS "Part 21" regulations. The outcome airworthiness certification matrix provides a flexible, systematic and justifiable method for promulgating airworthiness regulations for UAS. In addition, an approach for deriving "Part 1309" regulations for UAS is presented. In contrast to existing approaches, the approach presented in this thesis facilitates a traceable and objective tailoring of system-level reliability requirements across the diverse range of UAS operations. The significance of the research contained in this thesis is clearly demonstrated by its practical real world outcomes. Industry regulatory development groups and the Civil Aviation Safety Authority have endorsed the proposed airworthiness certification matrix. The risk models have also been used to support research undertaken by the Australian Department of Defence. Ultimately, it is hoped that the outcomes from this research will play a significant part in the shaping of regulations for civil UAS, here in Australia and around the world.

Envisaging alternatives for practice : a study into the way concepts of sustain-ability can be explored within an interactive media arts practice

This practice-led study explores different ways the subject of sustain-ability can be addressed within an Interactive Media Arts practice. The exploration encompasses three creative projects, Charmed, Distracted and e. Menura superba. Grounded in an ecological philosophy inspired by vegetarianism and the critical design philosophy of defuturing, the work shows how such a philosophical position can guide the redirection of practice. The concern for sustain-ability within my practice, and more generally the question of Interactive Media Arts and sustain-ability, I refer to as a problématique. The objective of this study is not one of finding an answer or a truth to an instrumentally posed question, but to explore the complexities of the problématique through a program of practice and intellectual investigation. The aim being to redirect my practice and to find a renewed raison d’être for practice through a process of opening up, encountering, and discovering otherwise unknown possibilities for practice. In the context of sustain-ability, this opening up of possibilities can be considered a form of futuring. A futuring I argue is only possible if the things we take for granted as integral aspects of our being, practices and life worlds, are revealed in ways that estrange them, rendering them visible in ways that allow questioning and change.

Researching doctoral pedagogy close up : design and action in two doctoral programs

With growing international interest in diversifying sites for pedagogical work within the doctorate, doctoral programs of different kinds are being developed in different disciplinary, institutional and national settings. However, little is known about how the pedagogical work of these programs is designed and enacted, and with what effects. In this paper, we present two cases of doctoral pedagogical work being undertaken within different disciplinary and institutional settings to describe how learning opportunities were designed and to theorise what it means to be engaged in doing doctoral pedagogy. Starting from the position that working from a design model supports systematic and rigorous documentation and development of pedagogy, we employ the twin concepts of design and action, drawing broadly on rhetorical and ethnomethodological understandings of pedagogy as social action. Of particular interest within the concept of design itself is the concept of enactment, the translation of designs into the practices of doctoral work. Together, the two cases become a resource for ‘slowing down’ and making visible the practices of doctoral pedagogy that often go unrecognised because they appear so ordinary and everyday. This call for examining close-up existing doctoral education practices and relationships is attending to the ‘next challenge for doctoral education’ (Green, 2009).

Analyzing the factors influencing the successful design and uptake of interactive systems to support social networks in urban neighborhoods

In urban residential environments in Australia and other developed countries, Internet access is on the verge of becoming a ubiquitous utility like gas or electricity. From an urban sociology and community informatics perspective, this article discusses new emerging social formations of urban residents that are based on networked individualism and the potential of Internet-based systems to support them. It proposes that one of the main reasons for the disappearance or nonexistence of urban residential communities is a lack of appropriate opportunities and instruments to encourage and support local interaction in urban neighborhoods. The article challenges the view that a mere reappropriation of applications used to support dispersed virtual communities is adequate to meet the place and proximity-based design requirements that community networks in urban neighborhoods pose. It argues that the key factors influencing the successful design and uptake of interactive systems to support social networks in urban neighborhoods include the swarming social behavior of urban dwellers; the dynamics of their existing communicative ecology; and the serendipitous, voluntary, and place-based quality of interaction between residents on the basis of choice, like-mindedness, mutual interest and support needs. Drawing on an analysis of these factors, the conceptual design framework of a prototype system — the urban tribe incubator — is presented.