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No description available.

No description available.

Thesis / Doctor of Philosophy (PhD)

This thesis addresses health-policy relevant questions regarding quantity and quality of service delivery in primary healthcare using health administrative data from the province of Ontario. It is comprised of four chapters that explore the following questions: (1) What is the impact of switching from an enhanced fee-for-service (EFFS) payment model to a blended capitation payment model on the specialist referral rates of primary care physicians? (2) What are the rates of inappropriate laboratory testing in the province of Ontario? (3) What are the costs and determinants (physician and practice characteristics) of these inappropriate tests? (4) What is the impact of primary care payment structure on the quantity (number and cost) and the quality (appropriateness) of clinical laboratory testing? Fee-for-service (FFS) payment systems give physicians an incentive to treat patients on the margin of being referred, whereas in capitation systems physicians do not have a financial incentive to treat such marginal patients. Chapter 1 empirically examines how these two payment systems affect referral rates. The results show an increase in specialist visits upon a switch from an EFFS model to a blended capitation model when the physician is listed as the referring physician in the data, but no change in total specialist visits for these physicians’ patients. This change is not observed immediately upon switching payment models. Physicians paid by blended capitation who practice in an interdisciplinary health team have fewer specialist visits per rostered patient compared to EFFS physicians, despite an increase in their patients’ specialist visits after joining the interdisciplinary team. Using a definition of inappropriateness that quantifies ordering clinical laboratory tests too often or too soon following a previous test, Chapter 2 examines the rates of inappropriate laboratory testing for nine selected analytes in Ontario. The chapter finds that the percentage of inappropriate tests ranges from 6% to 20%. Moreover, between 60% and 85% of the time, the physician ordering an inappropriate test is the same physician who ordered the previous test. The findings also show that specialists are more likely than primary care physicians to order repeat tests too soon. Chapter 3 examines the costs and determinants associated with the rates of inappropriate laboratory utilization. The associated costs of inappropriate/redundant laboratory testing for the selected analytes ranges between 6 – 20% of the total cost of each test. Statistical analyses of the association of physician and practice characteristics with inappropriate testing are done using a logit model. Conditional upon the variables within the model, male physicians, physicians trained outside of Canada, older physicians, and a younger patient population are all shown to be associated with less inappropriate testing. Primary care physicians in group practices and in payment models with pay-for-performance (P4P) incentives are less likely to order inappropriate tests and specialist physicians are twice as likely to order inappropriately compared to FFS primary care physicians. Differences in physician, practice and patient characteristics, however, explain only a small amount of the variation in inappropriate utilization. Chapter 4 examines how physicians’ laboratory test ordering patterns change following a switch from an FFS payment model enhanced with P4P to a blended capitation payment model, and the differences in ordering patterns between traditional staffing and interdisciplinary teams within the blended capitation model. Using a propensity score weighted fixed-effects specification to address selection, the chapter estimates that a mandatory switch to capitation would lead to an average of 3% fewer laboratory requisitions per patient. Patients’ laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, physicians order 3% fewer inappropriate/redundant tests after joining the blended model and 9% fewer if they joined an interdisciplinary care team within the blended model. / Thesis / Doctor of Philosophy (PhD)

This research study explored the theoretical underpinnings of implementing government reform in the National Aeronautics and Space Administration (NASA), specifically focusing on a management philosophy called Faster, Better, Cheaper (FBC). It is situated within the broader context of Government reform efforts that attempt to increase the efficiency and effectiveness of government organizations in their delivery of products and services to the public. This study employed the Grounded Theory qualitative research methodology that concentrates on a central phenomenon and generates a theory from a category or construct-oriented approach. The objective is to generate a substantive-level theory that describes the practice of FBC within NASA and is grounded in the data collected from the organization. The following research questions guided this study: 1.What is the meaning of Faster, Better, Cheaper for Public Professionals in the NASA organizational environment? 2.What are the interrelationships between concepts of faster, better, and cheaper? 3.How does the technical and cultural structure of NASA influence the implementation of Faster, Better, Cheaper? 4.What are the required workforce capabilities to perform Faster, Better, Cheaper in NASA? The theoretical sample for this study consisted of interviews scheduled with NASA personnel involved in Faster, Better, Cheaper projects. NASA documents and reports were analyzed to saturate the initial 29 provisional categories. A representation of the phenomenon of FBC was developed following the data analysis, including causal conditions, strategies, environmental conditions and context, and consequences. Several findings addressed the meaning of FBC, the interrelationships between the concepts, the impact of organizational infrastructure, and required workforce capabilities. Topics for future research are the nature of risk in public organizations, tools for aligning and measuring public policy alignment and implementation, leadership of public sector teams, and generalizing the findings to other organizations. / Ph. D.

The purpose of this study was to determine the impact of the professional development component of Comprehensive School Reform on the mathematics achievement of third and fifth grade students attending selected Title I schools in Virginia. A qualitative research design was used to examine data from a focus group of four technical assistance providers, six principal interviews, and thirteen teacher surveys. This study involved participants of the 2003 cohort of the Comprehensive School Reform process during a 3-year period from 2003 through 2006. A set of questions was developed for each group of participants to acquire their perceptions of the components of professional development that impacted instruction and enhanced student achievement in mathematics. A constant comparative method was used to analyze key words and direct quotes from the focus group interview, principal interviews, and teacher surveys. Triangulation of these data was utilized to identify emergent themes. The findings revealed that the professional development component of Comprehensive School Reform had a significant impact on classroom instruction and student achievement in mathematics. Findings also revealed that the technical assistance provider served as a coach and resource for professional development. Findings indicated that professional development included data analysis and research-based instructional strategies as contributing factors for increased student achievement. The Virginia Standards of Learning pass rates of spring 2006 showed significant gains in the mathematics achievement of students in Grades 3 and 5 attending the Title I schools participating in Comprehensive School Reform. It was evident in the findings of this study that professional development significantly impacted the mathematics achievement of students attending the 2003 Comprehensive School Reform cohort of selected schools in Virginia. This information will serve as a resource for administrators of Title I schools in Virginia that have not met the Adequate Yearly Progress (AYP) requirements of the No Child Left Behind Act of 2001. / Ph. D.

The face of America's schools is changing. An increasingly diverse and challenging population of students blends assorted ethnic backgrounds, varied approaches to learning, and different socio-economic backgrounds into one student body. Faced with the realities of environmental and educational stressors, some students may find the educational milieu difficult. One particular group of students who may fit this category are those placed at-risk of school failure. The No Child Left Behind Act of 2001, the latest government reform in education to affect our nation's schools, created additional pressures on educators and students alike. In this climate of increased testing and accountability, educators must be trained to work with today's students. Staff development is one method of assisting educators to become knowledgeable about the needs of students placed at-risk of school failure in the current reform era. Guiding issues for this study were the nature of staff development with regard to students placed at-risk of school failure in an era of educational reform as viewed through staff development. Guiding questions were how many staff development courses were aimed at meeting the needs of students placed at-risk of school failure and how much of this training was done relative to content-based staff development. Staff development offices were chosen because they are the conduits through which school district employees often gain substantial knowledge and training, and because of their importance in the field of training and professional development. The method used in this study was a content analysis of staff development course documents from the 100 largest school districts in the United States. The intent of this quantitative content analysis was to explore how school district staff development offices approach the task of educating their employees to work with a complex, diverse school population, often seen as at-risk of school failure. This study was important to the field of educational leadership because it provided essential and useful information, both for educators working with an increasingly diverse student population, especially students at-risk of school failure, and for district leaders whose task it is to provide staff development for those who teach our children. Quantitative analyses of the staff development course documents showed no relationship between school district size and number of courses with coded words; the total number of courses a school district offered was, however, a predictor for the total number of targeted courses. All but one of the school districts sampled had at least one course with a coded word. A qualitative analysis of the coding of the categories and indicators revealed that the coded words were applied broadly to the themes and patterns that emerged. School district staff development offices continue to play a positive role in the training of educators striving to meet the needs of a diverse student body in the 21st century. / Ed. D.

The purpose of this study was to assess the climate for the adoption of a proposed reform model for secondary trade and industrial (T&I) education in Virginia. Vocational administrators and T&I instructors beliefs about the extent to which the adoption of the proposed model would precipitate selected outcomes were measured by using an instrument developed specifically for this study. The population of this study included two sub-groups: secondary vocational administrators and secondary T&I instructors. Equal representation from the groups could not be guaranteed as a result of the sampling procedures employed for this study. Questionnaires were mailed to 145 vocational administrators identified from the list provided by the Virginia Department of Education. Responses were received from 120 administrators 83%). Two-hundred-ninety-five questionnaires were distributed to T&I instructors. Responses were received from 129 instructors (43.7%). The study examined the climate for change in secondary T&I education programs in Virginia. It examined whether vocational administrators and T&I instructors believe that implementation of the proposed model would be likely to increase access to, the flexibility of, or the cost effectiveness of T&I programs. The extent to which administrators and instructors believed that increasing access, flexibility, and cost effectiveness would affect selected outcomes was also investigated. Finally, the study examined the degree of personal importance administrators and instructors placed on selected outcomes. There was a similar belief between both groups that implementation of the proposed T&I reform model would result in increased access, flexibility, and cost effectiveness. Both groups were optimistic that access and flexibility would be increased with slightly less optimism being shown for increased cost effectiveness. Also, both groups were optimistic that outcomes dealing with "quality" issues (improve quality of programs and increase student quality) would be affected positively as a result of model implementation and that the image of T&I programs would also be improved by implementation of the proposed T&I reform model. In general, administrators believed some reform outcomes less likely to be affected by increased access, flexibility, or cost effectiveness than others. Specifically, they believed it less likely that resources will increase or that the number of qualified instructors will increase merely as a result of implementation of the proposed model. Instructors' responses were optimistic for all outcomes except the extent that increased cost effectiveness would achieve selected outcomes. Instructors, like administrators, did not show strong support concerning the likelihood of model implementation increasing cost effectiveness. As a whole, both sub-groups appeared to be receptive to change. Although the proposed trade and industrial reform model may not in its current form accomplish the needed changes, administrators and instructors would seem to be accepting of attempts to reform secondary trade and industrial education in Virginia. / Ph. D.