Fiscal approach actually raises department’s standing
Dean V. Marek
What is an expense per unit of service?
I didn’t know in 1998, when I had to come up with the answer for the Department of Chaplain Services at Mayo Clinic, Rochester. But I was told that we would have to calculate the cost of each patient and family visit. I protested, “How is that possible? No two visits are alike. No two chaplains are alike!”
“You have no choice in the matter,” our administrator countered. “Every department has done it. Now it’s your turn.” A saving grace came when he said, “We don’t want to tell you what to do. We want you to tell us what you do.”
When I brought the idea to our staff, their initial response was similar to mine. “How can we standardize a spiritual care encounter? We should be exempt from such an unholy process. Imagine, putting a cost on spiritual services! Would charging for pastoral care be next?”
Seven years later, however, we can see how this bottom-line approach benefited our work. We began to think in terms of services provided instead of patients visited. We have a comprehensive list of spiritual care services to share with administrators whose understanding of our ministry sometimes seemed limited to praying with patients or saving souls. And by 2003, we added nine full-time equivalents.
After the initial decree was handed down, we were somewhat relieved when an accountant met with us and showed how the process worked. It was relatively simple. For a period of six months we would have to track the number of minutes it took to complete each patient visit and then divide our budget by those numbers. The result would be our expense per unit of service. Actually, it was a bit more complicated than that, but not beyond Math 101.
And then we learned that our budget would be managed by our expense per unit of service (UOS).We would be expected to meet or beat that expense on a monthly basis. Finally, there was this great incentive; we could add staff to the department if we were able to demonstrate that in doing so we would not raise our expense per UOS.
Gathering Data — the CARE Program
We needed a computer program to record our visits. In consultation with Mayo Information Technology, a Microsoft Access program was written and named CARE (Chaplain Activity Record – Electronic). The program logs our visits and tracks the time spent for each.
Defining What We Do — Service Types
If logging our activities in the CARE Program was to be undertaken with integrity, we first had to name and define each of our visits. We eventually dropped the term “visit” and replaced it with a more accurate descriptor, “service type.” The result was a catalogue of 28 Direct Service Types (see box) that explain the scope and extent of the spiritual care ministry we provide to patients, families, staff, and institution. The 14 Indirect Service Types track internal departmental activities. We hope this catalogue will eventually contribute to a common dictionary of chaplain-provided spiritual services for our profession.
Each service type is described as clearly as possible so that chaplains are able to record with accuracy the services they provide. When a patient or family encounter includes several services, they are recorded separately. The catalogue is reviewed periodically, service types are added as needed, and definitions are refined.
Space prohibits listing the complete catalogue, but you may request one from marek.dean@mayo.edu. For the sake of illustration, here are four service types.
Anticipated Death: Anticipated Death: Spiritual care provided prior to death, which may include guidance with decisions to withdraw treatment, facilitation of anticipatory grief, and prayers of support for loved ones.
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Direct Service Types |
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AM Admit |
Home Visit |
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Indirect Service Types |
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Administration |
Mission Support |
Death: Spiritual care provided at the time of death. It may include religious rituals, prayers of commendation, facilitation of grief, assistance with the Deceased Patient Protocol, and/or arrangements for loved ones to leave the hospital.
Pastoral Contact: An initial patient contact to establish a pastoral relationship, make a religious or spiritual needs assessment, and/or share information about the availability of chaplain services. Also, a short follow-up visit without any other service event.
Spiritual Care: A dynamic process wherein the chaplain assists a patient/client as a co-journer to find meaning in the experience of illness. Themes explored include, but are not limited to: life story; relevance of faith and belief in God; meaning of suffering; the effect of anger, resentment, despair, anxiety, shame, guilt, sin, forgiveness, and reconciliation on health/illness/well being; modalities of healing; means of coping; sources of support; fear of death; life review; and hopes for the future.
Calculating a Relative Resource Unit (RRU)
After tracking our spiritual care services over a six-month period, even with all the variant patient/family dynamics and chaplain pastoral styles, we found that there is a verifiable average time for every service type. The times in the four examples below approximate our actual minutes but are rounded to the nearest 10 for ease of calculation.
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Anticipated Death |
40 minutes |
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Death |
50 minutes |
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Pastoral Contact |
10 minutes |
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Spiritual Care |
30 minutes |
To assign a relative resource unit (RRU) to each service type, start with the service that requires the least amount of time and degree of competence. That is our Pastoral Contact, which averages 10 minutes. It is our baseline service and is assigned an RRU factor of 1.00. Now divide the minutes it takes to provide every other service type by the baseline service RRU, which is 10. The resultant RRU factors for the four examples are:
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Anticipated Death |
40 minutes ÷ 10 = RRU factor of 4.0 |
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Death |
50 minutes ÷ 10 = RRU factor of 5.0 |
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Pastoral Contact |
10 minutes ÷ 10 = RRU factor of 1.0 |
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Spiritual Care |
30 minutes ÷ 10 = RRU factor of 3.0 |
Not surprisingly, there is often a connection between higher competence and the greater amount of time it takes to provide the services.
Calculating an Expense per Unit of Service (UOS)
What follows is the method for calculating an expense per unit of service (UOS) using a one-month hypothetical budget of $25,000. Of course, an actual expense per UOS would be calculated using an entire year’s budget. Salaries of chaplains, administrative assistants, CPE residents, and all operating expenses, including paper clips, are incorporated.
Here are the final steps in the process, using our four examples.
1. Multiply the number of each service type for the month by its RRU factor:
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50 Anticipated Death |
x 4.0 = 200 UOS |
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55 Death |
x 5.0 = 275 UOS |
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120 Pastoral Contact |
x 1.0 = 120 UOS |
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210 Spiritual Care |
x 3.0 = 630 UOS |
2. Add all UOS for Total Units of Service: 1,225 UOS
3. divide the budget by the total number of UOS for the month:
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$25,000 ÷ 1,225 = $20.41. This is the expense per UOS. |
4. Now multiply the expense per UOS of $20.41 by the RRU factor for each service type. The result is the cost for each service provided:
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Anticipated Death |
$20.41 x 4.0 = $ 81.64 |
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Death |
$20.41 x 5.0 = $102.05 |
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Pastoral Contact |
$20.41 x 1.0 = $ 20.41 |
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Spiritual Care |
$20.41 x 3.0 = $ 61.23 |
If our chaplain services were income-producing, these costs would be billed directly to the patients who are served. However, since we are not income-producing entities, a portion of the cost for chaplain services is included as an indirect charge in all patient bills.
If we chaplains were in business for ourselves, the cost for every spiritual care service would have to be calculated in a similar fashion. If not, we would not be in business very long.
Conclusion
By now, if you read this far, you might be asking, "What’s this got to do with being a chaplain?"
Management by an expense per unit of service has taught us to be accountable to our institution for the funds provided to our department. We have learned that our services are relatively inexpensive compared to those of other departments. We have learned to value our work. We have learned that increased productivity on our part reduces the cost of spiritual care services to patients.
Developing a catalogue of services has been crucial in reminding us that spiritual care is an added value to the patients, families, and staff who come to our institution for medical care. Our list of services has greatly assisted in explaining the exact nature and breadth of our ministry to our administration. And, wonder of wonders, we chaplains — not known for our love of budgets or the bottom line — can give an exact accounting of the cost for each of our spiritual care interventions.
And believe it or not, we have learned with the CARE Program the value of computers in gathering data that can help us communicate with each other in ministry. The CARE Program is also a treasure chest of information for research and administrative reports. And it can tell us what we have accomplished with the staff we have, and what additional staff it would take to address what always remains to be done.
Finally, the expense per unit of service and the CARE Program provide each chaplain with a daily report of productivity, which is shared with his or her director on a monthly basis. Chaplains probably like this part of CARE the least, until we realize that it is an effort in teamwork, that it contributes to the accountability and financial health of our department, and that it gives us a way to be recognized and thanked for our efforts in ministry.
Rev. Dean V. Marek, NACC Cert., is Director of Chaplain Services at the Mayo Clinic in Rochester, MN.
This article first appeared in Vision, July 2005.
