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JCAHO and Spiritual Care:
An Invitation for Chaplains to Educate and Advocate

I , the Lord, have called you for the victory of justice, I have grasped you by the hand; I formed you, and set you as a covenant of the people, a light for the nations, to open the eyes of the blind, to bring out prisoners from confinement, and from the dungeon, those who live in darkness.

– Isaiah 42:6-7

Chaplain Michele Le Doux Sakurai
Chair, JCAPS

As the NACC Commissioner to JCAPS (Joint Commission for the Accreditation of Pastoral Services), I have had the opportunity and the privilege to dialogue with members of JCAHO’s administration. This dialogue began four years ago when JCAHO (Joint Commission on Accreditation of Healthcare Organizations), in its attempts to broaden health care to include the spiritual dimension of the patient, approached JCAPS. Finding a shared vocabulary has been a challenge, in part because JCAPS talked of the discipline of professional pastoral care (i.e., chaplains), while JCAHO spoke out of the context of patient rights. While both JCAPS and JCAHO have worked towards a shared understanding of spiritual care, it is vital for chaplains to recognize that JCAHO’s expectations of institutions are somewhat dynamic and not always predictable. This is not surprising considering JCAHO’s paradigm.

JCAHO is entrenched in the medical model. This model has definitive indicators which can be measured. Spiritual care carries few clear indicators, and as result, JCAHO has (initially at least) depended on those areas in which spiritual care is hooked into the medical model, such as:

  1. How is patient confidentiality protected? Who has access to church and denominational lists?
  2. What is the denominational/ church preference of the patient, and are there beliefs which impact the care plan for the patient?

These questions make sense in light of JCAHO’s concern for patient rights. JCAPS’ dialogue with JCAHO has focused on broadening JCAHO’s vision to include a more comprehensive understanding of spiritual care. On their website (, JCAHO has updated (as of June 1999) a spiritual assessment which reflects such an understanding. (Look under Standards.) Although JCAHO does not require a chaplain to do the assessment, it is a good tool.

Ultimately, it is the survey team that determines whether an institution meets the needed criteria. The questions that the team asks come out of their own understanding of spiritual care as much as out of prescribed questions. For example, in our last JCAHO survey, the surveyor was interested in the spiritual care plan we had developed for a Catholic patient who was NPO and unable to receive communion. It was clear that this surveyor understood the importance of sacramental support for Catholic patients. And yes, he did verify that spiritual care had been documented in the chart of the patient.

An area that seems to be the foster child of pastoral care is Advance Directives. All hospitals are required to provide this information to patients, and some Pastoral Care Departments have taken on this responsibility. JCAHO’s interest lies in the questions being asked, not in who asks the questions. (If your pastoral care department is being asked by the health care institution to take on this responsibility, be prepared for not only questions regarding the process of administering and charting the directives, but the question, “What percentage of your patients have completed Advance Directives?”)

JCAPS is continuing its efforts to advocate for patient rights by educating accrediting organizations, such as JCAHO, as to the need to have certified chaplains in all hospitals. As JCAHO becomes more familiar with the parameters of qualified, professional pastoral care, JCAHO’s expectation should become less dynamic and more predictable.

If we, as chaplains, wait for this to occur, we will miss a vital opportunity. JCAHO’s struggle to understand spiritual care is our invitation to name ourselves and the work we do. Chaplains should be involved at all levels of a JCAHO survey.

1. Be proactive when preparing for the survey. JCAHO has moved from prescriptive to functional standards over the past four years. What this means is that JCAHO will not prescribe who is to provide support, but whether support is provided by someone qualified. As a result, JCAHO is asking chaplains about their training and education. At this time, JCAHO does not require chaplains to be certified, but JCAHO will protect patient rights by asking pastoral caregivers about their role and function in the care setting. For this reason, it is important that chaplains anticipate the questions.

Know the standards which address spiritual care better than the JCAHO surveyors. Under Patient Rights and Organizational Ethics, spiritual care is addressed in:

  • The "Overview:" "Patients have a fundamental right to considerate care that safeguards their personal dignity and respects their cultural, psychosocial, and spiritual values..."(CAMH update August 1997);
  • RI.1.1 Intent: "b. The patient's right to care that is considerate and respectful of his or her personal values and beliefs";
  • RI.1.2 Intent: "Patients' psychosocial, spiritual, and cultural values affect how they respond to their care. The hospital allows patients and their families to express their spiritual beliefs and cultural practices, as long as these do not harm others or interfere with treatment.";
  • Under RI.1.2.3 Examples of Implementation: "...Hospital policy directs clinicians to refer family members to appropriate clergy or other organization spiritual advisor for consultation when the issue of withholding resuscitative services arises." (Please note: Unlike the Intent of Standards, the Examples of Implementation are advisory only.)
  • RI.1.2.7 Intent: "The hospital's framework for addressing issues related to care at the end of life provides for ... Respecting the patient's values, religion, and philosophy,....Responding to the psychological, social, emotional, spiritual, and cultural concerns of the patient and the family.";
  • RI.1.2.8 Intent: "After taking into account personal, cultural, spiritual, and/or ethnic beliefs, communicating to patients and families that pain management is an important part of care. (This Standard will not be scored for compliance in the year 2000, but at a later date to be determined.)"
  • RI.1.3: "The hospital demonstrates respect for the following patient needs: ... RI.1.3.5 pastoral care and other spiritual services"; and
  • RI.2. Intent: "The hospital's staff exercises discretion and sensitivity to the circumstances, beliefs, and desires of the families of potential donors;"
(Above information: CAMH Update 3, August 1999).

Also be aware of those standards inclusive of all disciplines:

  • "PF.1.1 The assessment considers cultural and religious practices, emotional barriers, desire and motivation to learn, physical and cognitive limitations, language barriers, and financial implications of care choices";
  • "IM.2 Confidentiality, security and integrity of data and information are maintained";
  • "IM.7.1 The hospital initiates and maintains a medical record for every individual assessed or treated";
  • "IM.7.2 The medical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course, and results and promote continuity of care among health care providers";
  • "TX.1.2 Care is planned and provided in an interdisciplinary, collaborative manner by qualified individuals";
  • LD.2.11 Departments that are not medical staff services that provide patient care are directed by one or more qualified individuals";
  • HR.2 The hospital provides an adequate number of staff members whose qualifications are consistent with job responsibilities."
(Above information: CAMH 1998, COMISS/JCAPS Crosswalk).

2. Chart on all patients. To be fully integrated into the team, chaplains must chart. If charting on all patients is not possible due to FTE limitations, adopt a policy which addresses the criteria by which charting will be required (i.e., at all deaths, codes, patient/ staff request for a chaplain visit, etc.)

3. Maintain a high profile. Be involved prior to the survey, and be present at all JCAHO surveys on patient care units as well as ethics, the emergency department, etc.

4. During the survey, don’t merely respond; be proactive. (At our sister hospital, the JCAHO surveyor, while in the Emergency Department, remarked to the chaplain that he remembered seeing her on the surgery floor. Her response was, “Yes, but my role down here is very different than up in the wards.” What a wonderful entree into the breadth and depth of chaplaincy.)

5. Use this opportunity to educate, to help the surveyors recognize the need for chaplains (not other disciplines) to do the spiritual assessments. (Would JCAHO find it acceptable for chaplains to do nursing assessments?)

6. As your research uncovers other standards or areas of concerns, share this information. JCAPS is continuing its dialogue with JCAHO. If you have statistical or anecdotal evidence which supports the use of certified chaplains, exemplifies problems which occur when others besides trained chaplains are doing assessments/ interventions, or because of limited FTE, patient rights are being compromised, please e-mail me at I will be happy to share your concerns with JCAHO.

This is an exciting time for chaplaincy. The spiritual dimension of patients is being taken seriously. As chaplains, we have the opportunity to advocate well for those we serve by educating interdisciplinary teams, administrators, and accrediting organizations such as JCAHO. We do this because not only it is demanded of us as professionals, but more importantly, we advocate because this is our calling.

(This article appeared in the NACC Vision, March 2000, Vol. 10, No. 3, pages 6–7.)