This thesis addresses questions of how to incorporate quality of care, represented by disutility-bearing effects such as mortality, morbidity and re-admission, in measuring relative performance of public hospitals. Currently, case-mix funding and performance, measured with costs per case-mix adjusted separation, hold hospitals accountable for costs, but not effects, of care, creating economic incentives for quality of care minimising cost per admission. To allow an appropriate trade-off between the value and cost of quality of care a correspondence is demonstrated between maximising net benefit and minimising costs plus decision makers??? value of disutility events, where effects of care can be represented by disutility events and hospitals face a common comparator. Applying this correspondence to performance measurement, frontier methods specifying disutility events as inputs are illustrated to have distinct advantages over output specifications, allowing estimation of: 1. economic efficiency conditional on the value of avoiding disutility events. 2. technical, scale and congestion sources of net benefit efficiency; 3. best practice peers over potential decision makers??? value of quality; and 4. industry shadow price of avoiding disutility events. The accountability this performance measurement framework provides for effects and cost of quality of care are also illustrated as the basis for moving from case-mix funding towards a funding mechanism based on maximising net benefit. Links to evidence-based medicine in health technology assessment are emphasised in illustrating application of the correspondence to comparison of multiple strategies in the cost-disutility plane, where radial properties as shown to provide distinct advantages over comparison in the cost-effectiveness plane. The identified performance measurement and funding framework allows policy makers to create economic incentives consistent with evidence-based medicine in practice, while avoiding incentives for cream-skimming and cost-shifting. The linear nature of the net benefit correspondence theorem allows simple inclusion of multiple effects of quality, whether expressed as not meeting a standard, functional limitation or disutility directly. In applying the net benefit correspondence theorem to hospitals a clinical activity level is suggested, to allow correspondence conditions to be robustly satisfied in identification of effects with decision analytic methods, adjustment for within DRG risk factors and data linkage to effects beyond separation.

Health promotion research and practice reveal that goal setting and monitoring have gained increased acceptance at international, national, provincial/state, regional and local levels as a means to guide health planning, promote health-enhancing public policy, monitor reductions in health inequities, set health priorities, facilitate resource allocation, support accountability in health care, and track the health of populations. The global adoption of health goals as a strategy for population health promotion has occurred even though few protocols or guidelines to support the health goals development process have been published; and limited study has occurred on the variation in approach to health goals planning, or on the complex, multiple forces that influence the development process. This is an exploratory and descriptive case study that endeavours to advance knowledge about the process and contribution of health goals development as a strategy for population health promotion. This study seeks to track the pathways to health goals in British Columbia (BC) and to uncover influential factors in rendering the final version of health goals adopted by the government of BC. Specifically, this study explores the forces that obstructed and facilitated the formulation and articulation of health goals. It considers also implications of health goals development for planning theory, research and health promotion planning. Data collection consisted of twenty-three semi-structured interviews with key participants and systematic review of BC source documents on health goals. Data analysis uncovered nearly 100 factors that facilitated or obstructed the BC health goals initiative, organized around three phases of health goals development. Key factors influencing the premonitory phase included (a) government endorsement of health goals that addressed the multiple influences on health, (b) expected benefits of health goals combined with mounting concern about return on dollars invested in health, and (c) effective leadership by a trusted champion of health goals. Key influencing factors in the formulation phase included (a) the positioning of the health goals as a government-wide initiative versus a ministry-specific initiative, (b) the "conditioning" of the health goals process through the use of pre-established health goals and "orchestrated" consultation sessions, and (c) the make-up and degree of autonomy of the health goals coordinating mechanism. The articulation phase of health goals development revealed several influencing factors in relation to two chief issues that characterized this phase: (a) the lack of specificity of the health goals, and (b) the variable portrayal of the "health care system" as a priority area in the BC health goals. This study also revealed several concessions and trade-offs that characterized the BC health goals process. For example, the formulation of health goals that addressed the broader health determinants yielded health goals without the capacity for measurement, (b) the operational and bureaucratic autonomy of the health goals coordinating mechanism led to feelings of alienation from the health goals process and product among some branches of the Ministry of Health and some established health interests, and (c) the use of pre-determined health goals and the delivery of educative sessions based on the determinants of health generated claims of bias and a lack of trust and fairness in consultation processes and mechanisms.

In Alberta, decision-making in the health system has been devolved to seventeen Regional Health Authorities (RHAs). This thesis undertakes a broad analysis of the values that underlie this regionalization. Divided into two parts, the first half of the thesis develops a liberal egalitarian theory for the distribution of resources in society that turns on the importance of providing all people with the basic resources required to plan for, develop and achieve their life goals. Four requirements for any health system that seeks to uphold the values inherent in this theory are then articulated. These requirements include the need for the health system to be sensitive to the broader determinants of health, and the need for understanding the concepts of health and disease within the context of the social and cultural communities that the system is meant to serve. Part One concludes with an argument suggesting that expressions of Canadian values cohere with the normative theory developed. In Part Two the evolution of Alberta's regionalized healthcare system is traced. The values implicit in the regionalization of the health system in this province are then examined for their congruence with the four requirements developed in Part One. Following this, the ethical difficulties faced by RHAs are considered. The thesis culminates with thoughts on the ethical challenges Alberta's regionalized healthcare system must confront, offering recommendations for how some of these challenges may be addressed. It is concluded in the thesis that while a regionalized health system is not necessary for meeting the requirements elucidated, these standards can be met with a regionalized approach. However, at least in the case of the Alberta experience, a number of important changes would have to take place for this to occur. Among these changes is a paradigm shift in the way health and disease are understood towards a more evaluative approach; the recentralization of public health initiatives to the provincial level; and an overall change in governmental health policy recognizing that many areas of society, and consequently the policies of government agencies beyond a disease-based healthcare system, impact health and well-being.

No description available.

This work develops an opportunity for transgressive resistance to discursively formed structures of material and theoretical power and closure, based on a methodology of amateurism. The concept of amateurism draws heavily on the writing of Edward Said. This work synthesises Said with a broader corpus of postcolonial theory, following a theoretically postcolonial trajectory which applies the lessons from that referent to an engagement with traditional theoretical and cultural closure. The central thesis of the engagement follows a critique of strong ontology and vertical epistemology, or of expertise. Through an examination of health policy around birth, and sociological approaches to health, that critique is deployed to invigorate a new critical direction for the Left with a focus on subjectivity, social policy, social democracy and substantive citizenship. / Thesis (Ph.D.) - University of Adelaide, School of History and Politics, 2008

This work develops an opportunity for transgressive resistance to discursively formed structures of material and theoretical power and closure, based on a methodology of amateurism. The concept of amateurism draws heavily on the writing of Edward Said. This work synthesises Said with a broader corpus of postcolonial theory, following a theoretically postcolonial trajectory which applies the lessons from that referent to an engagement with traditional theoretical and cultural closure. The central thesis of the engagement follows a critique of strong ontology and vertical epistemology, or of expertise. Through an examination of health policy around birth, and sociological approaches to health, that critique is deployed to invigorate a new critical direction for the Left with a focus on subjectivity, social policy, social democracy and substantive citizenship. / Thesis (Ph.D.) - University of Adelaide, School of History and Politics, 2008

This thesis addresses questions of how to incorporate quality of care, represented by disutility-bearing effects such as mortality, morbidity and re-admission, in measuring relative performance of public hospitals. Currently, case-mix funding and performance, measured with costs per case-mix adjusted separation, hold hospitals accountable for costs, but not effects, of care, creating economic incentives for quality of care minimising cost per admission. To allow an appropriate trade-off between the value and cost of quality of care a correspondence is demonstrated between maximising net benefit and minimising costs plus decision makers??? value of disutility events, where effects of care can be represented by disutility events and hospitals face a common comparator. Applying this correspondence to performance measurement, frontier methods specifying disutility events as inputs are illustrated to have distinct advantages over output specifications, allowing estimation of: 1. economic efficiency conditional on the value of avoiding disutility events. 2. technical, scale and congestion sources of net benefit efficiency; 3. best practice peers over potential decision makers??? value of quality; and 4. industry shadow price of avoiding disutility events. The accountability this performance measurement framework provides for effects and cost of quality of care are also illustrated as the basis for moving from case-mix funding towards a funding mechanism based on maximising net benefit. Links to evidence-based medicine in health technology assessment are emphasised in illustrating application of the correspondence to comparison of multiple strategies in the cost-disutility plane, where radial properties as shown to provide distinct advantages over comparison in the cost-effectiveness plane. The identified performance measurement and funding framework allows policy makers to create economic incentives consistent with evidence-based medicine in practice, while avoiding incentives for cream-skimming and cost-shifting. The linear nature of the net benefit correspondence theorem allows simple inclusion of multiple effects of quality, whether expressed as not meeting a standard, functional limitation or disutility directly. In applying the net benefit correspondence theorem to hospitals a clinical activity level is suggested, to allow correspondence conditions to be robustly satisfied in identification of effects with decision analytic methods, adjustment for within DRG risk factors and data linkage to effects beyond separation.

Thesis (Ph.D.) -- McMaster University, 1998. / Includes bibliographical references (leaves 143-147). Also available via World Wide Web.

Thesis (Ph. D.)--University of New South Wales, 2004. / Also available online.

Thesis (Ph.D.)--University of Melbourne, Dept. of General Practice and Centre for Health and Society, 2007. / Typescript. Includes bibliographical references (leaves 252-278).