By David Lichter
Executive Director
We know chaplaincy has had to address several key business issues, such as productivity (what is done by a chaplain?), effectiveness (is it working?), and impact (can it be measured?).
Recently, however, the Quality Subcommittee of the CHA Pastoral Care Advisory Committee has been working on evidencing quality in spiritual care. The Institute of Medicine in 2001 defined quality health care as “safe, effective, patient-centered, timely, efficient and equitable.” Spiritual care providers need to take the lead in creating a culture of quality care and measure the quality of services. But what does quality look like in spiritual care? What is an improving quality in spiritual care? Over the past year or so, the PCAC’s Quality Subcommittee has tried to provide some answers. Along with me, members include Marie Parker, RSM, Director of Mission and Spiritual Care at Trinity Health; Tim Serban, Chief Mission Integration Officer at Oregon Providence Health & Services; and Mark A. Skaja, Vice President of Mission Integration and Spiritual Care at Mercy Health.
Determining Measures for Quality
The fundamental question was “How can we articulate an overall approach to and measure quality in spiritual care?” At the suggestion of Mark Skaja, John Meyer, vice president of the hospital efficiency improvement program at Mercy Health, provided a framework. The threefold approach considers process measures, outcome measures, and performance aligned with standards.
A process measure focuses on a process that leads to a certain outcome. So the questions are: Did you do it (services complete)? Did you do it right? Process measures can be isolated to a particular activity. For example, newly admitted patients are to be seen within 24 hours of admission, one is to chart within 30 minutes after the patient encounter, or the spiritual care department is to be notified within 60 minutes of a referral. Is the process designed and implemented to gather the identified elements?
Outcome measures focus on results. Did the completed process get the desired/expected outcome? Are provisions made to standardize, update, improve, and review outcomes? For example, is the chaplain meeting a patient’s spiritual or emotional need? What does the patient report? If a chaplain was called to comfort an anxious patient, did that person’s anxiety lessen?
Performance aligned with standards focuses on the measurable standards agreed upon across the profession. For instance, professional chaplaincy has standards for certification and standards of professional chaplains in acute, long-term care, and hospice and palliative care. Does a chaplain’s performance meet those standards? How would a spiritual care department measure those standards? For instance, consider auditing a specific number of patient charts each month.
These three forms of measuring quality can work together. Spiritual care is an integral component of the palliative care team, so the process measure might be that palliative care initiates contact with chaplain upon patient admission within 24 hours. Performance aligned with standard might be that annually the palliative care team evaluates whether the chaplain’s performance meets standards 1 through 6 of the Standards of Practice for Professional Chaplains in Acute Care. And the outcome measure might be that the chaplain tracks the number of palliative care patients seen, so that one could measure the variables in patients seen and not seen by chaplain.
In a non-acute care setting, perhaps the spiritual care department trains outpatient clinical staff on spiritual distress screening tools, so they can better identify spiritual and emotional distress that needs to be addressed by chaplains, thus generating spiritual care referrals. The process measure might be to report the number of staff trained in assessment, and the number of referrals made to spiritual care staff. The outcome measure might involve having the staff take pre- and post-tests that indicate level of comfort with detecting spiritual care distress. Performance aligned with standards might impose a standard that screening and referral tools and processes will be in place, with gradual training of all staff, such as year one 50%, year two 80%, year three 100%.
Early in 2014, the CHA Quality Subcommittee invited spiritual care leaders to share their experiences and practices with their spiritual care assessments in the electronic medical records. Participants included Beverly Beltramo, Oakwood Health System, Dearborn, MI; Carolanne Hauck, Lancaster General Health, Lancaster PA; Julie Houser, NYCHHC; Mary Lou O’Gorman, St. Thomas (Ascension Health), TN; Tim Serban, Providence Health and Services, OR; Mark Skaja/Amy Marcum, Mercy Health, OH; Mary Toole, St. Francis Hospital, Roslyn, NY, part of CHSLI; Mary Jo Zacher, OSF HomeCare Services, Peoria IL; Kay Gorka, Providence Health and Services, Spokane, WA; Matthew Kronberg, Dignity Health, California; and Richard Brochu, along with Sr. Marie Parker, VP Mission, Trinity Health. Gordon Hilsman, retired CPE supervisor, formerly with CHI Franciscan Health in Tacoma, WA, served as a consultant.
After a few meetings, we learned that we needed a common understanding of the purpose of spiritual assessments to share in broader publics. Some of the common understandings included:
- The practice is grounded in the dignity and wholeness of the human person.
- Identifying and addressing resistances to healing also affects the ability to cure.
- Providing to the interdisciplinary team quality spiritual assessment information offers insight into patient’s personal values, goals of care, and preferences for treatment, and how to communicate with the person regarding treatment options.
- If spiritual and religious emotional needs/distress are not addressed, it adversely affects choice of treatments, health outcomes, the patient experience, and the perception of quality care.
Also, we needed to articulate a common understanding of why spiritual assessments, including charting, should be integrated into EMRs. We agreed that:
- EMRs are the interdisciplinary team vehicle for information transmission, so the chaplain needs to contribute to it.
- One of the chaplain’s core competencies is capturing in words the present humanness/soul of the patient, thus contributing unique and vital knowledge.
- This information helps IDT members find direction as their discipline might recede toward futility, especially in some specialties, such as hospice, ICU, and palliative care.
- EMRs help clarify the chaplain’s mind and communicate to other chaplains who may subsequently encounter the patient.
- For the patient and family members (who activate their right to see medical records), these records summarize how the patient is being treated as a fine human being regardless of any difficulties s/he may be seen as causing.
Grounded with these two areas of common understanding, the group examined their common experience and practices through the lens of the three approaches to measuring quality.
The process measure identifies common elements that could become part of the spiritual care assessment. One could measure whether these elements were in place. The most common included:
- Some assessment model, such as APIE (Assessment, Plan, Implementation and Evaluation) or SOAP (Subjective, Objective, Assessment, and Plan) that comprises core elements such as:
- Types of intervention (initial/ongoing/crisis/sacrament/mediation/grief)
- Connection with family
- Religious affiliation
- Connection with faith community — requests contact with faith community
- Fear level (severe substantial, moderate, mild)
- Ethical issues identified
- Spiritual care interventions
- Consult /referral to other services
Other elements that were not as common but considered important included:
- Sense of holy/God
- Peace/comfort
- Spiritual strengths
- Role of the faith community (meals, grief counseling)
- Physical pain (hospice-centric)
- Future care that included a brief narrative and types
- A mutuality screen that was shared with and used by members of the IDT
Through the lens of measuring performance aligned with standards, one could first include the professional chaplaincy standards for certification (303.8, 304.6, 305.1) and Standards 1 and 3 of the standards of practice to measure their performance aligned with standards.
Three potential standards for spiritual care assessments within EMRs could be:
- An SCA is in place with specific core content that includes:
- Referral source/comment
- Type of assessment/clinical encounter (e.g. initial, crisis, mediation, grief work, palliative care)
- A specific assessment model (e.g. APIE, SOAP, SOAPIER)
- Key interventions — perhaps top five (drop-down boxes) with specific and clear list available to chaplain, IDT, and others
- Free-form narrative capability
- The quality of the chaplain’s SCA is measured by whether it:
- Is available to all and in all settings
- Is transparent to patients, colleagues, and care teams
- Is patient-focused
- Is IDT-inclusive (including complementary healing disciplines)
- Employs clear, defined, common terminology (such as assessment, intervention, goals, outcomes)
- Utilizes both assets and distress language
- Includes common spiritual assessment categories (such as meaning, hope/peacefulness, concept of the holy); referral to others; community/support system; narrative/documentation; plan for future care
- Assists in creating a spiritual integration network in each community
- The quality of the narrative documentation is measured by whether the narrative:
- Has a clear and mutually understood structure; e.g. Why were you called? Who was present? What were the interventions? How were the interventions received? What’s the future plan?
- Is understandable, concise, substantive
- Is affirmed as helpful by IDT through feedback
Finally, for the outcome measure, the group suggested that one can measure by whether provisions are made for spiritual care departments to provide ongoing education on quality documentation, and for processes to continue to improve the SCA in EMR, including:
- Input of the IDT on usefulness of chaplain interventions and notes
- Designed and utilized criteria template for chart review, utilizing current chart review teams in quality departments
- A regular chart review by the spiritual care department and the IDT
If you are familiar with SCAs within EMRs, we hope you see the potential for identifying and utilizing specific measures for quality improvement that will help us improve our role on the IDT. Our group continues to learn from one another and look for others to join them in this important venture. If you have feedback or would like to participate, please contact David Lichter (dlichter@nacc.org).
