Some years ago, when I was a priest in the Diocese of Michigan, Old Mariners Church decided to leave the Diocese.
I write that as if the events related to that were simple. In fact they weren’t. The Diocese sued for control of the property, and lost. The Diocese appealed, and lost. As I recall, it cost the Diocese something on the order of $75,000, and there was certainly disappointment within the Diocese, both at the losses and at the expenditure.
The Diocese lost because the founding of Mariners Church was unique. It was founded with funds donated by two sisters as an independent congregation. It later requested to join the Diocese, apparently in keeping with the wishes of the sisters; but it had retained in its corporate bylaws some unique characteristics that were meaningful in Michigan property laws. The congregation won because of certain unique and very specific characteristics.
Which ultimately served the Diocese. I have long felt that the Diocese lost the battle and won the war. You see, there were a number of other congregations in the Diocese watching all this closely. They largely agreed with the folks at Mariners Church (in this case, about continued use of the 1928 Book of Common Prayer, and about the social agenda of the Episcopal Church), and they were considering themselves leaving the Diocese.
What they discovered was that they couldn’t. They didn’t have the specific and unique characteristics of their foundation that Mariners Church had. As was made clear by the court decisions, without those characteristics there was no question that the Constitution and Canons of the Episcopal Church applied, and that in any legal dispute the Diocese would win. So, the Diocese lost one case, and so was spared another five or six. What seemed money lost was actually well invested.
I find myself thinking about this as I look at the initial court decision regarding the congregations in Virginia that have left that diocese to join the Anglican District of Virginia and the Convocation of Anglicans in North America (CANA), a ministry of (or a boundary violation by, depending on perspective) the Church of Nigeria – Anglican. That case also has aspects of uniqueness. First, there is the assertion by some of those congregations that their histories predate the founding of the Diocese of Virginia – a characteristic that must certainly apply in limited cases (if perhaps not as limited in Virginia as in other states). Second, there is the uniqueness of the Virginia law on divisions within congregations, a law not shared by any other of the United States.
I’m not an attorney, much less a Virginia attorney. On the other hand, I did read the appellate opinion in California which included that court’s detailed review of relevant cases in the federal courts. I personally don’t think it likely the Virginia congregations will win in the end, although I do expect it to take a while, including some time in the federal courts.
But, suppose they do? If they win based on those unique characteristics, they will also demonstrate how few other congregations can follow their lead. The state judge in Virginia has indeed decided that this specific law does apply; but there is no such law anywhere else. Nor do I think it likely that any other state could get such a law through legislatures these days. In no other state could congregations make such an assertion.
And, if they win based on assertion of historical precedence, that the congregations predate formation of the diocese: that, too, will offer little comfort outside their own region. There are certainly more such congregations along the Atlantic coast, and some may also think about departure. But, that won’t apply to most along the East Coast, and there will be none west of the Alleghenies. Even if some were founded before a diocesan structure existed, they were founded under the jurisdiction of missionary bishops elected by and serving under the General Convention of the Episcopal Church. It would be hard to argue that the Constitution and Canons don’t apply.
So, it seems to me quite possible that a victory for the Anglican District of Virginia and CANA would be Pyrrhic: in defining why they might leave, they would define clearly why the vast majority of congregations couldn’t. It’s certainly too soon to tell, and the legal process in California is also going to be interesting. But it seems to me that in pressing on the Diocese of Virginia and the Episcopal Church can win the war, even if they lose this battle.
Friday, April 11, 2008
Assessing Organ Donation Efforts - and Asking the Right Questions
The Joint Commission is coming. Well, no, not this week. But it's our year - our third year in a 3-year cycle. So, sometime this year surveyors from the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) will arrive on our doorstep, with a mandate to assess how we do what we do, from the bedside to the boiler room. (And we pay them for this!)
Ours is a small hospital, and many of us in leadership have multiple roles. One of mine is to oversee our compliance on organ and tissue donation. That involves a number of things: reviewing policies, teaching nurses, monitoring charts, and keeping statistics. It definitely involves preparation for one question: "What is your conversion rate?"
"Conversion rate" is the percentage of severely brain-injured, ventilator-dependent patients eligible to donate organs, whose families do consent to donate. It is a statistic monitored by the Center for Medicare/Medicaid Services (CMS), and so on their behalf by the Joint Commission. It's considered a measure of the institution's commitment to organ donation efforts; and institutions not sufficiently committed can lose Medicare funding. It is the one question related to donation that I know the surveyors will ask.
And, based on past experience, it's the only question the surveyors will ask; and that troubles me. You see, I think that can be a misleading statistic in a hospital like mine.
First and foremost, my hospital is a small, suburban community hospital. We're not a trauma center or a major stroke center, so most patients who might be eligible - severely brain-injured and needing a ventilator - pass us by. In the last two years we had only a handful of brain-injured, ventilator dependent patients, and all but one were ineligible to donate for medical reasons. So, we had one patient who might have been eligible. His family chose not to donate; so, our “conversion rate” for that period of time was 0%. Of course, that wasn’t the fault of our hospital. The death was appropriately reported, and the family was appropriately approached. They simply declined to donate; but their decision is somehow a reflection on us. And, of course, with so few patients in the “eligible” group (N=1), the statistical consequences of even one family’s decision to decline are significant.
Second, the family’s decision isn’t really reflection of the process of the hospital or the organ procurement organization, much less the hospital’s commitment to that process. The process functioned, but wasn’t really measured. Only the outcome was measured, and that, again, was largely the result of factors beyond our control. We can offer families the opportunity to donate. We can discuss the need, and the generosity the gift would demonstrate. We can describe it as a service to the family, and as a gift that brings some blessing in their grief. What we can’t do is control their decision. Indeed, to suggest we could control the decision would be to imply coercion, or, worse, to encourage it.
There are other questions that might be asked, and these would provide a much better, and certainly more complete, perspective on the institution’s commitment to donation. The first would be to ask about the hospital’s “referral rate.” We, like other hospitals, are required to inform the organ procurement organization (OPO) of every death. So, a good measure would be how consistently we make that required phone call, and make it in the appropriate time frame (a measure that in my hospital is, by the way, 100%). Hospitals with lower referral rates would certainly demonstrate less commitment to donation.
The second question that might be asked would be about the conversion rate for donation of tissues. Skin, long bones, heart valves, corneas, and other tissues that aren’t directly sustained by blood flow, can be donated by patients who have died cardiac death, and so have not been severely brain injured, or sustained on the vent. The corollary to the low incidence of deaths of severely brain-injured patients in my hospital is that all the other deaths were cardiac deaths. Those patients were appropriately assessed for their potential for tissue or cornea donation; and when the patients were eligible, their families were appropriately approached. For hospitals like ours, with so few patients who might even be assessed for organ donation, eligibility for tissue donation and tissue conversion rates would seem more appropriate measures.
Now, the number of families who choose to donate is certainly a relevant number. Even with recent questions about the accuracy and adequacy of the lists of patients who would benefit from transplants, there is agreement that there are many more patients who might benefit from transplant than there are organs currently being donated. And for large hospitals, and especially those with transplant services, trauma centers, large stroke programs, or other factors that would suggest larger populations of patients who might be eligible, perhaps there’s some reason to measure the conversion rate. However, that number is really controlled by families making decisions in emotionally difficult times. That means the number is really more a factor of discussions that happen over the dinner table than of discussions, however persuasive, at the bedside in ICU. Rates of donation will be affected much more by education and information in the community than by even the best recovery processes of hospitals or organ procurement organizations. That doesn’t mean hospitals and OPO’s shouldn’t be involved; but perhaps the questions need to be about their educational and public service efforts, as well as rates of appropriate referral. Those activities will have a better effect on how many families are willing to donate. So, those questions would say a lot more than conversion rates about an institution’s support for donation efforts.
Ours is a small hospital, and many of us in leadership have multiple roles. One of mine is to oversee our compliance on organ and tissue donation. That involves a number of things: reviewing policies, teaching nurses, monitoring charts, and keeping statistics. It definitely involves preparation for one question: "What is your conversion rate?"
"Conversion rate" is the percentage of severely brain-injured, ventilator-dependent patients eligible to donate organs, whose families do consent to donate. It is a statistic monitored by the Center for Medicare/Medicaid Services (CMS), and so on their behalf by the Joint Commission. It's considered a measure of the institution's commitment to organ donation efforts; and institutions not sufficiently committed can lose Medicare funding. It is the one question related to donation that I know the surveyors will ask.
And, based on past experience, it's the only question the surveyors will ask; and that troubles me. You see, I think that can be a misleading statistic in a hospital like mine.
First and foremost, my hospital is a small, suburban community hospital. We're not a trauma center or a major stroke center, so most patients who might be eligible - severely brain-injured and needing a ventilator - pass us by. In the last two years we had only a handful of brain-injured, ventilator dependent patients, and all but one were ineligible to donate for medical reasons. So, we had one patient who might have been eligible. His family chose not to donate; so, our “conversion rate” for that period of time was 0%. Of course, that wasn’t the fault of our hospital. The death was appropriately reported, and the family was appropriately approached. They simply declined to donate; but their decision is somehow a reflection on us. And, of course, with so few patients in the “eligible” group (N=1), the statistical consequences of even one family’s decision to decline are significant.
Second, the family’s decision isn’t really reflection of the process of the hospital or the organ procurement organization, much less the hospital’s commitment to that process. The process functioned, but wasn’t really measured. Only the outcome was measured, and that, again, was largely the result of factors beyond our control. We can offer families the opportunity to donate. We can discuss the need, and the generosity the gift would demonstrate. We can describe it as a service to the family, and as a gift that brings some blessing in their grief. What we can’t do is control their decision. Indeed, to suggest we could control the decision would be to imply coercion, or, worse, to encourage it.
There are other questions that might be asked, and these would provide a much better, and certainly more complete, perspective on the institution’s commitment to donation. The first would be to ask about the hospital’s “referral rate.” We, like other hospitals, are required to inform the organ procurement organization (OPO) of every death. So, a good measure would be how consistently we make that required phone call, and make it in the appropriate time frame (a measure that in my hospital is, by the way, 100%). Hospitals with lower referral rates would certainly demonstrate less commitment to donation.
The second question that might be asked would be about the conversion rate for donation of tissues. Skin, long bones, heart valves, corneas, and other tissues that aren’t directly sustained by blood flow, can be donated by patients who have died cardiac death, and so have not been severely brain injured, or sustained on the vent. The corollary to the low incidence of deaths of severely brain-injured patients in my hospital is that all the other deaths were cardiac deaths. Those patients were appropriately assessed for their potential for tissue or cornea donation; and when the patients were eligible, their families were appropriately approached. For hospitals like ours, with so few patients who might even be assessed for organ donation, eligibility for tissue donation and tissue conversion rates would seem more appropriate measures.
Now, the number of families who choose to donate is certainly a relevant number. Even with recent questions about the accuracy and adequacy of the lists of patients who would benefit from transplants, there is agreement that there are many more patients who might benefit from transplant than there are organs currently being donated. And for large hospitals, and especially those with transplant services, trauma centers, large stroke programs, or other factors that would suggest larger populations of patients who might be eligible, perhaps there’s some reason to measure the conversion rate. However, that number is really controlled by families making decisions in emotionally difficult times. That means the number is really more a factor of discussions that happen over the dinner table than of discussions, however persuasive, at the bedside in ICU. Rates of donation will be affected much more by education and information in the community than by even the best recovery processes of hospitals or organ procurement organizations. That doesn’t mean hospitals and OPO’s shouldn’t be involved; but perhaps the questions need to be about their educational and public service efforts, as well as rates of appropriate referral. Those activities will have a better effect on how many families are willing to donate. So, those questions would say a lot more than conversion rates about an institution’s support for donation efforts.
Monday, April 07, 2008
Getting Ready for Anaheim: Commission on Health
As I write this, I'm on my way home from a meeting of the Standing Commission on Health of the General Convention. I have written before that the General Convention in 2006 reestablished the Commission as part of an extensive reorganization of Convention Commissions. Actually, it was reauthorized in 2003; but in 2006 they also approved a budget, which makes a big difference.
Mind you, it wasn't a big budget, and so this may be the only face to face meeting between Conventions. So, Commission members and invited guests like me discussed what issues the Commission might address in 2009, both in their Commission report, and also in resolutions.
There were many ministries discussed, addressing many different facets and issues in health care. Some seemed suitable for resolutions and simply for inclusion in the report. Some seemed to be more in line with the mission and resources of another commission or committee. Some we just weren't sure how to deal with, as valid as the concerns might seem. Issues that seemed within the mission of the Commission were delegated to various persons, both members and guests, for further work. I have some work to do myself on universal access to health care, and on care at the end of life.
Which brings me to you, faithful reader. What are the issues that you might want the Standing Commission on Health to address? I'm not a member of the Commission, but I know who to call. And if perhaps it doesn't really fit within the mission and resources of the Commission, I know how to pass the word along.
So, tell me what you think. What should the Commission on Health address at the 2009 General Convention? I can't wait to hear your ideas.
Mind you, it wasn't a big budget, and so this may be the only face to face meeting between Conventions. So, Commission members and invited guests like me discussed what issues the Commission might address in 2009, both in their Commission report, and also in resolutions.
There were many ministries discussed, addressing many different facets and issues in health care. Some seemed suitable for resolutions and simply for inclusion in the report. Some seemed to be more in line with the mission and resources of another commission or committee. Some we just weren't sure how to deal with, as valid as the concerns might seem. Issues that seemed within the mission of the Commission were delegated to various persons, both members and guests, for further work. I have some work to do myself on universal access to health care, and on care at the end of life.
Which brings me to you, faithful reader. What are the issues that you might want the Standing Commission on Health to address? I'm not a member of the Commission, but I know who to call. And if perhaps it doesn't really fit within the mission and resources of the Commission, I know how to pass the word along.
So, tell me what you think. What should the Commission on Health address at the 2009 General Convention? I can't wait to hear your ideas.
Tuesday, April 01, 2008
What, Annunciation? Now?
I have to admit that this has been something of an odd day for me. It may be April 1, but it’s also the Feast of the Annunciation.
I know, I know: the Feast of the Annunciation is March 25 (Nine months to the day from Christmas! Isn’t that an interesting coincidence?) However, this week, with our early Easter, March 25 feel during Easter Week. In the calendar of the Church, nothing else takes priority over Easter Week; and so the Feast of the Annunciation was, as we say, transferred to the first available day. (Note that the first available day wasn’t Monday. That went to the transferal of the feast of St. Joseph, which this year fell during Holy Week – another week over which nothing else can take priority.)
This caused me some small distraction in part because I was ordained a deacon years ago on the Feast of the Annunciation. In those days I was in my first CPE Residency (for those unfamiliar, a year of clinical education in pastoral ministry, serving as a hospital chaplain) at Children’s Memorial and Grant Hospitals of Chicago, two fine hospitals joined in those days only by a shared Pastoral Care Department and a long block of Lincoln Avenue. (The Avenue remains; the department is long gone.) I was from the Diocese of Tennessee, much less Anglo-catholic than my surroundings in Chicago, and much less Anglo-catholic than I am now. I had had a confrontation with both rector and organist of the parish I attended over a hymn to the Blessed Mother sung on the previous Fourth Sunday of Advent (for which the lesson that year was indeed the Annunciation). I had no problem with the first verse speaking of the Blessed Mother as witness to the Incarnation; nor to the second verse speaking of her as witness to the Crucifixion; nor even to the third verse speaking of her as witness to the Resurrection. However, when the fourth verse referred to her bodily Assumption, I almost walked out. Granted there are many who believe in it, and even in the Episcopal Church there were some who held to it as a part of their private piety. But, not being based in Scripture, it couldn’t be taught as doctrine in the Episcopal Church (who says I don’t love the 39 Articles?), and certainly shouldn’t be used in worship. I phoned that afternoon to express my concern to both the rector and the organist, each of whom proceeded to blame the other.
So, when I announced to the rector the date of my ordination to the diaconate, he asked, “You mean, you’re being ordained on the Feast of the Annunciation of the Blessed Virgin Mary?” With a righteous rigor that is only palatable in one so young, I responded, “No, I’m being ordained on the Feast of the Annunciation of our Lord Jesus Christ to the Blessed Virgin Mary.” He smiled a thin smile. (Perhaps my righteous rigor wasn’t so palatable. After all, I had already lost the privilege of preaching in the parish on somewhat similar grounds; and even after my ordination all I was ever invited to do was take a chalice and chant the Gospel.)
So, I remember March 25 and the Feast of the Annunciation as the anniversary of my ordination as a deacon. The transferal of the date has been just a bit disorienting.
We do have a special devotion to the Blessed Mother in our house. This is particularly true of my Best Beloved, who has a shrine in her room and a collection of rosaries; but it’s true of me as well. While it’s not a common part of my private piety, I don’t have any trouble praying the “Hail Mary” with my Catholic patients; and I have the opportunity often enough to explain to non-Catholics the difference between devotion to the saints and asking their intercession, and true worship, which is due only to God.
And, after all, the Blessed Mother picked out our puppy. Those years ago when we were thinking of a puppy, and touring various opportunities for adoption (well, my Best Beloved was thinking of a puppy; I was thinking of wee hours trips to the back yard, without much enthusiasm, but with a fine devotion to my Best Beloved), my Best Beloved would tell me she would “just know” when we had found the right dog. In fact one Saturday afternoon she said, “This is it. This is her.” Sass was, and is, a sweet, somewhat submissive, little bitch of uncertain ancestry, and she has turned out to be a great success. When I asked my Best Beloved how she had chosen her, she replied, “Oh, the Blessed Mother spoke to me. She said, “There’s your dog. What are you waiting for?” Not that I was inclined to argue with my Best Beloved anyway; but, who was I to argue with the Blessed Mother? And after all: the dog has turned out to be a great success.
So, all in all the transferal of the Feast of the Annunciation has been something of a disruption of routine. I did observe it today, in the Daily Offices if not in the Eucharist. (I decided the transferal would take more time to explain than I had in a half-hour hospital service.) I did give thanks for my ordination, and for the gracious service of the Blessed Mother, well established in Scripture. And now I can give thanks that I may never see so significant a disruption of my routine in my lifetime; for it will be long and long before Easter comes anything like this early again.
Holy Mary, Mother of God, pray for this sinner, now and in the hour of my death. Amen.
I know, I know: the Feast of the Annunciation is March 25 (Nine months to the day from Christmas! Isn’t that an interesting coincidence?) However, this week, with our early Easter, March 25 feel during Easter Week. In the calendar of the Church, nothing else takes priority over Easter Week; and so the Feast of the Annunciation was, as we say, transferred to the first available day. (Note that the first available day wasn’t Monday. That went to the transferal of the feast of St. Joseph, which this year fell during Holy Week – another week over which nothing else can take priority.)
This caused me some small distraction in part because I was ordained a deacon years ago on the Feast of the Annunciation. In those days I was in my first CPE Residency (for those unfamiliar, a year of clinical education in pastoral ministry, serving as a hospital chaplain) at Children’s Memorial and Grant Hospitals of Chicago, two fine hospitals joined in those days only by a shared Pastoral Care Department and a long block of Lincoln Avenue. (The Avenue remains; the department is long gone.) I was from the Diocese of Tennessee, much less Anglo-catholic than my surroundings in Chicago, and much less Anglo-catholic than I am now. I had had a confrontation with both rector and organist of the parish I attended over a hymn to the Blessed Mother sung on the previous Fourth Sunday of Advent (for which the lesson that year was indeed the Annunciation). I had no problem with the first verse speaking of the Blessed Mother as witness to the Incarnation; nor to the second verse speaking of her as witness to the Crucifixion; nor even to the third verse speaking of her as witness to the Resurrection. However, when the fourth verse referred to her bodily Assumption, I almost walked out. Granted there are many who believe in it, and even in the Episcopal Church there were some who held to it as a part of their private piety. But, not being based in Scripture, it couldn’t be taught as doctrine in the Episcopal Church (who says I don’t love the 39 Articles?), and certainly shouldn’t be used in worship. I phoned that afternoon to express my concern to both the rector and the organist, each of whom proceeded to blame the other.
So, when I announced to the rector the date of my ordination to the diaconate, he asked, “You mean, you’re being ordained on the Feast of the Annunciation of the Blessed Virgin Mary?” With a righteous rigor that is only palatable in one so young, I responded, “No, I’m being ordained on the Feast of the Annunciation of our Lord Jesus Christ to the Blessed Virgin Mary.” He smiled a thin smile. (Perhaps my righteous rigor wasn’t so palatable. After all, I had already lost the privilege of preaching in the parish on somewhat similar grounds; and even after my ordination all I was ever invited to do was take a chalice and chant the Gospel.)
So, I remember March 25 and the Feast of the Annunciation as the anniversary of my ordination as a deacon. The transferal of the date has been just a bit disorienting.
We do have a special devotion to the Blessed Mother in our house. This is particularly true of my Best Beloved, who has a shrine in her room and a collection of rosaries; but it’s true of me as well. While it’s not a common part of my private piety, I don’t have any trouble praying the “Hail Mary” with my Catholic patients; and I have the opportunity often enough to explain to non-Catholics the difference between devotion to the saints and asking their intercession, and true worship, which is due only to God.
And, after all, the Blessed Mother picked out our puppy. Those years ago when we were thinking of a puppy, and touring various opportunities for adoption (well, my Best Beloved was thinking of a puppy; I was thinking of wee hours trips to the back yard, without much enthusiasm, but with a fine devotion to my Best Beloved), my Best Beloved would tell me she would “just know” when we had found the right dog. In fact one Saturday afternoon she said, “This is it. This is her.” Sass was, and is, a sweet, somewhat submissive, little bitch of uncertain ancestry, and she has turned out to be a great success. When I asked my Best Beloved how she had chosen her, she replied, “Oh, the Blessed Mother spoke to me. She said, “There’s your dog. What are you waiting for?” Not that I was inclined to argue with my Best Beloved anyway; but, who was I to argue with the Blessed Mother? And after all: the dog has turned out to be a great success.
So, all in all the transferal of the Feast of the Annunciation has been something of a disruption of routine. I did observe it today, in the Daily Offices if not in the Eucharist. (I decided the transferal would take more time to explain than I had in a half-hour hospital service.) I did give thanks for my ordination, and for the gracious service of the Blessed Mother, well established in Scripture. And now I can give thanks that I may never see so significant a disruption of my routine in my lifetime; for it will be long and long before Easter comes anything like this early again.
Holy Mary, Mother of God, pray for this sinner, now and in the hour of my death. Amen.
Picked Up for Grand Rounds
One of my recent posts has been accepted for this week's Medical Grand Rounds, a blog carnival on all things health care that's now in its fourth year. This week responsibility for posting has been shared among three different host blogs. My post is linked at GruntDoc's. The second section is at Dr. Val's (and hers is clearly a reasonable voice). Finally, the third section is at David Williams' Health Business Blog.
Take some time to take in these interesting posts. The topics are wide-ranging, and the posts are very interesting (at least all those I've had a chance to look at so far). I'm pleased to be in such good company.
Take some time to take in these interesting posts. The topics are wide-ranging, and the posts are very interesting (at least all those I've had a chance to look at so far). I'm pleased to be in such good company.
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