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.

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