Professional Chaplains and Health Care Quality Improvement: Tales of a Research Project

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Professional Chaplains and Health Care Quality
ImprovementTales of a Research Project

• Nancy Berlinger, Ph.D., M.Div
• The Hastings Center
• Themes in Pastoral Theology
• February 5, 2009

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Overview

• Research project on chaplaincy and quality
• Core Values
• Three roles of the chaplain
• Patient Satisfaction and QI projects
• Recommendations

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Who We Are

• George Fitchett, D.Min., Ph.D.
• Kathryn Lyndes, Ph.D.
• Clayton Thomason, J.D., M.Div.
• Martha Jacobs, D.Min., M.Div.
• Nancy Berlinger, Ph.D., M.Div.

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Research Project on Chaplains and Quality

• Aim
• To develop preliminary information about
  healthcare chaplains views about, and
  experiences with, quality and quality improvement
  in spiritual care.
• Sponsors
• The Hastings Center
• The HealthCare Chaplaincy
• Funding
• The Arthur Vining Davis Foundations

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Four Focus Groups
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Focus Group Questions

• Please describe any experience you have had as a
  chaplain with a quality improvement (QI) project
  in your department or your institution/agency.
• Please tell us your view of two indicators or
  components of high quality spiritual care. Or, if
  you prefer, of low quality spiritual care.
• If you had the authority, what one or two things
  would you do to improve the quality of spiritual
  care in your department?

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Methods

• Transcribed audio recordings of the groups
• Each member of research team extracted key themes
  from transcripts
• Team discussed these themes until we reached a
  consensus
• Selected quotes to illustrate each theme

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Table 1. Focus Group Participants
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Table 2. Participants Professional Background
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Table 3. Participants Workplace
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Chaplains Core Values

• Chaplains have a very strong commitment to
  providing quality spiritual care.
• Quality was described in relation to chaplains
  roles
• Caring for patient, family, and staff
• Creating space for healing
• Providing holistic care
• Offering presence
• Demonstrating competency

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Chaplains Core Values and Patient Centered Care

• There are strong similarities between chaplains
  core values and the values of patient-centered
  care, including
• the biopsychosocial model
• viewing patient as a person
• sharing power and responsibility
• building effective relationships

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Measuring Core Values

• The Tension Measurement is Impossible but
  Necessary
• Skeptical and resistant to quantifying values
• Open to the possibility of improving performance
  based on measures
• Realize the administrative need to measure
• Want to find meaningful measures of their work

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• Is quality spiritual care really measurable?
  Most of us work in institutions where the answer
  has to be yes in order to survive. But in the
  end, its a qualitative measure, not a
  quantitative measure, I think.
• And our job as managers of pastoral care
  departments is to come as close as possible to
  finding something that's measurable that actually
  makes a difference in what we do. And to me, it's
  up hill all the way.
• They want those numbers, and we have to bow to
  those numbersBut we also have to really answer
  to God and to our calling as chaplains.

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What Gets Counted?

• Concrete markers of quality in spiritual care
• Initial visits
• Chart notes
• Referrals
• Board certification
• Staff retention

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What Gets Counted?

• it was basically measuring how many people got
  visited.
• We did a quality improvement project on charting
  because our goal is to have 85 of the patients
  charted on by the spiritual care people.
• Tracking referrals is one way of measuring what,
  really I think shows quality in terms of whos
  referring, whos not.
• Two markers I would add would be staff retention
  and certification.

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Patient Satisfaction
I was struggling with the quality issue too, of
how do we define it. What is it? Is it patient
satisfaction? Is it perception of value? And
whos doing that perception?
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Tension Patient Satisfaction Surveys are
useless yet rough indicators of quality

• Pro
• Only patients can tell us when their spiritual
  needs have been met
• Surveys are the voice of the patients
• Departmental surveys may better capture service
  provision

• Con
• Patients dont always recognize what spiritual
  care is
• Patients and families may be poor judges of
  quality
• Surveys dont measure all dimensions of spiritual
  care

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Patient Satisfaction

• And even though we identify ourselves, every
  time we walk into the room. . . they dont
  recognize the fact that this is the chaplain.
  Its just this nice lady that came in and talked
  to me for a little while. They dont see that as
  spiritual care, when in fact it was!
• The truest measure of quality is the people we
  want to serve. . . And so we get their
  perspective.

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Departmental Institutional QI Projects

• It's a requirement for all departments to do a
  quality improvement project each year. It's
  usually not well received by my chaplains. They
  basically hate it, because it's very hard to
  quantify what we do.

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The Tension Requirement vs Opportunity

• Pro a range of views
• QI projects provide minimal benefit
• QI projects provide opportunities for meaningful
  change
• QI projects provide regular review of
  professional goals

• Con
• QI projects do little or nothing to improve
  quality

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Chaplains Experiences with QI Projects

• Chaplains have a range of experience with QI
• Some chaplains have no experience with QI
• Other chaplains work in institutions with highly
  developed QI programs and have received advanced
  training in QI (eg. Six Sigma greenbelts).

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Department/Institutional Projects

• We used to use aCPE model of presenting case
  studies on a rotating basis among the staff, and
  talking about our particular encounters with
  patients. And the quality goal was very
  specific,what did the presenter, the chaplain
  learn about himself or herself that increased
  their value as a chaplain and their ability to do
  pastoral care. It spoke, I think, to the heart
  of our work, although presenting cases is very
  challenging, very difficult.

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Managing Quality in Spiritual Care

• Most managers of chaplaincy departments can
  describe efforts to improve the services provided
  by their department.
• Few department managers think of these projects
  in QI terms.

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• We have to think creatively. There are things we
  can do. We can't see every patient, but we can
  make sure that there's a brochure about
  chaplaincy services in every patient's packet.
• I carry a pocket card. They're in a goldenrod
  color. You just can't miss them. It's just a
  protocol of when to call the chaplain, and who's
  available.Soevery timewhen I'm with a nurse
  who's new I give them a card, saying, This is
  when you call the chaplain.

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Institutional Chaplaincy The Chaplains Three
Roles

• Chaplain as Shepherd
• Bedside care of patients and families
• Chaplain as Administrator
• Institutional insider, shaping mission and
  culture
• Chaplain as Prophet
• Institutional critic

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Chaplain as Shepherd

• We skillfully facilitate an openness for persons
  to explore their spirituality, and particularly
  in regards to the crisis that they are facing in
  the moment, paying attention with listening
  skills and intervention techniques.
• We're not here to preachWe're here to travel
  with you, in your health care situation.

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Chaplain as Administrator

• My ministry is not just to the patients. My
  ministry is to the family members, to the staff,
  to administration, to people from the community
  coming into the hospital.
• You know, the Saintliness Healthcare System
  has a mission statement. I think finding our
  role in the mission statement is also very
  helpful. A positive way of asserting the role of
  chaplains, I think, is building on a mission
  statement.
• The ideal for what a hospital should be as a
  healing environment.

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Chaplain as Prophet

• Patients were treated as the appendectomy or the
  heart patient, and they were just sort of a
  machine that needed to be fixed. My goal is to
  teach the staff that spirituality is treating
  the whole person, the mind, body and spirit.
• I was thinking about wasting time with someone.
  Patients tell us thanks for spending the time,
  you spend a lot of time with me and it's almost
  an I'm not worthy for this.

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Chaplains Diverse Roles and QI

• It may be helpful to keep these three different
  roles in mind as we think about what the
  chaplains told us about the problems of measuring
  quality in spiritual care.
• As we heard, finding ways to measure quality in
  the chaplains shepherding role with patients and
  families is a challenge.
• However, because many models for QI focus on what
  happens in the clinician-patient encounter, it
  may be an even greater challenge to find ways to
  measure quality for the chaplains administrative
  and prophet functions.

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Recommendations

• Telling Our Story, Again
• Setting the Standards
• Sharing Bright Ideas

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Telling Our Story, Again

• I carry a pocket card. They're in a goldenrod
  color. You just can't miss them. It's just a
  protocol of when to call the chaplain, and who's
  available.So it's just a little thing and every
  timewhen I'm with somebody who's new I give
  them a card, saying, This is when you call the
  chaplain."
• A colleague and I did a presentation to a
  palliative care conference. And what we did was
  role play a verbatim. We brought down the
  house, because, it was like they
  neverexperienced a chaplain's visit before. I
  think we're going to try and do that for the new
  employee orientation, or the nurses, or whatever.
  Just so that they understand what it is we do.

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Setting the Standards

• I think it would be helpfulto have a
  conversation with organizations like APC to
  come up with some suggested matrix in terms of
  like, ratiosAgain, I keep going back to the
  standardized piece because again Im trying to go
  along with the culture of the hospital, and all
  these other disciplines have these standardized
  practices.
• We need researchers to help us develop targets
  so that we can break it down into bite-size
  pieces and get some kind of numbers and
  expectations that are reasonable and experiential
  and, and outcome-based and evidence-based and all
  of those buzz words that get thrown around in
  science today.

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Sharing Bright Ideas

• If the chaplain is staying with a patient
  because of either a trauma or around a very
  complicated death issue, its not just a visit,
  its a visit times this weighting factor so
  that it doesnt look as though you, well youve
  only seen three people. Youre an inadequate
  chaplain if youve only seen three people, but
  the, but the formulary says they were three
  complicated deaths.
• In October our institution stopped using Press
  Ganey.We are moving into another company,
  which has no provision for satisfaction with
  spiritual care services whatsoever. So in the
  absence of any standardizedthing, with the help
  of a local researcher, we've developed our own
  patient satisfaction and staff satisfaction
  surveys as a check on our performance and to
  demonstrate what we do.

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Conclusions Living with a Paradox

• Extrinsic Values
• The instrumental value of quantitative
  qualitative measures of quality to show the value
  of spiritual care
• Translational value in dialogue with
  administrators and other healthcare professionals

• Intrinsic Core Values
• The intrinsic value of quality patient, family,
  and staff care
• The transcendent value of spiritual care as a
  profession and vocation

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Summary

• While some chaplains voice skepticism about QI,
  there are leaders who are making creative efforts
  to develop and employ meaningful measures of
  quality in spiritual care.

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Summary
To survive we have to come up with something
measurable, because to certain people, thats the
only language they can speak. Our job is to come
as close to finding something thats measurable
that actually makes a difference in what we do.
To me, its up hill all the way.