Wednesday, December 31, 2008

Where She Leads

This is one for my Episcopal readers, and especially for Episcopal chaplains. The rest of you are certainly welcome as well.

If you've spent much time here, you know that to your left I have a link to The Bishop's Notebook, the blog of Bishop George Packard, Suffragan Bishop for Chaplaincies for the Episcopal Church. While he is directly responsible for Military and Federal Chaplains, he is also the contact person and advocate for healthcare and other chaplaincies at the Offices of the Episcopal Church and the House of Bishops.

You may have seen the story from the Episcopal News Service of the visits of Presiding Bishop Katherine Jefferts Schori with Bishop Packard and members of his staff to service members and veterans at Bolling Air Force Base, Walter Reed Medical Center, and the Pentagon. However, Bishop Packard tells on his blog a story that ENS didn't report, a story demonstrating at the bedside the pastoral focus and skill of the Presiding Bishop.

I won't quote Bishop Packard here. Rather, go and read the post. When you do, I think you'll know why I found it so exciting.

This has certainly been a tumultuous year for the Episcopal Church, and next year looks to be even more - is exciting the right word? Maybe. At any rate, when you read this anecdote about the Presiding Bishop, you'll see why many of us are so enthusiastic about her direction and her leadership.

Have a safe New Year's Eve, and a happy Feast of the Holy Name.

Thursday, December 25, 2008

Brief Reflection for Christmas

We have often enough said in moments of contentment, "God's in his heaven, and all's right with the world."  But, our empirical evidence is that all is not right with the world.  We are the Christmas people, the people who proclaim that God knows that all is not right, and is not satisfied just to stand afar off, there in heaven.  Instead, God became involved - intimately, inextricably, incomprehensibly involved; and by becoming part of God's own creation, God began the changes that will result in God's Kingdom, experienced in fullness.

Christmas is the day we proclaim that God is not just in heaven; and so we have the promise that all can and will be right with the world.

Tuesday, December 23, 2008

Once Again, Christmas with Amahl

This morning I am once again practicing my last Advent (or first Christmas) ritual: I am listening to “Amahl and the Night Visitors.” As “Jesus Christ Superstar” has long been my Holy Week ritual, I can’t be quite ready for Christmas until I’ve heard Amahl.

If you haven’t heard it before, I commend it to you. Gian Carlo Menotti composed it for the first broadcast of the Hallmark Hall of Fame on NBC. It was first broadcast on Christmas Eve, 1951, and every Christmas Eve after until 1966. It is a memory from my childhood, before we had joined the Episcopal Church and I had discovered Midnight Mass. Wikipedia has a good synopsis, with the history of the production, here. I have written some earlier reflections on the opera here.

As I listened this morning, I was particularly struck at how timely the setting is for this opera. Amahl’s mother is in her own survival mode. She can see no value beyond the economic, whether in her son’s poetry or in her guests’ possessions. It isn’t because she’s unfeeling. She loves her son powerfully, and wants, with what little she has – another “widow’s mite” – she wants to show hospitality. She is enough of a known person in her community that those around her will turn out in the middle of the night to extend their hospitality with hers.

At the same time, she is defeated, or so nearly so as not to matter. She is ashamed to consider begging, however exciting it might seem to her son; but she sees no other option for his survival, much less her own.

And so she is driven to theft. She considers differences in class: “I wonder if rich people know what to do with their gold,” thinking not of great luxury, but of the simple pleasures now beyond her reach, beyond her hope. She considers a greater good to be done: “Oh, what I could do for my child with that gold!” She considers even whatever incipient relationship, even obligation, she might have with her guests: “Why should it all go to a child they don’t even know?” Finally, she gives in, not for herself but for her child; not for it all, but for just what she might need: “If I take some they’ll never miss it.”

Perhaps; but she is caught in the act. And when caught, her humiliation, and that of her son, are complete. She is seized, and her only defender is her crippled son, too weak to do more than appeal plaintively to the kings themselves.

It is then that she discovers mercy: for the kings know she and her son are more important than the gold itself:

Oh, woman, you can keep the gold.
The Child we seek doesn’t need our gold.
On love, on love alone
He will build His kingdom.
His pierced hand will hold no scepter.
His haloed head will wear no crown.
His might will not be built on your toil.
Swifter than lightning
He will soon walk among us.
He will bring us new life
and receive our death,
and the keys to His city
belong to the poor.

And in that moment, there is a miracle – indeed, there are two. We will all celebrate with the second, when Amahl can walk, blessed with healing in the moment of his own greatest generosity. But, neither do we want to miss the first: for it is indeed miraculous when his mother’s eyes are opened, her imagination expanded, and her hope renewed. Indeed, her miracle is not so different from his; for as his body his healed, so is her spirit. She can see possibilities again, possibilities that take her beyond herself, even beyond her son: “For such a king I’ve waited all my life. And if I weren’t so poor, I would send a gift of my own to such a child.”

We are surrounded these days with the same desperation Amahl’s mother felt. We see it of course in any Christmas, and will until we see the Kingdom in fullness: those who, beat down by their circumstances, unable to imagine alternatives, will steal. Some will be simply and solely greedy; but many, like Amahl’s mother, will be unable to bear the shame of what they cannot do for another, for children or spouse or those otherwise family. But this year I fear there will be so many more. The economic devastation around us, wrought in no small part by our own inability to see value beyond the economic, our own poverty of spirit, leaves many, and more than usual, literally with “nothing to eat, not a stick of wood for the fire, not a drop of oil in the jug.”

Give thanks for those who can say, to whatever extent and in whatever way, “Oh, woman, you can keep the gold [because] the Child we seek doesn’t need our gold.” Give thanks and praise when you can and I can say that, for when we do we open up possibilities for miracles. Cry aloud, “On love, on love alone will he build his kingdom… and the keys to his city belong to the poor.”

And pray, pray now and always, for those miracles, whether as visible as a dancing child, or as profound as a healed and opened heart. Pray that as our hearts are opened, so might theirs be; so that all of our eyes might be opened to the miracles wrought in the name of the Child.

Blessings for Christmas, and for all in this season of Light, from the Episcopal Chaplain.

Friday, December 19, 2008

The Voice of Another Chaplain

Today I received an email message through my blog, saying in part:

Dear Marshall,
I thought that you and your readers would be very interested in the StoryCorps story of the day broadcast on NPR this morning. It is the story of hospital chaplain Janet Lutz from Atlanta telling her friend about the practice of blessing the hands of hospital workers. She also speaks about the quiet acts of kindness and prayer that happen every day in hospitals. It is a beautiful and heartwarming story.

The email was from Marisa Karplus, Senior Coordinator for Marketing & Communications at StoryCorps. I appreciate her calling this to my attention. Some of my readers know I listen regularly to NPR. I've enjoyed many of the conversations recorded and shared through StoryCorps.

Janet Lutz is a retired hospital chaplain, Board Certified by the Association of Professional Chaplains (APC). She speaks of the Blessing of Hands, which many of us find a powerful experience of ministering to, and being ministered to by, staff. You can hear her story at StoryCorps here, at with some additional information at NPR here. It’s well worth the few minutes it will take you.

I certainly value my own ministry to staff, and their ministries to patients. While not all of them will use this language, many will consider their various tasks as ministry. I do my best to honor this every orientation, acknowledging that I know I’m not the only person providing spiritual care in my hospital. I’m aware that many of our folks pray for patients, and a few even pray with patients – so far, in circumstances and with respect for the patient that I can fully support.

I’m also convinced that good pastoral care of the staff contributes good pastoral care of patients. First, it provides models of good spiritual support that staff may follow. Second, experiencing good care themselves they are in a better place to offer spiritual support. Finally, experiencing good care they are more likely to refer patients to receive care.

So, take a few minutes with Chaplain Lutz. Her story is moving. And, listen to her counsel to us, her colleagues. Taking the time to listen honors those we serve, and provides the basis for all other care we might give.

Wednesday, December 17, 2008

News on Episcopal Chaplains

Once again, there is news for those interested in chaplains and chaplaincy in the Episcopal Church. The newest edition of “Chaplair,” the newsletter of AEHC, is now available on line. You can reach it directly here, or link from the front page of the AEHC web site here.

There are a number of interesting articles including:
  • Information about AEHC events coming up in Orlando, and a Registration form
  • “A Day in the Life of” the Rev. Shiela Stanford, a colleague whose ministry has unique communication issues.
  • News about AEHC officers meeting with the Presiding Bishop
  • The experiences of AEHC President Gary Jones in ministering literally through the storm

Take a look and share what some Episcopal chaplains are doing. If you'd like more information on AEHC, you can email me from the AEHC site. And if you're going to be in Orlando and want to meet with others in the Episcopal Church, print off the Registration form and come join us.

Tuesday, December 16, 2008

PI/QI: Theological Reflections (6)

(This post is the last in a series on theological reflection on Performance Improvement/Quality Improvement. Original material for this series was first published in “Performance Improvement: Theological Reflections”, Chaplaincy Today, Vol. 16, Number 1 (Summer, 2000), and has been reedited for this setting. The information in this post is new for this series. For other posts in this series or in the series on measurement for chaplains, please select the label "PI/QI" in the left hand column.)

Performance Improvement: Theological Reflections, Part 6

Not long ago I attended my first CREDO Conference. CREDO is an initiative for wellness sponsored by the Church Pension Fund of the Episcopal Church. While it was initially oriented specifically to priests at various stages of life and ministry, there have now been CREDO Conferences for bishops, and will soon be conferences sponsored by the Presbyterian Church USA.

During the conference leaders introduced a four-step process for making plans and decisions. CREDO addresses a priest's ministry from a variety of perspectives - Health, Finances, Spirituality, Vocation, and - - and this tool was suggested as useful in each category, as well as in general.

As referenced in the CREDO 2007 Annual Report, the four steps are:

Identity: who am I?
Discernment: what are my priorities?
Practice: what is my plan?
Transformation: how am I changing?

The process as taught by CREDO is in language familiar to clergy. Indeed, they would be particularly comfortable for those of us with clinical training. We are, after all, trained to discern who we are, both in our identities and within our faith traditions, and to incorporate that discernment into our practice so as to see opportunities for transformation, both for ourselves and for those we serve.

When I heard this four-step process, it rang a bell. It was remarkably like the four step process for quality improvement, commonly known as the "Deming Model," after Dr. Deming. As described by the American Society for Quality, those four steps are:

Plan-Do-Check-Act Procedure
Plan. Recognize an opportunity and plan a change.
Do. Test the change. Carry out a small-scale study.
Check. Review the test, analyze the results and identify what you’ve learned.
Act. Take action based on what you learned in the study step: If the change did not work, go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, beginning the cycle again.

Now, these two four step schemes were not developed together, and are not perfectly analogous. However, it seems to me that they line up rather well:

Plan is very similar to Discernment. What are the opportunities available, and which seem to me to express priorities I agree with? Another way to consider it would be to recognize that it is my priorities that will determine what opportunities I see and which I might choose among those opportunities.

Do is similar to Practice. We are exploring opportunities and testing out new behaviors that express our priorities.

Check is similar to Transformation. We observe how things are changed – for the minister, how we are changed - as a result of or in the context of the opportunities and new behaviors we have practiced.

Finally, Act is similar to Identity. That is, the step Act in the Deming Cycle is one of appropriation and integration. It is the recognition and embracing of identity, which we may find either reaffirmed or re-understood in light of the changes we have implemented. And, in light of that recognition, we will likely also understand anew our priorities and see new opportunities.

Finally, while they are not exactly analogous and do line up perfectly, each is a cycle. Moreover, each is presented as a discipline for life, and not simply for a single decision or problem. So, while we may enter the cycle at different points, if we work our ways through steps in order we will see either program through, and will be able to continue going forward.

Here, then, is a process for growth in ministry that is remarkably congruent with the Deming Cycle for quality improvement. The terms are familiar and useful to us in ministry. In our efforts to appreciate the concept of Performance/Quality Improvement for our work as chaplains the contemporary model offered by the CREDO Program would seem remarkably timely and apt.


Certainly, the reflections in this series are incomplete, places only to begin. However, I have found them helpful in my own reflection and offer them in the hope that they will be helpful to others. These reflections are models, with the limitations implied in that concept. They hold similarities and differences, congruities and incongruities. However, they can provide handles with which to come to grips with the concepts.

Performance improvement is and will continue to be an important concept in health care. With important accrediting organizations using it as a standard for measurement, our institutions cannot ignore it. If they cannot, neither can we, if we are to carry out our ministries fully. As a profession, and as professionals, we must begin the discussion on this important concept. In this way we will serve well our institutions and associates and ultimately our patients.

Brief Thoughts of the Season

I have been addressing Christmas cards. Wishing everyone a Happy Christmas and a Blessed New Year has focused one of my continuing questions. I think that if we are to wish everyone a Merry Christmas and a Happy Easter, shouldn't we also have greetings appropriate to the other seasons of the Church Year? I think we should hope for everyone an Anxious Advent (or perhaps Anticipatory, but that’s a bit much); an Enlightened Epiphany; a Lousy Lent; a Horrible Holy Week; an Aspiring Ascenciontide (which could also, I suppose, be Anticipatory; but it’s still a bit much); and a Patient Pentecostide (or Persistent or Perduring or – too many P-words, I fear).

So, the time will come soon when I do wish readers a Merry Christmas. For now, I hope you’re having an Anxious, Anticipatory Advent. (Gee, it works better than I thought!)

Thursday, December 11, 2008

Performance/Quality Improvement for Chaplains: Measurement (3)

This is the third in a series of posts on Performance/Quality Improvement and measurement for Chaplains. If this is of interest, check the "Labels" section in the left column, and choose "PI/QI."

A third aspect of a chaplain's work that might be measured is interventions. That is, we might identify specific acts of a chaplain and simply count them.

This is a measure that might be useful to chaplains. It could provide a functional description of a chaplain's activities. As with time, measuring interventions can allow for some sophistication of detail: number of visits can be refined by number of prayers offered, instances of reading Scripture, etc. Recording could be reasonably straightforward, and numbers could be compared over time.

Counting interventions has some benefit in being easily described to administrators, other professionals, and to family members and to community clergy. Recording specific interventions is common in other professions, and is important for meeting standards for quality and patient safety, as well as for billing. It is also common in some sense for clergy outside the institution (so, in my own Episcopal Church we record number of services, and further refine to distinguish number of eucharists, baptisms, funerals, etc.).

Measuring interventions is straightforward, too, in that interventions are generally easy to identify. In general, they are discrete, concrete, and easily describable. Thus, they are easy to list and to count.

That said, I use the phrase “in general” advisedly. While such interventions as prayer and rites are easy to describe and to count, that is not so of all the interventions we might consider important to our work. The most immediate example would be what many of us term, “pastoral presence.” It is axiomatic in our profession, “Don’t just do something; stand there.” Indeed, one of my own most memorable interactions with a patient family, memorable especially for all I learned from it, was on in which my fear inhibited me from doing anything more than literally “standing there.” Yet, the learning came when the widow asked to speak to me weeks later, to tell me how important my presence – literally my presence, because I hadn’t managed any other intervention – had been to her and her family.

As professional chaplains we are, in my experience, all convinced of the importance of pastoral presence. However, how exactly do we quantify it? Is it simply hanging around in the general vicinity? Must there be a more concrete introduction, so that the who and the why of our “hanging around” are clear? Is it measured in units of time, as if five minutes of presence were less meaningful than 15 minutes of presence? Is it measured in units of contacts, so that the more people we hang around, the better; or the more previous visits we’ve made, the more meaningful? I have had, and I think many of us have had, encounters with families of dead or dying patients where any of these might have been meaningful – or not.

Another issue is that it can be hard to quantify, or even to identify, the import of a given intervention, the “value added” if you will for the patient and family. We as professionals and those we serve are convicted that our interventions benefit the patient; but that benefit is much more subjective than a difference in lab value or the timeliness of medication. Efforts have been made to demonstrate outcomes of various sorts, to the point of seeking to measure the efficacy of prayer. (Note that those studies particularly have been the subject of significant controversy about research method. I think the best I’ve seen took place in my health system and I had some small part in it; but I still acknowledge the concerns.) Measuring outcomes will be the subject in its own right of another post. However, measuring outcomes or our interventions is not straightforward.

Related to that is a question of whether the interventions we value most as professionals are those most valued by patients. Some patients will feel concrete value in explicitly religious interventions, while others will want more of a counseling, not to say therapeutic, intervention. Clinically trained chaplains can have a certain appreciation for (one might even say a bias toward) the counseling interventions. They are applicable to chaplains and to patients with widely differing faith backgrounds and with none, while rites and rituals are specific, both in the sense of who might wish to receive them and who can offer them. Sometimes, too, we have seen instances where community clergy have offered appropriate rites and rituals, without actually engaging the person sufficiently to provide support. Coming from a sacramental tradition, I certainly believe that rites can have meaning all their own; but they can be provided as impersonally as any pill or injection, leaving the patient and family feeling just as objectified. At the same time, there are those patients who understand their needs to be met by those rituals, even divorced from personal interaction. The sheer variability of this, a function both of the uniqueness of patient and family and of the chaplain, makes this hard to quantify, or at least hard to use once quantified.

That is not to say that there haven’t been important efforts to measure interventions, including measuring their importance for patients. However, much more needs to be done to establish professional norms.

So, we can measure interventions, and can do so relatively simply, just as we can contacts and time. However, we have more work to do in defining our interventions, and their value to patients, families, and institutions. Perhaps, then, we will see more value in our measurement if we look not simply at what we do and can measure, and consider how we might discern values in how they interact.

Wednesday, December 10, 2008

Brief Note: Politics

Not long ago my best beloved answered the phone to a machine call with a political survey. She always says she's "Moderate" and "Undecided," because otherwise they just sign off, and she wants to see who's calling and what they'll say.

From the tenor of the questions, she decided this survey was for a conservative client. She was particularly struck by two questions: "Do you think the Supreme Court should make decisions based on the law and the Consititution, or on fairness and justice;" and "Do you think recent decisions of the Supreme Court have been based on the law and the Constitution, or on fairness and justice?"

Since she was responding to a machine and not a person, she didn't just laugh at the absurdity of this false dichotomy. Still, we both thought is at best sad and at worst troubling that someone would think the dichotomy wasn't false.

Brief Note: Chaplaincy

We have all experienced those meetings where we go around the room, announcing our name and title or department. Every employee sees me in orientation, talking about my work and ouwr program for spiritual care. And often, since my collar tells most folks my title, in meetings I will introduce myself as responsible for “celestial engineering,” or “metaphysical medicine and rehabilitation” – or, since I'm in an Episcopal hospital and I’m an Episcopal priest, as “the owner’s rep.” (Interesting thing about that title is that they smile, but they also pay attention.)

Monday, December 08, 2008

PI/QI: Theological Reflections (5)

(This post is the third in a series on theological reflection on Performance Improvement/Quality Improvement. This material was first published in “Performance Improvement: Theological Reflections”, Chaplaincy Today, Vol. 16, Number 1 (Summer, 2000), and has been reedited for this setting. For future posts in this series or in the series on measurement for chaplains, please select the label "PI/QI" in the left hand column.)

Performance Improvement: Theological Reflections, Part 5

PI and the ministry of administration

Earlier in this paper I wrote of two pragmatic reasons that it was appropriate for us to reflect theologically on performance improvement: that it was an important and growing aspect of the health care environment, and that it was a tool potentially useful to us as professionals. However, there is a third and more basic reason. This is that our theological reflection is as much a part of our ministry of administration as it is of our ministry of direct care. In the process of being wise as serpents and innocent as doves, we come to recognize that without a good administrative foundation, our other ministries will be at best incomplete and at worst ineffective- or expendable.

Lawrence Holst spoke to this quite eloquently. He noted the concerns I spoke to earlier, as well as the general resistance many chaplains feel to administrative responsibility. However he also noted

If the hospital chaplain’s primary administrative responsibility is not to the patient but to a network of hospital administrators; and if his primary constituency does not usually experience or ‘consume’ clinical pastoral services, then this means that pastoral administration may provide that constituency with its only exposure to pastoral care [Holst’s emphasis].[1]

In essence, the chaplain’s most common ministry to and with administrators is in the practice of administration. Therefore, “…it is a legitimate expectation that chaplains will bring to their administrative tasks the values and convictions inherent in their faith.”[2]

In that perspective, it is important that we reflect on the language and philosophy of performance improvement in our role as theologians and even as maintainers of conscience and tradition in our institutions. Arguably, this is a part of our prophetic ministry. It speaks to the organizational ethics of our institutions and to the values lived out within them. Our ministry to our administrators calls for such reflection and, as I have argued, to particular issues such as performance improvement.

Performance improvement always involves change. While this is more immediately visible in the rapid, radical changes of reengineering, it is no less true in quality management. Performance improvement is a philosophy, reflecting a set of values. While these may not be in conflict with our faith traditions, they are stated in a different language. They will not translate automatically and should not be translated without reflection, either by us as chaplains or by our administrations. As practicing theologians, this reflection is a valuable ministry we can offer to our institutions.

[1] Lawrence E. Holst, “The Chaplain as Administrator”, in Lawrence E. Holst, ed., Hospital Ministry (New York: Crossroad, 1985), 178.
[2] Ibid., 180.

Next: a PI/QI language for clergy

Friday, December 05, 2008

PI/QI: Theological Reflections (4)

(This post is the fourth in a series on theological reflection on Performance Improvement/Quality Improvement. This material was first published in “Performance Improvement: Theological Reflections”, Chaplaincy Today, Vol. 16, Number 1 (Summer, 2000), and has been reedited for this setting. For future posts in this series or in the series on measurement for chaplains, please select the label "PI/QI" in the left hand column.)

Performance Improvement: Theological Reflections, Part 4

Clinical Pastoral Education and the PI process

In clinical ministry, we share a common experience of clinical education Most of us share some experience in Clinical Pastoral Education (CPE). Others may have experience in another model of clinical education, and some may have experienced more than one model. Clinical education is formative for us as ministers. Therefore, we have some expectation of, and hopefully some experience with, clinical education as theological education.

The point is pertinent to this discussion in that clinical education can be envisioned as a performance improvement process. It involves a process of learning as a professional in which performance is evaluated, and new and creative experiments are tried and assessed for incorporation into the skills of the minister.

This is straight forward in CPE. Events of ministry are reviewed and reflected on both by the student individually and in the context of the group. An accurate review of the experience is encouraged both by the effort at verbatim reporting and in the analytical questioning and reflection of the peer group and supervisor. New strategies and behaviors can be explored and modeled in the group to be applied by the student in group relations and in ministry. These new behaviors are then themselves open for examination and reflection.

This process, more than some others suggested in this series, is a true process of performance improvement. It reflects not only a commitment to improvement in the student’s immediate experience, but seeks to inculcate a commitment to continued growth as a practicing professional. It is based on an evaluation of actual experience, which is subject to some form of evaluation or measurement. Finally, it benefits from participation of a group, with each member bringing a different perspective to the issues at hand. Indeed, the accrediting organizations for CPE encourage not only experience with a peer group, but multidisciplinary experience as well.

This discussion of clinical education as a process of performance improvement is not, perhaps, as theological in tone as other parts of this paper. However, it allows us to consider performance improvement as it has functioned in our individual experience of ministry. Even when the experience of clinical education has not been explicitly theological, it has clearly shaped us as theologians. These experiences were training for ministry, and they affected not only our skills for ministry, but also our understanding of ourselves as ministers. This is, of course true of all theological education. However, the process of clinical education for ministry arguably has more in common with the implementation of performance improvement philosophy than it has with academic education for ministry.

Next: the ministry of Administration

Next AEHC Events

A number of readers come to this blog to find information about the Assembly of Episcopal Healthcare Chaplains (AEHC), or more generally about health care chaplaincy in the Episcopal Church. Well, plans are now in process for the next meeting of AEHC. We will be meeting in the context of Summit ’09 of the Spiritual Care Collaborative. Official dates of the Summit itself are Sunday, February 1, through Wednesday, February 4. However, some participating organizations may have events beginning as early as Wednesday, January 8.

There will be a Faith Group Breakfast for Episcopalians on Monday, February 2. While we encourage AEHC members to participate, this is an event of Summit ’09. In the past this has been supported in part by the Office of the Suffragan Bishop for Chaplaincies, Bishop George Packard. It is well worth the time and opportunity to meet Episcopalians across the participating organizations.

As I said, specific plans for AEHC activities are still in process. However, when they’re ready they will be posted on the AEHC web site on the “Key Events” page. If know you’re going to be attending Summit ’09, come and join us in AEHC and other Episcopal activities.

Thursday, December 04, 2008

Performance/Quality Improvement for Chaplains: Measurement (2)

This is the second in a series of posts on Performance/Quality Improvement and measurement for Chaplains. If this is of interest, check the "Labels" section in the left column, and choose "PI/QI."

Let me return to measurement for chaplains. After number of contacts, the next obvious aspect of a chaplain's work that we might measure is time. How does a chaplain use his or her time, and how much time does any specific activity take?

Like number of contacts, measuring time is fairly straightforward. A chaplain can keep a log, noting events and activities over time, and the amount of time taken for each event.

And the results can be useful. Measuring time can give some idea of the breadth of a chaplain's work. Time can be broken down into broad categories - for example, patient care, administration, teaching, committee work, etc. - and the categories themselves can be further refined. So, for example, patient care might be divided between bedside care, consultation with staff, and charting. Committee time might be broken down by the nature of the committee, chairing vs. participation, or inside vs. outside the institution.

This allows for identifying, evaluating, and setting priorities. This can be helpful both to the chaplain and to administration. It also allows for analysis through time/motion studies. (As annoying as these might be, they can be useful.) Over time, averages might be developed for activities, and even individual interventions. Parameters and norms could be developed for use of the chaplain's time. This could be useful for noting and responding to changes. So, time can become a factor to be considered in performance improvement.

Importantly, time usage can be sensitive to the intensity and acuity spiritual care. While there are certainly exceptions, it is reasonable to assume that cases that require more time will be more acute, and that more acute cases will require more time. For example, responding to a code crisis, or providing care at the time of death may not involve large numbers of people but they may well take a significant amount of time. So, a day might show a small number of interventions, serving a small number of people; but awareness of the time may demonstrate the high acuity of the situation.

There are, however, limitations in measuring time. The most important is that, while we might assume some correlation between time and acuity, that doesn’t imply a necessary correlation between time and quality. A visit might be long because it involved an intimate and intense encounter, or because the patient was charming and engaging, and so easy to meet at a social level. Patients and families respond differently based on different backgrounds and different contexts. So, some will feel well cared for by a relatively brief but explicitly religious intervention, while others will feel best supported by a supportive but largely silent ministry of presence. So, while time might be a factor in quality spiritual care (too brief a visit can hardly show quality - reference the “waive and heave offering” of my last post on this subject), it is by itself no guarantee of quality care.

By the same token, time is a measure that can be easily manipulated. Some of this might, certainly, be intentional. The measure would be easy to expand. It might also simply be a matter of measurement technique. Several questions come to mind. How will the time be measured? Will the measure depend on close timing, or on the general perception of the chaplain? In what increment will the time be measured – by the minute, or in five minute increments, or more? What will be the parameters of measurement? Will we measure strictly the time from entry into to exit from the patient’s room; or should we measure the time “door to door,” beginning with the time a referral is received or at the end of the last visit? That would be especially important in cases of emergency coverage out of house. So, does response time include the time spent preparing and traveling to the institution? These are issues that must be negotiated, often in this sort of detail, before time can be a meaningful measure even to compare one chaplain’s work from one day to another, much less to compare the work of more than one chaplain.

Again, as with simple contacts, measurement of time spent in group activities will require some parameters. Time spent in continuing education is certainly meaningful; but do we make a distinction between leading the group and simply participating? Do we make a distinction as to whether the chaplain “owns” the meeting, being responsible for agenda and content, or the chaplain is a team member. Do we make a distinction between explicitly “spiritual” function, whether based on activity (say, giving an invocation) or on content (a palliative care or ethics committee)?

There is a further consideration about the parameters of administrators. Any decision for measurement, including measurement of time, implies distinctions of values. Without professional norms from chaplains, do we simply accept the values of the administrator with whom we live, even of “a pharaoh who does not know Joseph?” How, then, would we maintain consistent measures from one institution to the next, or even from one administrator to the next within the same institution?

Thus, time is an aspect of a chaplain’s work that is measurable, and that measurement can be meaningful. It can certainly offer some objective measure suggesting the intensity and acuity of a given encounter. However, for that measurement to be meaningful parameters must be set of what time will be measured, how that time will be measured, and what values those decisions imply. Indeed, once again time is perhaps “necessary but not sufficient” in considering a chaplain’s work, and how principles of PI/QI might be applied.

Wednesday, December 03, 2008

PI/QI: Theological Reflections (3)

(This post is the third in a series on theological reflection on Performance Improvement/Quality Improvement. This material was first published in “Performance Improvement: Theological Reflections”, Chaplaincy Today, Vol. 16, Number 1 (Summer, 2000), and has been reedited for this setting. For future posts in this series or in the series on measurement for chaplains, please select the label "PI/QI" in the left hand column.)

Performance Improvement: Theological Reflections, Part 3

Ascetical theology: PI in spiritual practice

In the Christian tradition, there has been significant discussion of the doctrine of sanctification. Reflecting on our biblical heritage, we appreciate that sanctification is a gift of grace and a work of the Holy Spirit. At the same time, within our understanding of sanctification there is an important consideration of growth in grace. Thus, in baptism in the Episcopal Church parents are asked “Will you by your prayers and witness help this child to grow into the full stature of Christ?”[1] Whether this growth is solely the work of the Spirit or involves some participation on the part of the believer, was itself an issue for discussion and disagreement from the Reformation forward. However, the position that we participate in sanctification, working with the Spirit working in us to conform ourselves to Christ, is well attested in the Christian faith.

From the question of entry into the Christian life, we proceed to that of growth and progress in it; or in the traditional language, from justification to sanctification. Again, however, we are not to think of a sharp separation, but rather only of distinguishable aspects of a unitary process. Also, we are still to think in terms of a work that is initiated and carried through by God working in human lives, and yet a work which needs man’s response, cooperation, and highest effort if it is to go forward.[2]

Our participation we commonly call our spirituality, “the process of learning by which the disciple becomes more proficient in the Christian life and advances along the way of sanctification”[3].

While this understanding is primarily associated with the Roman Catholic, Orthodox, and Anglican traditions, it is also seen in Protestantism,. Luther maintained that sanctification, like justification, was solely by God’s grace. At the same time, he also understood that it brought about changes in behavior, changes that both engendered and reflected growth in grace.

He also sanctifies the Christians in the body and induces in them willingly to obey parents and rulers, to conduct themselves peacefully and humbly, to be not wrathful, vindictive, or malicious, but patient, friendly, obliging, brotherly and loving not unchaste, not adulterous or lewd, but chaste and pure with wife, child, and servants, or without wife and child. That is the work of the Holy Spirit, who sanctifies and also awakens the body to such a new life until it is perfected in the life beyond.[4]

This sense of growth is particularly evident in the ascetical traditions. While the consequences of spiritual discipline are clearly the results of God’s grace, there is an effort in the spiritual life to conform oneself to God’s will, and for the Christian, to Christ. An important experience in this pursuit of God is traditionally described as “the way of purgation”, an effort to purify and reform oneself. As Evelyn Underhill describes it,

It is the drastic turning of the self from the unreal to the real life: a setting of her house in order, an orientation of the mind to Truth. Its business is the getting rid, first of self-love; and secondly of all those foolish interests in which the surface-consciousness is steeped.[5]

This is an active and not a passive process. It requires both detachment and mortification. These are technical terms. Detachment is the capacity to step away from previous conceptions and misperception for an accurate perspective on oneself and one’s experience. For the Christian mystic, it is to focus first and primarily on Christ, and to see oneself and one’s experience in that light. “Poverty [of spirit, detachment], then, prepares man’s spirit for that union with God to which it aspires. She strips off the clothing which he so often mistakes or himself, tranvaluates all his values, and shows him things as they are”.[6]

Mortification follows upon detachment as action follows upon assessment. Mortiifcation “is to be understood [as] the positive aspect of purification: the remaking in relation to reality of the permanent elements of character."[7]

That is to say, the mystic life has got to express itself in action: and for this new paths must be cut and new habits formed – all, in spite of the new self’s enthusiasm, ‘against the grain’ – resulting in a complete sublimation of the personality. The energy which wells up incessantly in every living being must abandon the old road of least resistance and discharge itself in a new and more difficult way.[8]

This change is difficult, and even frightening. “Nevertheless, in spite of its etymological associations, the object of mortification is not death but life: the production of health and strength….”[9] Thus, the purgative way, as a part of the spiritual life, is a process of seeing oneself realistically in light of the image of God, and, for the Christian, the model of Christ; and making the appropriate changes in one’s life that bring one more and more into congruity and conformation to the model.

This radical language is similar to the performance improvement method of reengineering. Unlike the more incremental approach of CQI, reengineering calls for a review of an institution that allows for all systems to be evaluated in light of the organization’s goals. As a result of that evaluation, existing systems may be eliminated entirely. Instead of being modified for improvement, systems are completely redesigned and replaced. However, the purpose remains the same; more effective efforts toward institutional norms and goals.

One arena in which this is lived out personally and sacramentally is the sacrament of Penance or Confession. The experience of the sacrament for the penitent reiterates this process of analysis leading to change. The penitent begins by stating the sins for which he or she seeks forgiveness, and accuracy of this presentation is important. The priest functions at this point in consultation, helping the penitent explore the events presented, seeking again a broader and more thorough perspective. While the priest is then empowered to pronounce God’s act of absolution, there is an expectation of spiritual counsel from the priest and amendment of life from the penitent. That is, the expectation that the penitent will behave differently is central to the understanding of the sacrament. The Roman Catholic tradition of regular and frequent confession increases in some ways the parallels between the sacrament and the process of CQI.

[1] The Book of Common Prayer According to the use of The Episcopal Church (New York: Oxford University Press), 302.
[2] John Macquarrie, Principles of Christian Theology (New York: Charles Scribners and Sons, 1977), 344.
[3] Ibid., 497-98
[4] Martin Luther, Luther’s Works: Church and Ministry III (Philadelphia: Fortress Press, 1966), 146.
[5] Evelyn Underhill, Mysticism (New York: E.P. Dutton and Col, 1961), 204.
[6] Ibid., 208.
[7] Ibid., 216.
[8] Ibid., 217.
[9] Ibid.

Next: PI/QI and CPE

Tuesday, December 02, 2008

Respectful at Episcopal Cafe

My newest post is up today at Episcopal Cafe. It's timely, as it addresses how we might address those who will be part of the new union among the Common Cause Partnership, and their efforts for a new "Anglican" province in North America.

In an interesting coincidence, I met at a patient's bedside yesterday a priest of a local congregation that left an Episcopal diocese to seek oversight from Uganda. This particular priest had been arguably aggressive in encouraging Episcopalians to leave their congregations. When last I had seen him he was a deacon in the Episcopal Church. The meeting was pleasant and sociable, without reference to Episcopal/Anglican issues. At the patient's request, we prayed together. Both of us prayed, without any sense of stepping on each other's toes (well, no more than is common when any congregational minister and I meet at the bedside of that minister's member, whatever the tradition). The patient was pleased. God was served. The encounter was good.

As a colleague said later, "Perhaps if we spent more time praying together, we wouldn't have these tensions...." I would respectfully agree.

Monday, December 01, 2008

PI/QI: Theological Reflections (2)

(This post is the second in a series on theological reflection on Performance Improvement/Quality Improvement. This material was first published in “Performance Improvement: Theological Reflections”, Chaplaincy Today, Vol. 16, Number 1 (Summer, 2000), and has been reedited for this setting. For future posts in this series or in the series on measurement for chaplains, please select the label "PI/QI" in the left hand column.)

Performance Improvement: Theological Reflections, Part 2
Scriptural Images and PI

While I would not state that the performance improvement process as we use it is laid out explicitly in Scripture, I would suggest that there are a number of themes and traditions in Scripture that offer models within which performance improvement, or some aspect of the process, makes sense. One theme is that of the journey of formation. Abraham commits himself to a journey, and it is the events of that journey that inform and shape his relationship with God. Jacob’s history is shaped by choices and even by experimentation, and his failures are as instructive as his successes. Their stories reflect a commitment to live within a relationship that will change not only their behaviors, but their names and their personhood. In parallel, performance improvement is based on a commitment to a long-term process resulting in not only changes in particular tasks and systems, but also a pervasive change in the corporate culture of the institution. It is , in a way, formative of the community within an organization as the wilderness experience was formative for Israel. (I will grant that some who have been involved in a performance improvement project may see another parallel with Israel: the process can seem to take a long time to reach its goal.)

The importance of this commitment to pervasive change is expressed most clearly in two of the principles of W. Edwards Deming, whose management philosophy is fundamental for performance improvement. His first two principles for change are “Create constancy of purpose for the improvement of product and service,” and “Adopt the new philosophy.”[1] Clearly, Deming understood that long-term improvement requires a commitment to a new vision, and not simply changes of separate tasks or positions within the system.

One aspect of Scripture in which there is some reflection of performance improvement, in the sense we would use the term, is in the writings of the Prophets of the Hebrew Scriptures. The role of the Prophet in Israel’s history, as reflected in Scripture, is to confront Israel regarding behavior. The Prophets called for both personal and corporate self-evaluation and change. When Israel does not heed the call to reflection and renewal, the people suffer. When Israel does repent, Israel is blessed.

This is reflected in the prophetic books both in narrative and in prophecy per se. Thus, when Nineveh hears the half-hearted ministry of Jonah, the people respond with behaviors of repentance, and the Lord withholds his wrath. (Jon. 3)[2] Conversely, Amos is extensive, and even bitter, in his description of the sins of Israel. He writes,
Seek the Lord and live,
or he will break out
against the house of Joseph like fire,
and it will devour Bethel, with no one to quench it.
Ah, you that turn justice to wormwood,
and bring righteousness to the ground!
They hate the one who reproves in the gate,
and they abhor the one who speaks the truth.
Therefore, because you trample on the poor
and take from them levies of grain,
you have built houses of hewn stone,
but you shall not live in them;
you have planted pleasant vineyards,
but you shall not drink their wine.
For I know how many are your transgressions,
and how great are your sins—
you who afflict the righteous, who take a bribe,
and push aside the needy in the gate.
Therefore the prudent will keep silent in such a time;
for it is an evil time.
Seek good and not evil,
that you may live;
and so the Lord, the God of hosts, will be with you,
just as you have said.
Hate evil and love good,
and establish justice in the gate;
it may be that the Lord, the God of hosts,
will be gracious to the remnant of Joseph. (Amos 5:6-7, 10-15)

It is notable in this passage, as well as in comparable passages in Jeremiah and Micah, that the emphasis is on performance. The Lord is displeased with Israel because of failures to provide services for those in need. There is also a strong implication that a part of the failure is in the people’s false belief that they are pleasing God and that God is pleased with them. In that sense, they are currently acting on their own perceptions and not on measured data. At the same time, in the prophetic literature, standards are proclaimed that might also be called “operational norms”. Thus, Micah 6:8 records, “He has told you, O mortal, what is good; and what does the Lord require of you but to do justice, and to love kindness, and to walk humbly with your God?”

An example of this comes from the Second Book of Kings, chapter 22 and following. In the process of renovation to the Temple under Josiah, a text, “the book of the law”, was discovered. While we might not call the consequences of that discovery performance improvement, there are certain parallels. The text itself became the new data regarding the behavior of the people of Judah. This was confirmed by consultation of the prophetess Huldah, who might be said to have provided both additional data and some evaluation. With this data, Josiah entered into a radical refocusing of the religious and political practices of the people. This was not a gradual change, a sort of CQI, but a rapid and fundamental change more similar to reengineering . All these changes had short-term consequences of returning Judah to traditional norms of life as God’s people and had the long-term consequence of staving off God’s wrath against Jerusalem during Josiah’s lifetime.

In the Christian Scriptures of the New Testament, once again there is no explicit reference to performance improvement as such. However, there are images that would be consistent. In the Sermon on the Mount, Jesus describes standards for behavior that would allow for measurement. He calls for an accurate self-assessment:

Why do you see the speck in your neighbor’s eye but do not notice the log in your own eye? Or how can you say to your neighbor, “Let me take the speck out of your eye”, while the log is in your own eye? You hypocrite, first take the log out of your own eye, and then you will see clearly to take the speck out of your neighbor’s eye. (Matt. 7:3-5)

Moreover, within the sermon, there is a mandate that lends itself readily to a philosophy of continuous improvement: “Be perfect, therefore, as your heavenly Father is perfect.” (Matt 5:48)

Another image which readily lends itself to performance improvement as we understand it is Paul’s frequent reference to the athlete. He does this fully in First Corinthians:

Do you not know that in a race the runners all compete, but only one receives the prize? Run in such a way that you may win it. Athletes exercise self-control in all things; they do it to receive a perishable wreath, but we an imperishable one. So I do not run aimlessly, nor do I box as though beating the air; but I punish my body and enslave it, so that after proclaiming to others I myself should not be disqualified. (1Cor.9:24-27)
While this is not an explicit reference to performance improvement, the reference to a training regimen and to competition offers some parallel.

[1] Mary Walton, The Deming Management Method (New York: Perigee Books, 1986), 55ff.
[2] All quotations from Christian Scripture are from the New Revised Standard Version of the Bible (NRSV)
Next: PI and Ascetical Theology

Wednesday, November 26, 2008

PI/QI: Theological Reflections (1)

(This post is the first in a series on theological reflection on Performance Improvement/Quality Improvement. This material was first published in “Performance Improvement: Theological Reflections”, Chaplaincy Today, Vol. 16, Number 1 (Summer, 2000), and has been reedited for this setting. For future posts in this series or in the series on measurement for chaplains, please select the label "PI/QI" in the left hand column.)

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. [1]

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. [2]

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.

[1] Owen C. Thomas, Introduction to Theology (Cambridge, MA: Greeno, Hadden, and Company, Ltd., 1973).
[2] 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.)

Tuesday, November 25, 2008

Performance/Quality Improvement for Chaplains: Measurement (1)

With this post I'm beginning a series of posts on Performance/Quality Improvement and measurement for Chaplains. If this is of interest, check the "Labels" section in the left column, and choose "PI/QI."

There’s a new publication I would encourage chaplains and those who support them institutionally to read. The project, “Professional Chaplains and Health Care Quality Improvement.” is the work of The Hastings Center, a well known institution in the field of health care and bioethics, in collaboration with The HealthCare Chaplaincy, an organization providing chaplaincy and clinical pastoral education programs to institutions in New York. The project has now released two publications. One is a Summary of Activities for 2008. The second, and more important, is Can We Measure Good Chaplaincy, a collection of essays published in the current edition of The Hastings Center Report (Volume 38 No. 6, November-December 2008). You can access both reports here (and a hat tip to PlainViews for pointing to these).

The five essays in Can We Measure Good Chaplaincy focus on application of principles of Quality Improvement (QI) to the practice of professional chaplaincy. For those interested, and for the many familiar with these principles from other industries, other ways of talking about this are Total Quality Management (TQM); Continuous Quality Improvement (CQI); Performance Improvement (PI); and Reengineering (which, I suppose, needs no abbreviation). The standards of the Center for Medicare/Medicaid Services (CMS) and of such accrediting bodies as the Joint Commission for the Accreditation for Healthcare Organizations (JCAHO, or simply “The Joint”) assume an environment of PI/QI in healthcare institutions. Such institutions as the Institute of Medicine (IOM, part of the National Academies); the Agency for Healthcare Research and Quality (AHRQ); the Institute for Healthcare Improvement; and the National Quality Forum have called for a PI/QI approach across the board in health care.

And “across the board in health care” should include pastoral care. I have long been a proponent of this. I have mentioned it here before. I’ve written at greater length elsewhere in an article I hope to serialize here soon. For all our resistance as spiritual caregivers to the corporate models that so often seem to objectify the people we seek to serve, I believe there are within our traditions models that can allow us to see value in PI/QI in ministry. These five essays speak to this meaningfully.

That said, they do not address one aspect of that process that is explicit in the title of the collection. The difficult question among chaplains is whether in fact we can measure chaplaincy at all, much less use it to tell “good” from “bad,” and offer directions for “improvement.”

So, let me think a little about that question in this way: what can we measure about our work, and how is any individual measure helpful (or not). After all, no one is arguing we should be trying to figure out how to measure quantitatively an increase a closer relationship with God, or even an increase in or loss of hope. Indeed, in the fifth essay, "The Nature of Chaplaincy and the Goals of QI: Patient-Centered Care as Professional Responsibility,” Nancy Berlinger of the Hastings Center recalls that

the Institute of Medicine gave us six ways of looking at the QI wall in its influential 2001 report, Crossing the Quality Chasm. The report described six goals, or “aims,” for QI in health care: it should aim to make health care safe, effective, patient-centered, timely, efficient, and equitable.

She recommends that chaplains focus on contributing to making care patient-centered.

There has been research on how spiritual care might make health care more effective, but even the best of such studies – including one in which I was involved – had methodological issues. Most critically, it has been hard to demonstrate a result that was actually causal, and not merely coincidental.

So, what can we measure, and how is what we can measure useful? Think about this with me.

We can measure persons contacted, a basic head count. It’s a relatively easy number to arrive at. We can track it day by day, and can measure the result against an agreed standard. We can, for example, compare it to the number of beds in the institution, or the number of patients admitted each day. It is a method that in once sense measures the various contexts in which we work. It allows for some distinction and sophistication by allowing different categories – patients, families and staff, inpatients and outpatients, etc. It can provide guidance for practice. For example, a plateau in the number of contacts, or in the proportion of patients contacted might be indication for redefining a job description, coaching a chaplain, or adding an additional position. It reflects an assumption that many of us find appealing: that many patients, if not all, benefit from the availability of spiritual care, and the more patients contacted the more patients who are benefiting. Moreover, it is a straightforward measure to explain to administrators who may not have much experience working with chaplains.

However, there are also limitations to a simple head count. To begin with, whom or what are we really counting? Do we focus on patients, or do we include others – family members, staff persons, etc. What is a contact? If I see one patient who is being visited by three friends and then consult with the nurse caring for that patient, is that one contact or five? If I speak to an orientation group or to a leadership meeting, is that one contact or 25? If I visit the patient and family, then consult with the nurse, and then return to the room is that one visit or two, five contacts or eight? A simple head count is pretty simple to pad, to exaggerate.

Moreover, a simple head count really says little or nothing about the quality of the visit. There are chaplains who, driven by their own expectations or those of their managers, try to see every patient every day, or as close as possible. Too often they provide what I call, from the Biblical literature, “a wave and a heave offering:” they stop by just long enough to wave from the door and then heave ho for the next room. Such measures are not sensitive to the various needs of patients. A meaningful patient visit may be as short as ten minutes, or as long as thirty. Providing support for a grieving family at the time of death may take hours, hours of great intensity but not that many people.

A head count also allows for a very limited purview for the chaplain. It is not terribly sensitive to a chaplain’s possible participation in education of patients, staff, or the community, in ethics issues, in policy development, or in research, writing, or continuing education.

A head count is a crude measure of productivity, without offering any real measure of the product. It is reasonable, and reasonably simple to measure. It can be mined for data, although while the data might be relevant arguably it is not sufficient. It is easy to explain to administrators, but does not give meaningful measures of either the intensity or breadth of the chaplain’s work. Still, because it is easy to explain to administrators, it is one we need to consider, and one many of us have to work with, like it or not.

Stay tuned. Future posts will look at other possibilities for measurement.

Wednesday, November 19, 2008

More on Mount Calvary

There's a news story in today's New York Times about Mount Calvary and the monks of the Order of the Holy Cross. You can read it here. (And thanks to Episcopal Cafe for that.)

Please continue to pray for the Order, for the monks specifically of Mount Calvary, and for all the others around them who have lost so much in the fires.

And for my fellow Associates of the Order: there is a Yahoo Group for Associates. There aren't many of us on it, and there isn't much traffic. We'd love to have you join us on the Group. If you'd like to subscribe, email me from the link on my Profile page, and I'll be happy to send the information.

Saturday, November 15, 2008

Called to Risk: Reflections on Proper 28 (RCL)

Zephaniah 1:7,12-18; 1 Thessalonians 5:1-11; Matthew 25:14-30

I’ve been pondering the lessons for Proper 28, preparing for my sermon tomorrow (it’s not unusual at all for me to be this late; indeed, it’s more the rule than the exception; but that’s a story for another post.). Central to that consideration has been that story we all know so well, the Parable of the Talents.

We all do know it, of course. The householder is leaving for an extended trip, and wants to set matters in order. He calls his three slaves and gives each of them a large amount of money, different amounts, as Matthew writes, “to each according to his ability.” At the householder’s return, each of the first two slaves had traded with their funds, and each had doubled their funds. The third had instead buried it in the back yard – literally! He lost nothing; but, having gained nothing, he suffered his master’s wrath and was thrown out.

As I looked at what others had written about this story, I found something interesting. Several wrote of the money given to each of the slaves as “gifts.” Perhaps that appeals to our use of the word “talent:” an aptitude, a skill, a capacity, something that we might indeed see as a “charism,” a spiritual gift.

The more I looked at it, though, that idea didn’t make sense. First, these were slaves. Whatever the capacity these huge sums of money might have allowed – and these were huge sums of money! – the slaves remained slaves, not simply responsible to the master but owned by him, body and soul. Second, the money was never the slaves’. It always remained the property of the master, whatever latitude the slaves might have had in using it. After all, when the third slave returned his money the master identified it as “my own,: Third, the master’s clear expectation was that the money would be used. Certainly, he was not at all pleased with the third slave, even though he as master had lost nothing.

No, the money was not, was never a gift. The money was a responsibility, a charge given by the master.

Now, the tasks were not assigned blindly, as it were. The master gave a different sum “to each according to his ability.” So, the master never expected as much of the third slave as he did of the second, much less of the first. The third slave was assessed to have the least capacity from the beginning. We could wonder, then, why the master was so disappointed, when, after all, the third slave hadn’t really failed. He didn’t lose anything, so he didn’t really fail, did he?

But we know that the answer is yes, he did fail. But his failure was not measured by how much money he made, or might have made. His failure was not his failure to profit, but his failure to try. What did the master say? “So, you knew me so well? You found me so frightening? Then you could at least have done something worthwhile, instead of simply sitting on what you had.”

The hard part for the third slave was that he lacked faith. Isn’t that what the master said? Those who succeeded were “good, with faith.” They had the faith to take some risk with their talents. Notably, they had some faith, faith in their master and faith in themselves, recognizing the faith that their master had in them. He had judged them each to have the capacity to manage those large amounts of money. They accepted his assessment, and felt they could take the risks of trading with those large amounts of somebody else’s money. When they took the risk, they had their faith confirmed. The third slave lacked faith in himself, and even in his master’s assessment of his capacity. He felt afraid, unwilling to take any risk; and so he failed in the eyes of his master.

We ourselves do talk about talents that God has given – both talents in the sense of capacities, and for many in the sense of financial resources to live out those capacities. We talk about them as gifts, and express our gratitude. At the same time, we need to remember that these are not really gifts. However great might be the capacities the God gives us, they do not make us God, or even gods. Instead, they are responsibilities. God gives them to us for God’s purposes, however much latitude we might feel in using them. We remain God’s servants, stewards of capacities and resources that remain God’s, to be used for God’s purposes.

And God expects us to take risks with those gifts, those capacities. After all, he has given them to us according to our abilities – that is, God has faith in our abilities to do something good, if we will only take the risk to try. God will certainly expect different things of different ones of us; but of each of us God expects us to take a risk and make an effort. And God will be displeased, not if we try and fail, but rather if we don’t try at all.

Zephaniah brings that home to us. He proclaims the Day of the Lord, and it looks like a difficult day for all. Yet, the target audience, if you will, is really quite specific: “those who rest complacently,… who say, ‘The Lord won’t do either good or ill.’” Those whose homes will be plundered, whose lives will be uprooted and destroyed, are those who simply try to lay low, to try nothing, believing that thus they will lose nothing.

So clearly we are called to take risks with the capacities God gives us, to make efforts to carry out God’s purposes, without knowing whether we will succeed of fail. God has faith in us that we can do it. But, of course, it’s all too easy for us to lose faith in ourselves, to believe that we’re not good enough or strong enough or wise enough or enough of something else. After all, who knows our shortcomings better than we do? And so we lose faith in ourselves, and faith in God’s assessment of us. We can lose faith, too, in God’s promise. Christ has told of us of God’s wonderful promises for us if we walk in faith before him. But there are so many places and so many voices to tell us just how frightening God can be. Like the third servant, we can become immobilized, to afraid of failure, and too afraid of God, to take the very risks God asks of us.

But Paul had a word for us on that. He reminded us, with the Thessalonians, that we are children of the light and the day, not of darkness. He reminded us, with them, that God has destined us not for destruction but for salvation.

So, let us have faith – faith in God and faith in ourselves and faith in the capacities God has given us, however great or small they might seem. God has given to each of us capacities according to our abilities. What God expects of us is that we do something with his capacities, for a while put under our stewardship. And what God expects of us is not a specific measure of success, but a willingness to risk: to take these capacities and use them for God’s purposes. We’re not certain of success if we do; we’ve seen enough history to be aware of that. But we’re certain to disappoint God if we don’t.

Friday, November 14, 2008

Mount Calvary Burned

As an Associate of the Order of the Holy Cross I am among those saddened at the loss of the Mount Calvary Monastery and Retreat Center in the Tea Fire in Montecito, California. You can read an ENS reports about it here, and can see local TV news reporting here. As the TV footage shows, there was terrible destruction at the Center, and yet some things were saved. Strikingly, the garden cross still stands.

The brothers were safely evacuated, and are staying for now with the Sisters of the Holy Nativity at St. Mary's Retreat House. We're thankful that none of them was injured.

I have visited other houses of the Order, including the recently-closed Incarnation Priory in Berkeley (most of whose monks were relocated to Mount Calvary). I had hoped one day to visit Mount Calvary as well. While that hope isn't gone, it is certainly put off. With many others, I look forward to the new monastery that will be built, and pray for the continued ministry of the Order, not only in the Santa Barbara area, but also for the larger church.

Thursday, November 13, 2008

More Good Stuff for Chaplains (and Others)

It's a rich week!  I normally point to Episcopal Cafe when I've had something new posted there.  However, my friend and colleague Andrew Gerns has a new post there that I think will be valuable and encouraging reading for chaplains, and at least quite interesting to others.  Before becoming Rector of Trinity Episcopal Church in Easton, Pennsylvania, Andrew was for some time a hospital chaplain.  Take a look at his new piece.  And, if you're interested, you can see other things he's written at his own blog, Andrew Plus.

Wednesday, November 12, 2008

Another Voice on CPE

Because each summer I look for and point to blogs discussing the experience of clinical pastoral education (CPE), folks periodically look here for information on the CPE experience. With that in mind, I encourage folks to check out this article at PlainViews, the online journal about chaplaincy. The author, DonnaLee Dougherty, is reflecting on her experience of her recent unit of CPE.

While there, take some time to look at current and past articles at PlainViews. For those of us in the business, and for those interested in chaplaincy, PlainViews is worth visiting regularly.

Tuesday, November 11, 2008

What General Convention (Hasn't) Said: Veterans and Health

This morning I happened to catch the repeat of “The News Hour” on PBS (in my market they run it the following morning). What caught my attention was this report: “Military, VA Confront Rising Suicide Rates Among Troops.” I encourage you to watch it. The information in it, and the concern for high rates of suicide and emotional trauma among veterans returning from Iraq and Afghanistan, are not new to me. This report suggested the Army is working hard to improve the response to these needs, while the Veterans Administration may be lagging behind.

That brought me to wonder what the General Convention had said about care, and especially health care, for veterans. When I searched actions of General Convention since 1976, I discovered that there was, sadly, very little. Indeed, there was only one resolution, dating all the way back to 1976. That year the General Convention passed resolution 1976-B182, titled “Affirm Bicentennial by Resolving Issues Relating to the Vietnam War.” While it did not speak specifically of health care, it did say in part,

1. Commend the leaders of the United States Government for the efforts and programs aimed at restoring to productive lives those who served the nation in the Indochina conflict as well as those who chose not to serve;

2. Urge the furtherance of those efforts by granting to Vietnam veterans benefits fully equivalent to those granted to veterans who served the nation in World War II and in the Korean conflict; ...

On this Veterans Day I would hope that all of us, without waiting for a resolution from General Convention, could support the same efforts for veterans from Iraq and Afghanistan; and, for that matter, of Panama, Grenada, Bosnia, Somalia, and elsewhere. Post Traumatic Stress Disorder isn’t really new. It’s just a medical diagnostic term for how emotional traumas have affected some veterans in any conflict. Thank God that more veterans have not been so seriously affected; but we are still called, both in national responsibility and in Christian compassion, to support appropriate services for those veterans who have been.

Again, I regret that General Convention has not had more to say on this over the last generation. On the other hand, we’ll soon be in Anaheim....

Monday, November 10, 2008

Of Justice and Long Nights: Reflections on Proper 27, Year A

Amos 5:18-24; Matthew 25:1-13. Preached (well, something like this was preached) 11/9/08.

"I hate, I despise your solemn assemblies" - what a passage to get when coming to an Episcopal Church! But, it is all too easy to become impressed with our own solemn assemblies, both religious and civil. We have been through a season especially heavy with the latter. And that season isn't really over. We're coming to Thanksgiving, a holiday both civil and religious. We'll soon enough experience the religious seasons of Advent and Christmas; and we'll hardly be past Epiphany and the Feast of the Baptism when we come to the civil assembly of the Inauguration.

"I take no pleasure in your burnt offerings...
But let justice roll down like water, and righteousness like an ever flowing stream."

For many of us this Inauguration will be special, and special in a way that speaks particularly of justice. Legal slavery ended perhaps 150 years ago; but the legal vestiges - economic and literacy requirements that prevented African-Americans from participating with anything approaching equality in the political, economic, and cultural life of the nation - were only successfully challenqed in living memory. And they didn't happen all at once by any means! Step by step, from Truman's integration of the military, to Brown vs. the Board of Education, to the Voting Rights Act, things changed. Step by step, from the brave children of Topeka and Little Rock, to the Montgomery Bus Boycott, to the summer of the Freedom Riders and the bridge at Selma, old ways were challenged. Not all at once, but step by step; and if, contrasted with 300 years of legal or economic slavery it appeared short, for those who lived through it, it seemed - indeed, it was - a lifetime. Is it any wonder we have heard so many say, "I hoped it would happen someday, but I never thought it would happen in my lifetime."

And so we look to this Inauguration, and it speaks to us of justice, doesn't it? Well, yes and no.

"Let justice roll down like waters, and righteousness like an ever-flowing stream."

Of course there is something of justice about this election and this inauguration, something we can and should celebrate. On the other hand, this is not justice accomplished; it is only one step forward. There is much to celebrate; but if we imagine that this means things are now just, that our work is over, this Inauguration will be just one more solemn assembly - self-satisfying, but insufficient. That’s especially true for us in the Church. If we come to this Eucharistic celebration, as the Eucharistic Prayer says, “for solace only, and not for strength,” this too will be just one more solemn assembly – self-satisfying, but not sufficient. It is important that we recognize that, while we have seen an important landmark, we haven’t experienced a sea change. We celebrate this moment that speaks of justice, but we also recognize that the world hasn’t really changed.

And that can be distressing. It’s all too easy to hope, to imagine that we’ve achieved justice, and to become depressed when it turns out this was only another step forward. And in our distress it is all too easy to become dejected and immobilized.

In a way I think that’s what happened with the wise and foolish virgins. Think about it. There wasn’t any real difference between the lamps of the wise and the foolish virgins. They worked: when lit, they shed bright light. There wasn’t any real difference between the virgins as virgins. All were looking forward to the party, waiting for the bridegroom. However, the foolish virgins weren’t prepared for a long night. They were just as enthusiastic as the wise virgins, and their lights were just as bright; but they weren’t prepared for the long haul.

By the same token, we need to be prepared for the long haul. We can celebrate this step forward, but we also need to be prepared for the fact that the world hasn’t really changed. We are. after all, the people called to proclaim God’s presence in the world. We are called to participate in God’s efforts for justice, to help make the presence of the Kingdom present even in our own time and place. That means proclaiming the presence of God, not just in our celebrations, but also in the long, often dark times between them. That means being prepared not just for the party, but also for the long night.

If we fail in that, our solemn assemblies, however wonderful they are, will indeed be empty show, perhaps satisfying to us, but certainly not to God. However, if we work for justice, if we work to demonstrate the presence of the Kingdom even in our own time, our assemblies will be more than empty parties. They will be landmarks, signs of hope as we wait for God to bring the Kingdom in fullness.