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.

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