Performance Improvement: Theological Reflections, Part 1
As a chaplain, I work in an environment of multiple (and occasionally conflicting) philosophies and value systems. As a chaplain in a church-related hospital, I take particularly seriously the call to reflect in the institution the values of the faith community in which the hospital is rooted, and for the institution to reflect those values in the community.
In that light, I am blessed. The administration, “a Pharaoh who knows Joseph” as it were, shares this concern. At the same time, my institution is like those around it, committed to good, competent business practices so as to continue to provide care. As a result, the language and philosophy of management is as much a part of the environment – sometimes more visibly a part of the environment- as the Christian tradition. In that context, I believe it is important to bring the process of theological reflection to this contemporary language and culture. This paper is written in that spirit.
A recurring and powerful concept in health care today is that of performance improvement (PI). Because of the importance of this concept in the organizational practices of my hospital and many others, I believe it calls for consideration and reflection in our capacity as the practicing theologians in our institutions.
This series is not written as a thorough and complete reflection on performance improvement. Indeed, I believe that undertaking is one of many of us in our profession, and not mine alone. At the same time, I would argue that this is an important task for us as chaplains at this time. In addition, I have shared elements from my own theological reflection process, out of my own Episcopal tradition, that I hope will provide places to start that process of reflection and discussion.
Our task: the need to reflect theologically on PI
It is important that we reflect theologically on performance improvement, as it is important to reflect on any part of our ministry. We are called to be theologians. Indeed, any person, or at least any person of faith, can be a theologian. This is because any person can have an opinion about God, and at base “opinion about God” is what “theology” means. At the same time, we people of faith, and especially we who feel called to ministry, are called to be good theologians. That is, we are called to be intentional and thoughtful about our theology and to be thinking theologically about all of our experience.
This is an ongoing process in the life of the community of faith as Owen C Thomas states:
The church has to reflect on its faith and message in every age, so that it can interpret and present it in a way that can be understood in each new period. If the church tries too hard to make its message relevant, it may lose its message and become simply a sanctification of the culture around it. But is may also be so concerned to maintain the purity of its message that it becomes unintelligible to the contemporary age. So the task of theology or the theological task of the church is to interpret its faith and message so that it can be understood and affirmed in each new age. 
Thus, early Christian writers used the framework of Neoplatonic philosophy to make a faith with Hebrew roots accessible to the people of the Roman Empire; this Neoplatonic framework was superseded by the Aristotelian in the High Middle Ages. As we particularize our ministry in our own time and place, we are called to reflect theologically on the language and culture within which we live. I would assert that this includes the larger culture of civil society and also the corporate culture of health care within which we function.
As chaplains, we also can feel the hazards to which Thomas refers. One common arena for that struggle is in our attitude as chaplains to administrative responsibilities. We might “maintain purity” by avoiding administration to focus on patient care. If so, we risk losing accountability and undermining our own authority in the context of our institutions. Conversely, we might become so accepting of the corporate culture in our institutions that we fail to uphold the primacy of care of persons as the purpose of health care, in principle if not in practice.
Therefore, we are called both to function fully in our institutions, and also to reflect on and sometimes confront them – to be in the world, but not of it. As an important piece of that environment, performance improvement is a process appropriate for our concern and our practice. It is the standard used by both the Center for Medicare/Medicaid Services (CMS) and by the Joint Commission for the Accreditation for Healthcare Organizations (JCAHO) for evaluating the quality of care in institutions. It is a common aspect of corporate culture in our society and a growing aspect of corporate culture in health care. Certainly, it is important enough to be worth our attention as theologians.
Performance improvement also can be a valuable tool, a technique for reflecting on professional practice. Thus, it also is worthy of our attention as ministers. In our understanding of ministry in general, and of clinical pastoral ministry in particular, reflection on practice that leads to improvement in practice is fundamental. Therefore, both as a present dynamic in practice and as a valuable tool for practice, performance improvement is well worth the effort of theological reflection.
Performance Improvement: an overview
To reflect theologically on performance improvement, it is helpful to review what it is. Performance improvement is essentially a result, the consequence of management processes that result in operation or service that is better according to the standards of the organization. It is the goal both of quality management, e.g., Total Quality Management (TQM), Continuous Quality Improvement (CQI), in which improvement is the result of incremental change, and of reengineering, in which improvement is the result of radical rethinking and restructuring of processes.
At the same time, the phrase “performance improvement”, has come to represent the institutional process of which such improvement is the goal. For example, the Performance Improvement Standards of the JCAHO do not specify what procedures should be used to pursue improvement, nor do they specify which process should be improved. Rather, they speak to a sense of purpose in the organization to pursue that goal: that there will be some program for improving some of the organization’s processes in progress at all times. Thus, for the JCAHO, an organization’s commitment to continuous, ongoing improvement in significant processes is an essential measure both of the organization’s commitment toquality, and of the organizations quality in the moment.
As a result, performance improvement is a philosophy. It is the philosophy undergirding two contemporary management strategies, quality management (most often TQM or CQI) and reengineering. These strategies appear to be different, but at heart they are not.
Reengineering and TQM are merely different pews in the church of process improvement. The two share an orientation toward process, a dedication to improvement, and a dogma that one begins with the customer. 
If we recognize performance improvement as a set of values, Michael Hammer’s use of church imagery here is particularly appropriate.
Whether the process is incremental, as with quality management, or radical, as with reengineering, there are certain characteristics of all programs for performance improvement. While these may be described somewhat differently in different institutions, we can describe those characteristics succinctly.
The first characteristic is a review of an existing process or processes based on facts and not on the opinions of those involved in the process. To this end, the first step in performance improvement is measurement and examination of the process, frequently using statistical and scientific tools. The principle is to base the assessment, and any potential changes, on data rather than on the impressions of those involved in the process.
Based on the data gathered, the next step is to choose and implement a change, a new procedure or task. In some programs this is divided into two stages: design and implementation. The data gathered are evaluated, and an area for change is targeted. A new approach to an aspect of the problem is selected and then begun. Various analytical tools may be brought to bear in evaluating information and determining where to begin.
Once selected and begun, the process is followed and measured, again to gather evaluative data. The information is not only to determine narrow standards of “better or worse” but to establish parameters for performance. That is, there is an acceptance that different individuals and different circumstances will affect any process. Therefore, norms are developed, expectations of standards operations. Any events or measurements that fall outside those norms are analyzed individually to understand the circumstances that make them exceptional. On that basis, norms may be changed, or new problems may be identified.
Finally, based on the experiment with the new approach, a decision is made to keep or discard the new process. Again, it is important to base this on data gathered during the implementation process. If the system is improved, it is now possible to identify how and why. If it is not, there is opportunity to review the system again and decide a new area for experimentation. In either case, the intent is for this cycle to begin again with new assessment of the data and renewed effort at improvement.
In practice, this is not often the process of an individual or even of an individual department. It is common to create a committee for the purpose, involving individuals from different disciplines. In addition to bringing different perspectives to the issue at hand, this involvement of a community, as it were, aids in the breadth and accuracy of the data collected and to the understanding of the system which may be improved.
It is this process, this continuing effort at improvement, that is of interest to organizations that survey health care institutions. For those institutions who are surveyed for Medicare reimbursement, whether by the JCAHO, HCFA or some other entity, it is this process that surveyors intend to document with tracking data from the institution. As a result, this philosophy, used originally in industrial management, has become a major concern in health care.
 Owen C. Thomas, Introduction to Theology (Cambridge, MA: Greeno, Hadden, and Company, Ltd., 1973).
 Michael Hammer, Beyond Reengineering (New York: HarperCollins, 1996), 81-2.
(Once again, look for future posts in this series under the "PI/QI" label in the left hand column.)