Thought the following is timely as we struggle with healthcare costs and innovative models of delivery.
Perceptions of Medical Directors and Hospital Executives Regarding the
Value of Inpatient Integrative Medicine Programs
Richard J. Gannotta, NP, MBA, James Zoller, PhD, Jeffrey Brantley,
MD,
Andrea White, PhD
Abstract
Objective: The objective of this study is to identify and assess
measures of success of inpatient integrative medicine programs by exploring and
comparing the experiences of program medical directors and the hospital
executive responsible for 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 participated 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 there 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.
Introduction:
Increasing demand 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, 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 programs. 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
(1). 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.
Research Question:
The objective of this study was to
identify and assess measures of success for inpatient integrative medicine
programs by exploring and comparing the experiences of program medical
directors and the responsible hospital executive. 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 inpatient integrative medicine programs. 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 (2) CAM
survey participants, The Bravewell Collaborative (3) 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 (4). 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 (5). The interviews were recorded
and subsequently analyzed to identify key themes.
Data Collection
Data
was acquired by focused interviews using a prepared interview guide for each
participant. This semi-structured
interview guide allowed participants to be asked questions that allowed for
open-ended responses. 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. Interviews were conducted via
telephone. 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 (6).
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?
Data Analysis
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.
Results:
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.
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.
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 there program. The majority
surveyed planned on “adding modalities and services” not currently offered.
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. 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.
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 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.
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.
Further scholarly work in the field
of integrative medicine and CAM programs will benefit the field and future
researchers and may mitigate these issues.
References:
1. 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.
2. AHA Health Forum from http://www.aha.org/ (2008)
3. Bravewell from
http://www.bravewell.org/ (2007)
4. NCCAM
Publication, No. D158, from http://nccam.nih.gov/about/ataglance/ (2008)
5. Shi, L (1997).
Health Services Research Methods.
Albany, NY: Thomson Learning.
6. 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.
