Rick Gannatta, NP, DHA: Duke Health Raleigh Hospital COO

Richard J. Gannotta, NP, DHA, the COO of

Richard J. Gannotta, NP, DHA, James Zoller, PhD,
Jeffrey Brantley, MD,  Andrea White, PhD

The views and opinions expressed in this article are wholly the work of the authors and should not in any way be thought to represent the views of any other organization or entity.

Abstract

Objective: The objective of this study is to identify and assess measures of success of inpatient integrative medicine programs in the United States.

Design: An exploratory qualitative approach was selected for the study, surveying a purposeful sample of approximately ten healthcare institutions with inpatient integrative medicine services.

Participants:   From each of eight participating healthcare institutions, the integrative service/program clinical director (physician) and the non-clinical executive/ director, charged with general program administration and budgetary responsibilities for the program were participants in the study.

Measures: A one-on-one or group (both the executive and clinician) semi-structured survey via telephone was conducted to identify critical factors associated with the success or failure of the program in three domains: 1) clinical outcomes, 2) financial performance, and 3) patient satisfaction.  The interviews were recorded and analyzed to identify key themes.

Results : In general, responses from medical directors and hospital executives regarding their perceptions of the value of the inpatient integrative program and the critical success factors associated with those programs were consistent and positive across the three domains investigated.  

Conclusions: Findings suggest that inpatient integrative programs are positively regarded by program leaders who believe that the service adds value as demonstrated in a number of key factors associated with clinical outcomes, patient satisfaction and financial performance.  Additional study to quantitatively assess program impact would be a logical next step.     

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Introduction:

Increasing demand (1) for integrative and complementary and alternative medicine (CAM) has led to its incorporation into a variety of patient settings. Some healthcare facilities have instituted inpatient programs specifically offering integrative medicine or CAM services. Despite this growth and due to a lack of consensus regarding a definition of a CAM inpatient service or program from academic, hospital and CAM organizations, the total number of inpatient programs in integrative medicine is difficult to determine.  This lack of a clear definition limits those institutions considering implementing such a program from easily recognizing model programs or their structures.

In addition, little scholarly work exists to assist in program development or analysis of factors associated with a successful inpatient program. Furthermore, no studies in the literature assess the perspectives of program leadership on performance in centers where a service has been identified and implemented.

As organizations look at new strategies to define clinical value, market share and recruitment and retention efforts, many may consider adding integrative programs. Further, growing consumer awareness may drive healthcare organizations/hospitals to "reinvent" themselves by challenging traditional approaches to care delivery.  These factors may encourage organizations to consider the inclusion of inpatient integrative medicine programs (2). Because so little is known about the value of these programs in these increasingly competitive and challenging times, the perspectives of CAM program medical directors and the responsible healthcare executive experienced with these programs become particularly important.  These individuals can shed some light on CAM's value to the bottom line, to patient satisfaction, and to quality care.

The objective of this study was to identify and assess measures of success for inpatient integrative medicine programs. The research question is what value do inpatient CAM programs offer their organizations from the perspectives of hospital executives and medical directors?

The goal was to examine perspectives of key people involved in existing integrative medicine programs in inpatient settings and determine their assessments of the success of the program. This determination was made by identifying and analyzing themes and findings related to program performance. 

Methods:

The study was approved by the Medical University of South Carolina Institutional Review Board.

An exploratory qualitative approach was selected for the study surveying a purposeful sample of eight healthcare institutions with inpatient integrative medicine services selected from the AHA Health Forum (3) CAM survey participants, The Bravewell Collaborative (4) and an internet search.

Of the programs surveyed seven were part of an integrated delivery system and one operated as a free standing community hospital.

The hospitals in the study offered at least one of the modalities which are part of the four major categories of complementary and alternative medicine recognized by the National Center for Complementary and Alternative Medicine (5). These modalities included, biologically based practices, energy medicine, manipulative and body-based practices, and mind-body medicine. In addition Traditional Chinese Medicine (e.g.; acupuncture) was also identified as a modality offered to inpatients. 

The participant programs average years in operation were 6.75. 

Selected program directors and executives were contacted by e-mail or by telephone to determine if they were willing to participate in the study. 

Four integrative service/program clinical directors (physician), five responsible executives, i.e.; the primarily non-clinical executive/ director, and one "hybrid" i.e. an individual who functioned in both roles, were identified and included in the study.

A semi-structured survey interview was conducted via telephone with each program participant to identify critical factors associated with success or failure of the program in three domains: 1) clinical outcomes, 2) financial performance, and 3) patient satisfaction (6).  The interviews were recorded and subsequently analyzed to identify key themes.

In addition to audio recording, field notes were taken which allowed the researcher to write down impressions and ideas about other questions that might be useful to ask.  In most cases, questions were intentionally open ended and non directive, with participants encouraged to expand on their answers if they so desired.

The recorded interviews and the text of the interviews were analyzed for themes as well as direct (positive and negative) answers to the questions posed. Initial responses were followed by more penetrating questions from the interviewer.  The questioner avoided providing any information about other participants' responses to prevent the introduction of bias.

Questions asked in the instrument were adapted from balanced scorecard indicators noted in Ransom, Joshi, and Nash (7).

In an effort to enhance the relevant value of information for organizations considering starting programs, several indicators were expanded by the author to increase the depth of responses.

Questions Asked during interview

Clinical Outcomes 

• In what ways has the integrative medicine service had an impact on clinical outcomes? (positive, negative, no change
• In what ways has the integrative medicine service had an impact on length of stay? (increased, decreased, no change)

Patient Satisfaction

• In what ways has the integrative medicine service had an impact on patient satisfaction? (positive, negative, no impact), (why/why not?)
• How does the integrative medicine service compare to other inpatient programs/services with respect to patient satisfaction?  (positive/better, negative/worse)

Financial Performance

• Does the organization expect the service to be profitable? (yes/no), (why/why not?)
• Is the service profitable?
• Are there any plans to discontinue the service?
• Are there plans to expand the service?
• Are there plans to contract/shrink the service?

Questions were open ended with the interviewer (where applicable) following up with additional inquiry e.g.; in what ways has it?   

Results

Responses collected from the interview process were initially coded into words and phrases by the investigator. These words and phrases were analyzed within the context of the question asked. Frequency data provided the number of statements/responses per category.

These responses were then coded into categories (focused coding), which combined smaller coding units and repeating responses into larger ones which identified critical factors associated with the success or failure of that element the program and any key themes.   

To ensure accuracy and consistency of the data analysis process, a peer researcher was asked to listen to the recordings and identify what s/he heard (themes). That information was compared to the investigators findings and reviewed for similarities.  

Clinical Outcomes 
 
Initial Coding revealed a number of repeating words and phrases revolving around; "pain control", "reduction in the use of pain medication", "less medication usage", a "reduction in nausea and vomiting" after treatment and or surgery, an enhanced sense of "well being", "less stress and anxiety", "length of stay reductions" associated with medication reduction and "positive" post operative outcomes.

Specific responses from participants in the survey included:

"My perception is that it has made an amazing difference in quality of life." 

"The service reduced use of medication, especially anxiety medication for surgery patients."

"Clinically, in the hospital where we have seen the most improvement has been in pain and anxiety and tension." 

"I think the most significant clinical outcome (impact) that we have so far are pain scales, we have over the last two years solicited results from before and after (an intervention). On average, after an integrative medicine intervention of any form, not any specific modality, we've had more than a three point - an average of more than a three point reduction in pain scores post treatment."

"People that receive (integrative) care specifically around pain management had a drop in pain scale scores."

"We see positive outcomes with pain first - anxiety, nausea, vomiting, sleep deprivation, and then we get into more of the psycho social, like grief and situational depression."

"We initiated an informal study that looked at length of stay, pain, request for pain medication, (and) found specifically that the length of stay was decreased and the need for pain medication was definitely reduced."

Focused Coding of these words and phrases demonstrated that there was belief that overall clinical outcomes were improved. This improvement was seen in the areas of:

1.      Pain reduction, and the need for less pain medication 
2.      Reduction in nausea and vomiting
3.      Reduction in stress and anxiety and greater sense of well being
4.      In general terms a belief that length of stay decreased

Patient Satisfaction
 
Words and phrases associated with responses for these questions included; overall "positive scores", positive "letters" specifically referencing the integrative service, "increased satisfaction scores" associated with specific specialties within the departments of surgery or medicine, positive "impact on work culture" within the organization and a desire to choose the hospital because of the service.

Responses from participants in the survey included:

"I think that the most significant impact that I have noticed is patient satisfaction, there is a lot of patients that have expressed increased satisfaction with their hospital stay after having received integrative medicine treatments, and many of them have faxed in surveys - 100% of them actually have indicated that they would receive an integrative medicine modality / treatment again."

"What I've noticed is that after patients receive an integrative medicine modality it decreases the stress of the nurse."

"Overwhelmingly (positive), our satisfaction score for our services is 96%." 

"Some of the comments make you laugh or make you smile, but these people love having that individual attention and so that's got to cross over to the kinds of scores they give."

"There are surgeons who do their surgery at our hospital because their patients are so pleased, happy with the care."

-The key themes associated with these responses include:

1.      A belief that patient satisfaction associated with the service is positive
2.      The inpatient integrative service positively influences satisfaction scores for other departments i.e.; medicine and surgery
3.      In general there is the perception that work culture is positively influenced by the program
4.      Satisfaction with the service may influence patient choice

Financial Performance

Initial coding produced a large number of responses to this multi-part question specific to profitability and the programs future (discontinuance, contraction or expansion). The largest number of responses were associated with profitability and included; inpatient integrative service seen as a "loss leader", part of the organizations "mission", key for "attracting patients, physicians and clinical/support staff",  part of overall "strategy" and offering a "competitive advantage" in key markets.

Additional responses noted that program profitability could be demonstrated by its impact on "reduced medication use", "shorter lengths of stay", "incremental business" and that the success of key service lines is increasingly influenced (positively) by the inclusion of integrative medicine.

Funding sources included leveraging "outpatient program funds", allocations from "other divisions", "grants / research funding" and "philanthropy". All study participants indicated that there were "no plans" to discontinue or scale back their program. The majority surveyed planned on "adding modalities and services" not currently offered.

Specific responses from participants:

"I think the only way to be profitable is to drive (revenue) from the outpatient (side), I doubt that inpatient services will ever be profitable unless we begin to factor in and track length of stay and less use of medication, but that will be down the road."

"Stand alone - it is costing, if you just look at it that way - it is costing our organization money.  So our organization contributes financially out of their operations $1 million a year to help the process." 

"The way that we supplement that right now is through philanthropy, but we are - our strategy to help offset that, continue to prove our worth through this indirectly- and the other is to develop external strategies for revenue."

"Everything we have done comes from donations; the inpatient side is not a money maker at all.  Everything that we have done on the inpatient side is with philanthropy."

"I can tell you right now, every area (department) wants it, we just have to go step by step and see how we are going to fund that and pay for it."

"They (patients) choose to come here from California bypassing other great institutions because they value that holistic approach to their care in the pre and post-op settings.  That doesn't show up on the balance sheet, but for an institution of this kind of stature, it can't buy that kind of goodwill and that kind of publicity."

"If things keep getting stretched tighter and tighter and tighter, it's easy to look and say well this is something relatively new, - where we axe it, on the other hand, the actual cost associated with the amount of work that is getting done (inpatient) is relatively low."

"Some people have started to consider - if you are in a market like we are people choose to come here specifically because we have an integrative medicine service, actually increasing the use of the hospital (inpatient) for surgery - because we have this service, you can argue that this generates revenue for the hospital."

Focused coding revealed the following key themes:

1.      Expectation that programs cover expenses
2.      Funding was derived from four primary sources

a.       Leveraged (integrative medicine) outpatient margins to cover inpatient programs
b.      "Other" hospital divisions/services
c.       Philanthropy
d.      Grants /research

3.      General perception that better clinical outcomes associated with inpatient integrative medicine programs have a positive impact on financial performance

4.      The program is a key part of strategy or mission and a competitive advantage for the organization

5.      Enhances the organizations financial performance by attracting:

Patients
Physicians
Recruiting and retaining hospital staff

Discussion:

The questions posed in this study are important to hospital administrators and clinicians because integrative medicine/CAM programs are a relatively new addition as a hospital service offering and information regarding their performance is limited. In addition, consumer and practitioner demand may accelerate CAM inclusion in the inpatient setting and hospital leadership should be familiar with CAM / integrative medicine and be prepared to engage there constituencies regarding its place within the healthcare delivery construct.   

From an economic and budgetary perspective, those programs which are able to demonstrate added value to the organization will, in general, be more successful in securing the resources necessary to maintain/expand their operations. Finally, few resources exist for those healthcare organizations considering adding an inpatient integrative medicine program.

The present study looked at the perceptions of program leaders, both clinical and administrative on what value and which success factors were associated with there programs success, failure and future direction. The study sample was homogeneous and there were no significant differences in responses between either clinical leaders or executives. Furthermore a relatively consistent list of critical factors associated with program success or failure was identified. This list can direct future scholarly work into areas where perceived value is high and linked to program success and guide administrators in program development.

Although program failure as a theme was not specifically evident in the responses, the number of responses associated with financial performance and depth of those responses could be an indicator of participant concern as it relates to program vulnerability and sustainability in uncertain economic times.  

In addition, the study identified additional benefits associated with inpatient integrative medicine programs including an enhanced work culture, as an effective strategy for employee recruitment and retention , in creating an overall sense of less stress and anxiety for staff directly or indirectly connected with the program and as a positive differentiator from other providers  in there local community. 

Limitations:

The primary limitation to the study was identifying programs which met the criteria for an operating inpatient service. Initial criteria included programs operating for more than three years, a structure which had an identified clinical and administrative leader, and a mechanism whereby an inpatient had access to the service via standing orders, consultation or nurse driven protocol.  Of the ten hospitals initially identified, two were dropped form the study; one due to lack of participant availability and one required a research fee to participate.  Of the eight hospitals surveyed five programs operated for greater than three years and three programs from one to three years. Because each of the programs not meeting the criteria for length of service also operated an outpatient service which had been in operation for greater than three years, the initial inclusion criteria was modified to allow these programs in the survey.

Although the parameters for study inclusion can be defined, locating existing programs  proved to be more challenging. There was no definitive source which identified inpatient programs. The lack of a standardized taxonomy (to define CAM vs. integrative medicine programs) was also a contributing factor to not easily identifying programs. 

Utilizing the three sources noted in the methods section; the AHA Health Forum (3) The Bravewell Collaborative (4) and an internet search, proved to be the best approach in identifying hospitals which had operating inpatient integrative medicine programs and met the studies inclusion criteria. 

In addition the reliability of the initial coded data and  final coded themes and categories  was dependent upon the researcher's subject knowledge and limited by the lack of previous scholarly work in the subject area.

Finally, the possibility that survey responses may be influenced by the participants   association with there programs development and ongoing operations should be considered.  

Further scholarly work in the field of integrative medicine and CAM programs which would include a comprehensive source to identify existing inpatient and outpatient programs will benefit the field and future researchers and may mitigate these issues.
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References:

1. Lundgren, J., Ugade, V. (2004). The Demographics and Economics of Complementary Alternative Medicine. Physical Medicine and rehabilitation Clinics of North America, Vol.15 (4) 
2. Christianson, J. B., Finch, M.D., Findlay, B., Jonas, W.B., Choate, C. G., (2007). Reinventing The Patient Experience, Strategies for Hospital Leaders. Chicago IL. ACHE Management Series.
3. AHA Health Forum from http://www.aha.org/ (2008)
4. Bravewell from http://www.bravewell.org/ (2007)
5. NCCAM Publication, No. D158, from http://nccam.nih.gov/about/ataglance/ (2008)
6. Shi, L (1997).  Health Services Research Methods.  Albany, NY:  Thomson Learning.
7. Ransom, E.R., Joshi, M.S., Nash, D.B. (November 2008). The Healthcare Quality Book: Vision, Strategy, and Tools, Second Edition.  Washington, DC:  Health Administration Press.

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