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.

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