System’s self-examination leads to better chart notes

By Kay Gorka

As chaplains, we are trained to be fully present, to provide nonjudgmental, confidential support, and to approach each patient without our own agendas. But historically, many chaplains have felt that charting undermines our values. As a result, at least in our hospital, the chaplains either did not chart or struggled to do it in a way that added value to the healthcare team. When our palliative care physicians audited charts, however, they identified multiple opportunities to improve the way chaplains documented spiritual assessments in the electronic medical record.

Our care facilities employ four staff chaplains in a community hospital of 197 beds and 12 staff chaplains in a 644-bed Level II trauma regional medical center that includes a children’s hospital. We partner with a palliative care team that includes four physicians, one nurse practitioner, two registered nurses, and one social worker. In November 2013, we began focusing on improving the quality of chaplains’ narrative documentation in the EMR.

Quality improvement requires awareness of the gap between where we are now and where we want to be. I recently watched a TED talk by business professor Linda Hill titled “How to Manage for Collective Creativity.” She emphasized there are three components needed in innovation: 1) creative abrasion — to amplify the differences; 2) creative agility — utilizing a scientific process and the creative process; and 3) creative resolution — combining opposing ideas. This requires action-reflection-integration, a process all too familiar to chaplains.

On our team, the creative abrasion began with amplifying three differences. First, the palliative care team requested that the chaplains write a well-organized narrative using a documentation tool. Second, the chaplains researched standard spiritual assessment tools for documentation and struggled to find an evidence-based tool that could be used in all clinical encounters. Third, the chaplains examined ways to integrate the Standards of Practice for Professional Chaplains in Acute Care, in particular, Standard 1 — Assessment and Standard 3 — Documentation of Care.

The palliative care team sought to easily acquire the information necessary for a holistic care plan including the concerns and hopes of the patient, and the resources available. The palliative care team preferred the acronym HOPE (Hope, Organized religion, Practices, Effects on healthcare). Chaplains, however, had trouble using this model consistently.

• The model was hard to write to when ministering to patients/families in trauma situations, medical/surgical units, codes/crisis, and mother/baby units.
• Spokane is 60% non-churched, and mostly people would classify themselves as spiritual and not religious.
• Chaplains struggled to know where to write their interventions or care plan.

Instead of throwing in the towel, the chaplains entered into the creative agility phase. We began with the scientific method of establishing our objectives: 1) to develop a standardized model that would work for any chaplain, in any assignment across our two hospital campuses; 2) to articulate a quality spiritual care encounter in the EMR; and 3) to have the chaplains’ written documentation be of value to the interdisciplinary team.

The process took 12 months. I met with each chaplain once a month as well as held chaplain team meetings at each hospital on a monthly basis. I met with the palliative care director quarterly throughout the year. Each time, we would focus on two questions: 1) What worked when you charted using the HOPE system? 2) What were the barriers when you charted this way?

In addition, we audited 10 chart notes by each chaplain. We quickly found we needed a standard tool to conduct chart audits. We researched what others were using; in particular, the NACC quality workgroup informed the tool we developed:

The second part of creative agility requires implementation of the creative process. After reflecting on the HOPE system, each chaplain developed a separate charting method, and we voted on one that best satisfied a chaplain’s need regardless of specialty or clinical area of practice. All our chaplains suggested improvements.

Finally, one of us collected the input of the chaplains and palliative care team, and then incorporated the standards of practice through an accessible format. All 16 chaplains at our two hospital campuses began charting with the same acronym for narrative documentation: CARE (Critical Information, Action, Resource, and Evaluation).

*Benefits especially the social workers
** Benefits especially the doctors and nurses

We immediately saw results. For example, when we started, the only time the palliative care team read the chaplain notes was during chart audits or if the team referred a patient to the chaplain. Now palliative care team members report that they consistently read chaplain notes before they enter patients’ rooms. One palliative physician estimated that reviewing chaplain notes saves her 30 minutes a day, and chaplains are receiving more referrals from the palliative care team and from other healthcare professionals in the hospital.

In addition, healthcare professionals outside the palliative care team have told us the chaplain narrative notes help inform their care plan and that they better understand the individual needs of the patient.

Going forward, three recommendations were identified: 1) The chaplain must close the loop by thanking the interdisciplinary team member who made the referral. 2) Quality in documentation is ongoing for all healthcare professionals, and we will continue chart audits. 3) More collaboration outside of the palliative care team will be needed to determine whether this is a valuable model across hospital specialty areas.

As professional members of the interdisciplinary clinical team, chaplains have an opportunity to hone our process and the way we organize our documentation. The gap is narrowing between where we want to be as integrated healthcare professionals and where we are now at the two hospitals in our local system.

Kay Gorka, BCC, is manager of spiritual care services at Providence SHMC/HFH in Spokane, WA.