| | Consumer-Focused Strategies of Innovative Hospitals: The Role of Complementary TherapiesAfter surviving a variety of threats to their financial viability over the last decade, hospitals now face the challenge of responding to an increasingly consumer-driven healthcare environment.1 For example, tiered-network health insurance products, although not yet common, contain financial incentives that reward patients who choose hospitals that score well on quality, cost, and patient satisfaction metrics.1 And, comparative information on hospital performance is becoming more accessible to consumers on the internet or through pamphlets and brochures provided by employers and health plans.2 In responding to the new challenge of healthcare consumerism, hospitals are increasingly marketing directly to consumers and reconsidering what should constitute the experience of hospitalized patients. In the latter respect, they can draw on the experience of a small number of hospitals that, over the past decade, have implemented innovative, multidimensional strategies to improve the patient experience in their facilities. Although these hospitals now believe their efforts will help attract and retain market share in an increasingly consumer-centered environment, their strategies were developed before the new consumerism in healthcare took center stage. In support of their strategies, the hospitals do not cite favorable financial projections or marketing considerations. Instead, they use phrases such as it’s the right thing to do and it’s what our patients want. In a forthcoming book, Christianson and colleagues3 report the findings from a research project that analyzed consumer-focused innovation strategies in eight early-adopting hospitals. Over the past decade, these hospitals, which vary considerably in size and geographic location, have implemented strategies that go beyond the now widespread employee training initiatives intended to improve staff-patient interactions. They have redesigned the physical environment for patients and families, implemented initiatives intended to change nurse-patient relationships at the bedside, and developed programs that address the spiritual and emotional needs of hospitalized patients and their families. However, in many respects their greatest challenge has been creating access for their patients to less traditional, complementary therapies. Complementary therapies  The American Hospital Association’s 2005 survey4 found that 26.5% of hospitals made one or more complementary therapies available to their patients, an increase from 7.7% in 1998 (because of the low survey response rate, it is not clear if the survey results are representative of hospitals in general). Among survey respondents, it was more common to offer these services to outpatients, but a significant percentage of hospitals said they offered some complementary therapies to inpatients as well. These inpatient therapies included massage therapy (37%), relaxation training (20%), acupuncture (12%), guided imagery (22%), therapeutic touch (25%), and music/art therapy (26%). The increase in availability of such therapies no doubt reflects, at least in part, a general increase in patient demand for them, even though a recent Institute of Medicine study found relatively little research assessing their effectiveness.5 In the American Hospital Association survey,4 hospital administrators cited patient demand, an evidence base, and practitioner availability as the factors that were important in their decisions to offer complementary therapies to inpatients. The hospital administrators in the eight study hospitals viewed making complementary therapies available to inpatients as challenging, primarily because they feared a negative reaction on the part of medical staff. They saw physicians as a powerful constituency in the hospital, and a group where “values fit” might be an issue with respect to acceptance of complementary therapies. Resistance to massage therapy, music therapy, and pet therapy was not expected, but administrators were worried about making other complementary therapies available to patients. Consequently, several of the study hospitals placed less emphasis on complementary therapies (in comparison to the other components of their consumer-focused strategies), whereas others introduced them gradually, focusing first on the least controversial. One administrator observed that he tried to keep the use of these therapies in the hospital “under the radar” of the medical staff, which is an apt description of the approach employed by other study hospitals as well. The different ways in which the hospitals approached implementation of complementary therapies can be illustrated by two hospitals in the study, one of which instituted an “order process” for complementary therapies, and a second that emphasized therapies that could be delivered at the bedside as part of nursing care. Hospital 1 One hospital, a large tertiary care hospital in an urban area, created opportunities for patients to access complementary therapies through use of a consultative model, facilitated by the hospital’s Institute for Health and Healing, established in 2002 with donor funding. The practice model developed by the Institute relied on teams consisting of (1) a nurse clinician with a background in providing acute inpatient care to specific types of patients, (2) a massage therapist with experience treating people with medical problems, and (3) an acupuncturist. For care to be integrated at the bedside, nurse involvement was believed to be essential. A massage therapist was included because this type of therapy was well accepted by clinicians as an effective means to reduce pain and stress. Similarly, acupuncture was accepted as effective pain treatment by most physicians, and an acupuncturist already was practicing on the hospital’s campus. The goal is for all nurses in the hospital to receive training in holistic nursing, massage techniques, guided imagery, relaxation techniques, and an overview of aromatherapy and acupuncture. Institute consultations may be ordered by any member of the patient’s healthcare team, including the patient or a family member (acupuncture consultations can be ordered only by a physician). These services include, but are not limited to, massage therapy, acupuncture, aromatherapy, biofeedback-guided imagery, and music therapy. An Institute practitioner assesses the patient’s condition, explains the services that are available, and working with the patient and healthcare team, develops a plan for incorporating specific services (primarily massage therapy or acupuncture) into the patient’s overall treatment. In 2003, when the teams were first formed, only five physicians on the medical staff referred patients to the Institute for consultations. Currently, there are 400 physicians (of 1,600 on the medical staff) who use Institute services. Hospital 2 A second, and quite different, approach to providing complementary therapies to inpatients is exemplified by Hospital 2, a small community hospital. This hospital employs a staff member to oversee the deployment and management of programs, including yoga, acupuncture, aromatherapy, biofeedback, massage therapy, Reiki, pet therapy, and drumming. This staff person also delivers various complementary therapies to hospitalized patients. When a new program is implemented, hospital staff members are trained in the therapy and its potential applications in patient care. Physicians on the medical staff are provided with published studies regarding the effectiveness of the therapies. There were instances where implementation of the programs by the hospital met with resistance. For example, the hospital was accused by some community members of supporting eastern religions when it offered yoga. However, provision of complementary therapies in the hospital was strongly supported by the hospital administrator, who believed that these therapies were essential to his vision for an integrative healthcare approach to patient care in the hospital. Implementation approaches Regardless of the design of their complementary therapy initiatives, most of the study hospitals proceeded cautiously in introducing them. Typically, they educated groups within the hospital about the innovations early in the implementation process. For instance, at one hospital, off-site training for 1,250 hospital staff members was carried out in 25-person groups. At another, administrators convened at an off-site, Saturday retreat where physician leaders experienced a variety of complementary therapies and discussed how these therapies might be employed in treating patients. A similar half-day session was conducted for nursing leaders. A third hospital established a program in which nurses are trained in a mind/body/spirit approach to nursing practice. In all these hospitals, education and training programs around complementary therapies sometimes had the ancillary effect of “weeding out” staff who were not comfortable working in a hospital environment that included provision of these types of care. Along with structured learning opportunities, a significant amount of experiential learning occurred at the hospitals. For example, practitioners provided stress management therapy to nursing staff so they could experience the potential benefits for patients. And, many study hospitals recounted a situation in which a physician who initially resisted nontraditional therapies subsequently became a supporter after observing the positive impact of a therapy on a patient. This impact typically involved pain reduction in a cancer patient or reduction in stress and anxiety in a patient prior to surgery. Perhaps the most important step taken by hospital leaders to address possible physician opposition was conveying a clear message that their hospitals should be, and would be, both high tech and high touch with respect to patient care. This was important in even the smallest facilities. Maintaining currency in the latest high-tech treatment approaches helped the study hospitals fend off any concerns that the provision of complementary therapies to inpatients might be a sign of the organization’s inability to compete in the delivery of high-tech specialized services. Financial challenges In addition to gaining physician acceptance for complementary therapies or minimizing their resistance, finding ways to pay for the therapies has been a significant implementation issue as well.2 Again, the experiences of Hospitals 1 and 2 described above are illustrative of these challenges. In Hospital 1, inpatients do not pay out-of-pocket for the Institute services they receive. The hospital subsidizes approximately $1 million per year in salaries, and in addition relies on $700,000 annually in donations. The Institute is now working with the hospital’s financial office to develop a business case for the services it provides to inpatients. The situation is different for complementary therapies provided to hospital outpatients, where there is health plan reimbursement for some services. Hospital 2 faces continuing financial challenges in providing complementary therapies. It subsidizes the costs of the therapies through profits from other activities, but its small size limits its ability to cover all costs in this manner. Currently, the hospital is reexamining the cost structures for some of the therapies. In most of the study hospitals, the cost of providing complementary therapies, especially if they could be integrated into patient care provided by nursing staff at the bedside, was viewed by financial officers as a relatively small budget item. Some of the hospitals conducted small-scale studies that they said demonstrated cost reductions associated with provision of specific therapies (eg, aromatherapy). Others felt therapies that expanded opportunities for nurses to deliver hands-on care resulted in increased nurse satisfaction and reduced turnover, generating significant savings in labor costs. In general, although the study hospitals all believed the development of a sustainable financial model for provision of complementary therapies to inpatients was important, they were optimistic that cost-offsets could be identified. The most common sources of cost savings were believed to be in reduced use of some medications, fewer falls, and reduced nurse turnover. However, the evidence supporting these beliefs was thin, and hospital administrators felt that larger scale studies were needed to support diffusion of more complementary therapies to more patients. References 1. 1Robinson JC. Managed consumerism in health care. Health Aff. 2005;24:1480–1489. 2. 2Nichols LM, O’Malley AS. Hospital payment systems: will payers like the future better than the past?. Health Aff. 2006;25:81–93. 3. 3Christianson JB, Finch M, Findlay B, Goertz C, Jonas WB. Reinventing the Hospital Experience. Chicago, IL: Health Administration Press. In press. 4. 4Health Forum. 2005 Complementary and Alternative Medicine Survey of Hospitals. Chicago, Illinois: American Hospital Association; 2006. 5. 5Institute of Medicine, Committee on the Use of Complementary and Alternative Medicine. Complementary and Alternative Medicine in the United States. Washington, DC: The National Academies Press; 2005;. Jon B. Christianson, PhD, a health economist, is the James A. Hamilton Chair in Health Policy and Management at the University of Minnesota. He serves on numerous editorial boards, including Health Affairs and the American Journal of Managed Care, and has published seven books and approximately 200 articles and book chapters. Michael D. Finch, PhD, is an adjunct associate professor in Health Policy and Management at the University of Minnesota and a senior fellow of the Samueli Institute. He is currently conducting research to examine the business case for healing environments in hospitals. Christine Goertz Choate, DC, PhD, is director for the Palmer Center for Chiropractic Research. Dr Goertz Choate came to Palmer College from the Samueli Institute for Information Biology in Alexandria, Virginia, where she served as director of Clinical Research from 2003 to 2005, until being named deputy director in 2005. Barbara Findlay, RN, BSN, is a vice president at the Samueli Institute, where she heads the Optimal Healing Environments Program. A registered nurse and researcher, she is a frequent presenter on the issues surrounding integrative healthcare and has coauthored a number of reports and peer-reviewed articles on this topic. PII: S1550-8307(06)00569-6 doi:10.1016/j.explore.2006.12.013 © 2007 Elsevier Inc. 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