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

1. Professional Chaplains and Health Care Quality Improvement:Tales of a Research Project Nancy Berlinger, Ph.D., M.Div The Hastings Center Themes in Pastoral Theology February 5, 2009

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

3. 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.

4. 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

5. Four Focus Groups

6. 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?

7. 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

8. Table 1. Focus Group Participants

9. Table 2. Participants’ Professional Background

10. Table 3. Participants’ Workplace

11. 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

12. 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

13. 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

14. “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, it’s 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 numbers…But we also have to really answer to God and to our calling as chaplains.”

15. What Gets Counted? • Concrete markers of quality in spiritual care: • Initial visits • Chart notes • Referrals • Board certification • Staff retention

16. 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 who’s referring, who’s not.” • “Two markers I would add would be staff retention and certification.”

17. 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 who’s doing that perception?”

18. 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 don’t always recognize what spiritual care is Patients and families may be poor judges of quality Surveys don’t measure all dimensions of spiritual care Tension: Patient Satisfaction Surveys are “useless” yet “rough indicators” of quality

19. Patient Satisfaction • “And even though we identify ourselves, every time we walk into the room. . . they don’t recognize the fact that this is the chaplain. It’s just this nice lady that came in and talked to me for a little while. They don’t 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.”

20. 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.”

21. 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 The Tension: Requirement vs Opportunity

22. 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).

23. Department/Institutional Projects • “…We used to use a…CPE 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.”

24. 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.

25. “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.…So…every time…when I'm with [a nurse] who's new [I give them a card, saying], ‘This is when you call the chaplain’.”

26. 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

27. 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 preach…We're here to travel with you, in your health care situation.”

28. 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.”

29. 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’.”

30. 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.

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

32. 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 time…when 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 never…experienced 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.”

33. Setting the Standards “I think it would be helpful…to have a conversation [with] organizations like APC [to] come up with some suggested matrix in terms of like, ratios…Again, I keep going back to the standardized piece because again I’m 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.”

34. Sharing Bright Ideas “…If [the chaplain] is staying with a patient because of either a trauma or around a very complicated death issue, it’s not just a visit, it’s a visit times this [weighting factor] so that it doesn’t look as though you, well you’ve only seen three people. You’re an inadequate chaplain if you’ve 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 standardized…thing, 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.”

35. Intrinsic Core Values: The intrinsic value of quality patient, family, and staff care The transcendent value of spiritual care as a profession and vocation 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 Conclusions: Living with a Paradox

36. 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.

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