Hospital COO Richard Gannotta Publishes on Outcomes of Inpatient Integrative Medicine Programs in 8 Systems

Summary: Duke Raleigh Hospital COO Richard J. Gannotta, NP, DHA discovered via a data search that the literature is exceedingly thin on inpatient integrative medicine programs. He wanted data on how programs are faring in the 3 critical areas of clinical effectiveness, patient satisfaction and, most importantly, financial performance. Gannotta identified 8 programs and assembled a research team through which they engaged structured interviews with the clinical and business leaders. The results are published here, in full, as Perceptions of Medical Directors and Hospital Executives Regarding the Value of Inpatient Integrative Medicine Programs. As Gannotta and his team noted, “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.” This is a useful look inside the mind and experience of integrative medicine integration in the pioneering hospitals with inpatient programs.

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

Richard J. Gannotta, NP, DHA, the COO of Duke Raleigh Hospital, shared his surprise on turning up very few articles when he explored the literature on the practical outcomes of integrative medicine programs in the inpatient care of US hospitals. I noted that practical outcomes have not been the focus of NIH NCCAM-funded research. Gannotta pointed to a deeper issue. He located very few inpatient programs that include the ability to “write for an integrative medicine consult” and then have patients receive integrative services delivered by a provider.

   
 Gannotta was also thinking forward
to how the
inpatient programs will
fare in the present economy.
The section on financial
performance

is particularly revealing.

 

Gannotta’s interest is stimulated both by a personal interest in integrative care and by professional interests: “From a research perspective, I’m interested in whole medicine systems outside of Western bio-medicine. I am also interested in organizational culture including how integrative medicine as a modality offered to patients appears to have a beneficial impact on staff and providers and subsequently the hospital and organizational culture.” all of a hospital’s culture.”
Gannotta was also thinking forward to how the programs will fare in the present economy. The section on financial performance is particularly revealing.

Gannotta, working with a team of researchers, identified 8 inpatient programs then chose an interview format to engage his subject matter. The study, its methods and results are printed in full below as Perceptions of Medical Directors and Hospital Executives Regarding the Value of Inpatient Integrative Medicine Programs.

Gannotta is also senior faculty at Cohvation, a think tank focused on healthcare
innovation and specifically on integrative medicine and the interface of spirituality and health
and individual and organizational well being.



Skimmers: Head immediately down to “Questions” and “Results.” Comments are welcome.

_____________________________________________


Perceptions of Medical Directors and Hospital Executives

Regarding the Value of Inpatient Integrative Medicine Programs


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.     

_____________________


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

ImageFinancial 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.

_____________________________

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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