Standards of Practice for Chaplain: Standard 1, Part A

I know it’s been a while. Bear with me.

Many of the professions involved in health care have long had Standards of Practice. For example, you can learn about nursing standards here; or about social workers here.

In 2009 a group  with representatives from the Association of Professional Chaplains (APC) and the National Association of Catholic Chaplains (NACC) produced a set of Standards of Practice for Chaplains in Acute Care (which is to say, in hospital settings). You can learn more about that process and access the Standards here.  The Standards may have several benefits for us in the profession.

Having Standards of Practice will now help chaplains communicate with others about chaplaincy and assist chaplains in discussions with other chaplains. Ultimately, the goal is to ensure a consistently high clinical practice for our profession.

With these goals in mind, my department is embracing these Standards of Practice. Over time they should become the framework for our work, and the way that we “tell our story” to other chaplains and to administrators.

That means I need to be thinking through these Standards myself. I need to be able to speak to them if I’m going to help others embrace them; and one of my most effective ways to think is to think out loud here.

The Standards are divided into three sections. Section 1 is Chaplaincy Care with Patients and Families. The sections begin with “Standard 1, Assessment: The chaplain gathers and evaluates relevant data pertinent to the patient’s situation and/or bio-psycho-social-spiritual/religious health.”

As I look at the Standard, the first issue has to be definition of terms. For me, the hardest isn’t really the strangest. “Bio-psycho-social-spiritual/religious health” is simply – no, let’s just say really – a jargonistic way to speak to the health of the whole person, incorporating an expectation that a person who is holistically healthy is spiritually healthy.

No, I’m much more concerned first about “relevant data pertinent to the patient’s situation….” What are we considering data?

One of the older documentation frameworks, used in many cases in Social Work and also sometimes by chaplains, is the classic SOAP note: Subjective, Objective, Assessment, Plan. The categories that are about data are Subjective and Objective: what are the statements the person can make based on perception (Subjective – like “Patient appears anxious”); and what are the statements that others would also see as facts (Objective – like “Patient is holding a rosary”). Both the subjective and objective statements are data; and by identifying some as “subjective” and some as “objective” there is some acknowledgement of differences of authority.

So, for chaplains, what might we consider data? What we perceive, certainly; and what is reported. For example, both what we have in the present moment can inform us, and also what stories we hear from patients and family members. A patient’s statement about church membership is data, and so is the patient’s story about a childhood experience in Sunday School.

Which confronts us with the qualifying term: what makes the data relevant? Actually, the Standard is to evaluate the data for relevance. Our models for evaluation are the frameworks within which we determine whether the data is relevant. So, let me think a bit and then come back in the next reflection.

New Resources for Episcopal Wonks

I have referred a number of times to great stuff one can find on line through the Digital Archives of the Episcopal Church. It's where I've found past Resolutions of General Convention and Actions of the Executive Council. Well, now there's a whole new resource there: the Reports to General Convention (better known as the Blue Book) for Conventions dating back to 1976.

What can you find there? Between Conventions there are a variety of groups who meet to carry forward the priorities set by each Convention. They are the Commissions, Committees, Agencies, and Boards (CCAB's) of the Church - some under the jurisdiction of General Convention itself, some of the Executive Council, and some of one or both of the Houses of Deputies and of Bishops (often referred to as the "Interim Bodies"). Each Interim Body reports to the next General Convention on its work. Part of those reports may be specific resolutions to General Convention (the "A" resolutions). However, each report also gives discussion, reflection, and rationale for the work and priorities of the Church. So, each report gives a window into the thinking within the Church on a given issue. To make matters easier, the good archivists separated out each report. So, you don't have to open up a 400+ page Blue Book. You can link to a specific report.

Now, sometimes you'll have to dig a little to see which body had responsibility for a particular topic. Some bodies have changed their names over time, and some have been added. However, each document is searchable. 

So, if you want to know what has been said to the General Convention on a topic, often by some of the best minds in the Episcopal Church, this is the place to look. It offers a depth and perspective on many issues that you won't get just looking at a resolution. And since these reports are received by General Convention, they will show for each Convention the best work for the time, if not necessarily the official statements (which resolutions would), often by some of our best minds.

So, go dive in. You'll be amazed (and perhaps sometimes appalled) by what you find.

Reflection for the Day 11-8-2012

A woman stopped me in a parking lot this morning. She wanted money for gas. I gave her some. She wanted a little more "for milk for the children." I gave her a little more.

I had two concerns that were both in my mind. One was whether I'd actually done her good. I couldn't know whether she would use the money well or poorly. I might be sustaining a vicious habit, ultimately harming her. Sometimes, we're told, better to say no and press the person to seek help from an agency that can provide access to more resources. So, one thought was to wonder whether I was helping or harming her.

The second thought was whether in the process I'd been cheerful enough.

More Data for More Reflection on Health Care and the Market

In my last post, I asked this question: "If [employer-provided] health insurance grew as a benefit because there were more jobs than workers, what can we expect when there are more workers than jobs?" Well, I think we have an answer, and it isn't a happy one. 

Take a look at this article from Associated Press, picked by the Huffington Post: "Darden Restaurants Tests Hiring Of More Part-Time Employees To Avoid Obamacare Costs." Darden Restaurants, Inc., best known as owners of Olive Garden and Red Lobster, is making a deliberate choice to reduce its costs for employer-provided health care by reducing the number of employees who work enough hours to qualify. The authors of the article also note that other restaurant chains are making the same decision.

Now, there's nothing illegal about this. I think it's immoral, but in one sense that's neither here nor there (and, in the classic trilogy, I would worry about "fattening," but that's for another time). I simply hold this up as the other side of depending on the market and competition to provide access to health care. If we believe that universal access to health care is a good thing, and should be seen as a civil right, we simply can't depend on the market and competition to bring it about.

More Reflection on Health Care and the Market

While I'm not watching the Vice Presidential Debate....

There are two things that bother me when anyone speaks optimistically about how a market approach and competition will solve problems of access to health care (whether in response to the Affordable Care Act, or as a means for changing Medicare). One is that those persons either don't know how the market for health care actually works, or they hope that we don't know.

The second is that we have seen how the market and competition will (or won't) work in providing access to health care. We have a long tradition of treating access to health care (not to say health itself) as a retail commodity. In private practice, each physician practice is a small business. It stands or falls on whether it makes enough revenue to pay the physician and all the physician's employees and all the business' expenses. That is, the physician practice needs to make a profit. 

The same is true of institutions. Oh, there are not-for-profit institutions; but they still have to keep ahead of the cost of living. Call it "margin" instead of "profit;" but the institution has to accomplish it. As the not-for-profit folks remind themselves, "no margin, no mission." For-profit institutions, like any other for-profit businesses, are accountable to their owners and investors to be profitable.

The same is true of insurance companies. Certainly, there are several important government insurance programs - Medicare, Medicaid, and TriCare - but the vast majority of insurers are for-profit corporations. The negotiations that happen, whether between individual and agent or between corporate  benefits departments and brokers, involve striking a balance between service and price. It's really not that different, really, from leasing a car.

Now, those negotiations rarely happen at "point of sale." That's because we do participate in groups to purchase access to health care. So, others do the negotiating on our behalf. So, maybe it's not retail. If not, though, it's wholesale, just as GM and Ford negotiate with their parts suppliers, and the person who purchases the car doesn't get to negotiate for one starter motor over another. Nobody questions that the wholesale process is a market process with a lot of competition involved.

Now, some might say that the government insurance programs have totally changed the market. I would suggest that they haven't for two reasons. The first is that most of us get our insurance, our access to health care, through an employer, whether our own or a family member's; and most of us don't work for government (including all the various governmental levels and bodies). The second is that the not-for-profit players haven't affected the ability of the for-profit players to make a profit. Sure, there are some insurers who don't have members because those members are covered by government; but all those government insurers are still doing business with physicians, institutions, pharmaceutical companies, etc, that are not government institutions, and most are making a reasonable and healthy profit.

There was, however, a time when we did have an entirely market orientation to health care. It lasted until the establishment of Medicare in 1967. Last weekend I spoke to nurses who graduated from nursing school well before that date. I was young then, but I still remember the public service announcements focusing on how many of our elderly were impoverished. One of the consequences of that poverty was that many couldn't afford health care. In recent years we've been concerned about seniors being faced with a choice between food and medicine. In those days it was also an issue - there just weren't as many medications available. Medicare wasn't created on a whim. It was created because this was a real problem, and people were suffering and dying for lack of care. The same is true of Medicaid. Medicare and Medicaid were developed because in a market approach to health care, competition wasn't working. If competition were going to work now, why wasn't it working then?

Now, some might ask about employer-based health care. Actually, employer-based health care was a result of competition in the market. In World War II there was a shortage of labor - more jobs than employees, what with so many in the military, and the demand so great for war materiel. However, wages were frozen, in an effort to control costs. So, employers had to find a new way to compete for employees. They started offering new benefits, including health insurance that the employer helped provide. So, employer-based health insurance did come as a result of a market.

But, that was a different market indeed. We're nowhere near the demand for labor that we knew in the War Years, or even in the Post-war Years. If health insurance grew as a benefit because there were more jobs than workers, what can we expect when there are more workers than jobs? See, that's the other problem with trusting competition to solve the issue. That works in the individual's favor when the market is up and tight, but the market isn't always up and tight. Indeed, it's not realistic to imagine that it will always be up and tight, or even much more than half the time. But, as we will remember if we remember what it was like before Medicare for seniors, or before the expansion that came with the Second World War, there were an awful lot of folks who couldn't afford health care. A market approach and competition just weren't getting the job done.

So, no, I'm not prepared to leave it to the market, or to trust competition to address the problem. It didn't it before. Indeed, it isn't doing it now, even with government programs to cover an awful lot of the most vulnerable, the least insurable. Based on history, on our national experience, I have no hope that it will work in the future.