I have been attending Summit ’09 of the Spiritual Care Collaborative. It has been an interesting experience, and mostly good.
It will have come to the attention of regular readers that I’m interested in research. It turns out that so are a lot of other chaplains. At Summit ’09 there were three separate 90-minute workshops on research for chaplains, not to mention any number that were in one sense or another were informed by research.
I like the concept of being “research informed” as a profession. I took the phrase from George Fitchett, expressed in one of the workshops mentioned above. He speaks in that phrase of a situation in which a few chaplains are actively involved in research, whether as primary investigators or collaborating with others; but all chaplains are aware of research and able to read and consider it critically.
I think this is a worthwhile goal. It’s not something we learn in our theological training. Oh, we do see the results of two sorts of research. We see the results of academic research – the results of extensive studies of articles and critical reflections. However, that research is, essentially, literature criticism. That is, it’s not quantitative, or even qualitative research resulting in numbers. (That’s not to say it’s not quality research; just that research done by an historian is usually different from research done by a physician; and for some important purposes chaplains need to be more in the second group.)
That said, I shared in the workshop my own concern that there are two resources for research that we need to attend to and work with. The first is research about spirituality and health care done by folks in other disciplines. Nurses, physicians, and social workers are publishing research related to spirituality. We as chaplains need to be looking at it for two reasons. First, some of it is actually useful, and we need to know about it. Second, some of it is really not good from our perspective, and we need to be responding critically to it. If those other journals started getting clear and reasoned responses from chaplains, our visibility would rise.
Second, and sadly, we haven’t really read each other’s research. I’m aware of that when, year after year, some of the same topics keep showing up – a new model for spiritual assessment, or a justification for demonstrating our work with numbers, for example. We need to be reading and reviewing one another’s work, and responding critically. Even more important, we need to be reading one another’s work and seeking to replicate studies. In any field, it is the replication that demonstrates that the work is valid and useful. It is also replication that allows us to meaningfully respond and perhaps tweak tools, categories, and hypotheses. If we want to discuss our work as “evidence-based” in the evidence-based world of health care, it is precisely that replication that will confirm the usefulness of our evidence.
This has been a worthwhile conference over all, and I will have other things to say or to point to. However, these thoughts came up in the context of a valuable workshop, and I wanted to get them out. It’s not enough for us to talk about being “evidence-based” or “research informed,” if we’re not making use and sense of the research already out there.
Showing posts with label PI/QI. Show all posts
Showing posts with label PI/QI. Show all posts
Wednesday, February 04, 2009
Tuesday, January 13, 2009
Performance/Quality Improvement for Chaplains: Measurement (4)
This is the fourth 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."
In addition to contacts, time, and interventions, chaplains have looked for opportunities to measure outcomes. That is, chaplains have sought to identify results or consequences of a chaplain’s interaction with a patient, and to measure how often those results might occur, and what actions of a chaplain might contribute.
Measuring outcomes would be the “gold standard” for determining the impact of a chaplain’s work. That would put the profession in concert with other professions in health care. The move toward “evidence-based practice” is established on discovering results and consequences, preferably those offering benefit, for the patient; and then refining practice to increase benefits and avoid injuries.
We might think of two sorts of outcomes that might be measured. The first would be clinical or objective outcomes. That is, outcomes that would themselves be measurable in terms of changes in the patient’s clinical results – lab values, increased function, etc. The various studies trying to measure the outcomes of prayer for patients have been efforts to see clinical changes.
The second sort of outcomes would be subjective, reflecting assessments of either patient or practitioner. This has in fact been the most common area for chaplain research, in that the largest category has been surveying customer satisfaction. That area is significant enough to require a post of its own. However, there have been a number of studies that assessed subjective reactions to the chaplain’s work, and they do have some value.
I think we also need to note that some studies seem to reflect both. Using a standardized instrument or set of questions gives greater consistency to the information gathered, even though the information itself is a subjective self-report. A favorite example might be the Myer-Briggs Type Indicator. It is an instrument many of us know and love. It has been “validated:” that is, it has been used many times over a long period of time, and the quality of the information gathered is consistent over time. Because of the large populations involved over time, the results can be applied to self-reflection and to analysis. At the same time, the information is largely about preferences and/or self-assessment, and so is subjective. Because the data gathering is standardized, the data gathered is more dependable, but still not necessarily objective. My own experience in taking the Myers-Briggs and the related Keirsey Bates Temperment Sorter is that the results change according to my mood, and according to whatever else is going on in my life. So, when life is difficult and I would like more structure, I am more likely to come out more “judging” than “perceiving” in my own results.
As I noted, there have been a number of efforts to quantify outcomes of prayer. More important have been a many studies done to correlate good health outcomes with religiosity and/or a religious lifestyle. Perhaps the most famous name for that research is Harold Koenig, MD, of the Center for Spirituality and Health at Duke University. He and similar researchers have found significant correlations between healthy spirituality and good health.
At the same time, there is criticism of this research. The most significant critique is to note that correlation is not the same as causation. That is, the fact that religious people are less likely to be depressed does not necessarily show that it is being religious that causes the effect. Some critics pointing this out do so because they are looking specifically for a spiritual, i.e. unexplainable, cause. They might, for example, suggest that better health outcomes come to, say, Amish farmers, not because they are religious but because they get more exercise in their daily life. However, they ignore the fact that they get more exercise precisely because their religious discipline shapes their daily life in that direction. While a consideration for any particular study, the aggregate information from multiple studies becomes more suggestive the more it is confirmed. Still, this is an important critique of the prayer studies.
We might also note that such research doesn’t necessarily help chaplains. Most of the correlative research has been done outside health care institutions, and so doesn’t suggest anything one way or another about the work of chaplains. The prayer studies by and large engaged prayer through prayer groups outside the institutions, and so once again didn’t really say anything about the effects of a chaplain’s work.
There have also been studies of the effects of a chaplain’s work, primarily by recording the subjective responses of patients to a chaplain’s support. Once again, much of this has been in the form of customer satisfaction studies, whether by independent researchers or by institutional quality and business research departments. However, some published studies have sought to measure effects at the bedside. One early study that stood out was that of Chaplain Greg Stoddard at Reading Memorial Hospital in Reading, Pennsylvania (“Chaplaincy by Referral: An Effective Model for Evaluating Staffing Needs;” The CareGiver Journal, Volume 10, Number 1, 1993) In Stoddard’s study, patients were evaluated by chaplains and CPE students using the nursing diagnostic categories of Spiritual Concern, Spiritual Distress, and Spiritual Despair. Patients were assessed at first contact and at subsequent visits, and determined to have improved (e.g., Distress to Concern) or gotten worse (e.g., Distress to Despair), based on relevant statements made by patients and families. While the purpose of the study was to evaluate staffing needs, it incorporated some measurement of outcomes of the chaplain’s visit. Once again, the measurement is subjective in both steps: both the patient’s report and the chaplain’s assessment. However, using standard terms and standard measures, significant efforts were made to standardize chaplain responses. In addition, this took place within the clinical setting, at the bedside, and so is more comparable to measurements of clinical outcomes in other disciplines.
There is the additional difficulty that the outcomes we are most aware of as chaplains are not those used by other disciplines. That is not to say that, like the studies of Koenig et al, we can’t look for such outcomes. They are not, however, those we most value in our own measures of our work. Nor are they within our practice to measure ourselves. That is, we might choose to track how blood pressure or agitation are affected by our work; but the actual measurement will be done by others, and without significant coordination, at their convenience and on their schedule.
Working as chaplains do in a environment of evidence based practice, measuring outcomes could be of great importance, especially in seeing pastoral care departments as necessary rather than as luxuries – useful and desirable, but still luxuries that can be dispensed with in hard times. At the same time, measuring outcomes can be difficult, especially because correlation is not necessarily causation, and because much of the information can be subjective. However, to the extent that we can measure outcomes and can relate those outcomes to patient wellness, it is worth our effort. It contributes to our claim that we are members of the team and important parts of the hospital’s purposes; and it adds to our abilities to communicate with professional colleagues in our institutions.
In addition to contacts, time, and interventions, chaplains have looked for opportunities to measure outcomes. That is, chaplains have sought to identify results or consequences of a chaplain’s interaction with a patient, and to measure how often those results might occur, and what actions of a chaplain might contribute.
Measuring outcomes would be the “gold standard” for determining the impact of a chaplain’s work. That would put the profession in concert with other professions in health care. The move toward “evidence-based practice” is established on discovering results and consequences, preferably those offering benefit, for the patient; and then refining practice to increase benefits and avoid injuries.
We might think of two sorts of outcomes that might be measured. The first would be clinical or objective outcomes. That is, outcomes that would themselves be measurable in terms of changes in the patient’s clinical results – lab values, increased function, etc. The various studies trying to measure the outcomes of prayer for patients have been efforts to see clinical changes.
The second sort of outcomes would be subjective, reflecting assessments of either patient or practitioner. This has in fact been the most common area for chaplain research, in that the largest category has been surveying customer satisfaction. That area is significant enough to require a post of its own. However, there have been a number of studies that assessed subjective reactions to the chaplain’s work, and they do have some value.
I think we also need to note that some studies seem to reflect both. Using a standardized instrument or set of questions gives greater consistency to the information gathered, even though the information itself is a subjective self-report. A favorite example might be the Myer-Briggs Type Indicator. It is an instrument many of us know and love. It has been “validated:” that is, it has been used many times over a long period of time, and the quality of the information gathered is consistent over time. Because of the large populations involved over time, the results can be applied to self-reflection and to analysis. At the same time, the information is largely about preferences and/or self-assessment, and so is subjective. Because the data gathering is standardized, the data gathered is more dependable, but still not necessarily objective. My own experience in taking the Myers-Briggs and the related Keirsey Bates Temperment Sorter is that the results change according to my mood, and according to whatever else is going on in my life. So, when life is difficult and I would like more structure, I am more likely to come out more “judging” than “perceiving” in my own results.
As I noted, there have been a number of efforts to quantify outcomes of prayer. More important have been a many studies done to correlate good health outcomes with religiosity and/or a religious lifestyle. Perhaps the most famous name for that research is Harold Koenig, MD, of the Center for Spirituality and Health at Duke University. He and similar researchers have found significant correlations between healthy spirituality and good health.
At the same time, there is criticism of this research. The most significant critique is to note that correlation is not the same as causation. That is, the fact that religious people are less likely to be depressed does not necessarily show that it is being religious that causes the effect. Some critics pointing this out do so because they are looking specifically for a spiritual, i.e. unexplainable, cause. They might, for example, suggest that better health outcomes come to, say, Amish farmers, not because they are religious but because they get more exercise in their daily life. However, they ignore the fact that they get more exercise precisely because their religious discipline shapes their daily life in that direction. While a consideration for any particular study, the aggregate information from multiple studies becomes more suggestive the more it is confirmed. Still, this is an important critique of the prayer studies.
We might also note that such research doesn’t necessarily help chaplains. Most of the correlative research has been done outside health care institutions, and so doesn’t suggest anything one way or another about the work of chaplains. The prayer studies by and large engaged prayer through prayer groups outside the institutions, and so once again didn’t really say anything about the effects of a chaplain’s work.
There have also been studies of the effects of a chaplain’s work, primarily by recording the subjective responses of patients to a chaplain’s support. Once again, much of this has been in the form of customer satisfaction studies, whether by independent researchers or by institutional quality and business research departments. However, some published studies have sought to measure effects at the bedside. One early study that stood out was that of Chaplain Greg Stoddard at Reading Memorial Hospital in Reading, Pennsylvania (“Chaplaincy by Referral: An Effective Model for Evaluating Staffing Needs;” The CareGiver Journal, Volume 10, Number 1, 1993) In Stoddard’s study, patients were evaluated by chaplains and CPE students using the nursing diagnostic categories of Spiritual Concern, Spiritual Distress, and Spiritual Despair. Patients were assessed at first contact and at subsequent visits, and determined to have improved (e.g., Distress to Concern) or gotten worse (e.g., Distress to Despair), based on relevant statements made by patients and families. While the purpose of the study was to evaluate staffing needs, it incorporated some measurement of outcomes of the chaplain’s visit. Once again, the measurement is subjective in both steps: both the patient’s report and the chaplain’s assessment. However, using standard terms and standard measures, significant efforts were made to standardize chaplain responses. In addition, this took place within the clinical setting, at the bedside, and so is more comparable to measurements of clinical outcomes in other disciplines.
There is the additional difficulty that the outcomes we are most aware of as chaplains are not those used by other disciplines. That is not to say that, like the studies of Koenig et al, we can’t look for such outcomes. They are not, however, those we most value in our own measures of our work. Nor are they within our practice to measure ourselves. That is, we might choose to track how blood pressure or agitation are affected by our work; but the actual measurement will be done by others, and without significant coordination, at their convenience and on their schedule.
Working as chaplains do in a environment of evidence based practice, measuring outcomes could be of great importance, especially in seeing pastoral care departments as necessary rather than as luxuries – useful and desirable, but still luxuries that can be dispensed with in hard times. At the same time, measuring outcomes can be difficult, especially because correlation is not necessarily causation, and because much of the information can be subjective. However, to the extent that we can measure outcomes and can relate those outcomes to patient wellness, it is worth our effort. It contributes to our claim that we are members of the team and important parts of the hospital’s purposes; and it adds to our abilities to communicate with professional colleagues in our institutions.
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.)
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:
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:
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.
Conclusions
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.
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.
Conclusions
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.
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.
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.
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
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
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
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
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.
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.
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.
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,
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
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
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
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:
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:
[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)
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,
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 poorand 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.)
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:
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.
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.)
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.
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