Measurement and Mystery May 31, 2013 National Association of Catholic Chaplains Day for Professional & Spiritual Enrichment Orange, California

Measurement and Mystery

May 31, 2013

National Association of Catholic ChaplainsDay for Professional & Spiritual Enrichment

Orange, California

2

Introduction

Why chose theme?

Challenge in the healthcare arena

Work that has been done to date

Ongoing efforts

3

Leadership Issues

Catholic Healthcare • Mission = Business• Financial Realities• Culture• Competition

Mission Leaders

4

Mystery

Can one really measure the work of spiritual care? What is the theological basis?

5

Theological Grounding

Nature and grace Incarnation

• John 1:14 Word became flesh and dwelt among us. Incarnation

‒ Tell John what you saw. Sacramental

‒ Outward sign of an invisible grace

6

Theological Grounding

Time• Chronos – Time spent on earth• Chairos – Time of salvation • Doing a time-study of the Jesus of the Gospels

7

Productivity? What is being done by chaplains?

Quality? Is what being done contributing to overall patient quality and satisfaction?

Effectiveness? Is what is being done effective?

Impact? Can one identify and measure the outcomes of spiritual care?

Challenge: Defining/Demonstrating the Value Proposition

8

Quality Improvement

Fundamental to HC Across all facets of HC SC providers take the lead in creating a culture of care

and measure quality of SC services Three perspectives for measuring quality

• Process Measures• Outcome Measures• Performance against Standards

9

Proc

ess

Mea

sure

sOutcom

e

Measures

Performance Against Standards

Integration

10

1. Process Measures- a measure which focuses on a process that leads to a certain outcome.

Can you answer the questions:

- Did you do it (services complete)?

- Did you do it right?

Process Measures

11

2. Outcome Measures - a measure of the results of a system, relative to aim.

Can you answer the question:

- Did the process you completed get the outcome desired/expected?

Outcome Measures

12

3. Performance against Standards

Can you answer the question:

- What are the measurable standards agreed upon across the profession that demonstrate effectiveness in spiritual care?

Performance against Standards

13

Spiritual Care Department is an integral component of the Palliative Care Team.

Process Measure: Palliative Care team initiates contact with chaplain upon patient admission to services within 24 hours.

Outcome Measure: Chaplains track number of palliative care patients seen. Patient encounter included with other quality data that shows variables in patients seen and not seen by chaplain.

Performance to Standards: Annually conduct an evaluation with Palliative Care team of chaplain performance against Standards 1-6. (Standards of Practice for Professional Chaplains in Acute Care.)

Acute Care Setting Example

14

Spiritual Care department to provide training to clinic staff on spiritual distress screening tools.

Staff screenings are designed to generate spiritual care referrals.

Process Measure: Report number of staff trained to utilize spiritual distress assessment tool and count number of referrals made to Spiritual Care staff.

Outcome Measure: Staff take pre and post test indicating level of comfort with detecting spiritual care distress.

Performance to Standards: Screening and referral tools and processes in place, with training of all (100%) of staff. Can build in year cycles (year one =50%, year two = 80%, year three = 100%)

Non Acute Care Setting Example

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I. Preamble: Acknowledge work• Benefits, challenges• Purpose: one voice

II. Introduction: ERDs • Spiritual care in context of Catholic health care: work of God• Part Two: respect human dignity, holistic, integral

III. Organization/System Level• Plan, policy, education of all staff importance/role• Organization chart, lines of responsibility• Full range of services, integrated into all services, facilities• Spiritual care models showing entire staff responsibilities

Support of all, screening by staff, specialist service of chaplains

Core Elements for System Standards

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IV. Spiritual Care Department• Plan• Model, staff composition• Qualified leader• Staff personnel, preparation, competencies• Job descriptions• Partnership with faith communities• Services covered based on 9 essential chaplain functions• Standards of Practices• Budget

Core Elements for System Standards, cont..

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V. Care Delivery• Scope of service clearly communicated

Extent of services • Collaborations and Relationships

Board Certified Chaplain part of interdisciplinary care team Role on Ethics Committee Orientation of new employees Screening and referral tools and processes Spiritual/emotional diagnosis part of interdisciplinary care team

deliberations Spiritual care assessment, care plan, all notes part of

documentation (EMR)

Core Elements for System Standards, cont..

18

Grateful to:

Rose Shandrow, M.Div., Director, Spiritual Care Services, Franciscan Health System in Tacoma, WA

Spiritual Care Services Process Improvement Team – Chaplain Measures

Prepared by Gordon J. Hilsman, D.Min., former Manager of CPE, St. Joseph Medical Center in Tacoma, WA

Measuring through AssessmentsCHI – Franciscan Health System, Tacoma WA

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Catholic Health Initiatives: Measures of Chaplain Performance and Productivity: Task Force Report published June 2002• Develop a common language to articulate what

chaplains do and the value added• Develop tools for managing performance and

productivity• Promote the professionalism of chaplains and the

integration of spiritual care

Integration of Spiritual Care

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Personal (Healthcare View)

Soul

BodyMind

21

21

1. Framework of Spiritual Assessment

2. Chaplain Functions

3. Spiritual Care Outcomes

4. Benefits of Framework

Objectives

22

1. Recordable

2. Establish Rapport first

3. Needs Focus (ad sedio)

4. Partnering Endeavor

5. Continued Learning

Assumptions - Spiritual Care

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All that an individual values, practices, believes, and decides in order to cope with and enjoy

what can’t be controlled, including relationships with oneself, other people, Transcendence

and communities of importance

Spirituality

24

A ministry event consists of a person functioning as a caregiver addressing the spiritual need of another person experiencing a difficult life situation.

Spiritual needs are seriously unsettling challenges to the human spirit of a given individual.

Ministry to Spiritual Need

25

Careful Listening Empathic Reflecting

Gentle Querying Insightful Interpreting

Establishing Rapport

Crisis Ministry Supportive Validating Informing Presence and Networking Resource Enhancing

Instructing Religious Support Spiritual Support Spiritual Counseling Facilitating Self Forgiveness Reconciling Estrangement

Grief Support Grief Counseling End of Life Care Adjustment Counseling

Emotional Support

Spiritual/Religious Concerns

Loss / Adjustment A S S E S S I N G

Ethics Consultation Family Systems Facilitating Advocacy Mental Health/Addictions Referral Family Referral Love Life Consulting

Advocacy /Referral

26

What does this person need emotionally right now? What has this person lost, recently and historically? What are the ways this person maintains and nurtures

her own human spirit? What does this person need that may be beyond my

relationship with him?

Basic Axis Questions

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What does this person need

emotionally right now, (from me)?

Axis One: Emotional Support

28

1. The Crisis Need for

Stabilizing

EMOTIONAL SUPPORT

2. The Expression

Need to Engage

and Share

3. The Anxious Need of Waiting Too Long

4. The Bewildering

Need for Basic

Information

5. The Regression Need to be

Empowered

29

Needing to cry, yell, share, or just tell

somebody how you feel about what is

happening to you

2. The Expression Need to Engage and Share

30

FunctionFunction Desired OutcomesDesired Outcomes

2. An Expressing person

• Talks openly

• Expresses feelings

• Cries

• Relaxes

• Considers resources

Supportive Validating

31

31

4. WaitingUpset feelings from waiting too long in an important situation

32

Presence & Networking

• Expresses situation

• Prays

• Acknowledges limitations

• Thankful

• Calm

4. A person who is waiting too long


33

What has this person lost, recently and historically, that still disturbs her/him at times?

Axis Two: Loss and Grief

34

Major Losses

6.Acute Grief

(in past 48 hours)

7.Prior Grief (Lost earlier)

8. Dying

9. Huge Life Adjustment

35

7. Prior GriefMajor past loss being currently grieved

36

• Mentions previous loss• Expresses emotion• Receives validation• Shares reminiscences • Cries while talking about

the lost loved one• Receives referral for

further grief assistance• Expresses greater hope

7. Prior Grief


Grief Counseling

37

0

10

20

30

40

50

60

70

80

90

Mention of the Loss

Observable Emotion

Receives Validation

Reminisces

Shows Tears

Considers Referrals

Signs of New Hope

7. Grief Counseling Outcomes (%)

38

How does this person maintain and nurture her own human spirit?

Axis Three: Spiritual Resources

39

Religious/ Spiritual

Care

10. Instruction

11. Religious Support

12. Spiritual Support

13. Spiritual Counsel

14. Self Forgiveness

15. Estrangement

40

The Need to feel the immediate

positive presence of Transcendence

11. Religious Support

41

Religious Support

• Sacrament/ spiritual ritual• Spiritual leader of choice• Religious

questions/problems• Prays


Person who is needing God

42

15. EstrangementNeed to re-connect with separated loved ones

43

Reconciling

• Talks about an estranged relationship

• Agrees to receiving contact with an estranged person

• Agrees to take initiative to contact an estranged person

• Accepts the adequacy of one’s efforts at reconciling

A person regretting estrangement


44

What does this person need that

may be beyond my relationship with

her/him?

Axis Four: Advocacy and Referral

45

Referral/Ethics

16. Medical Ethics

Concerns

17. Family Conflict

18. Advocacy

19. M. Health/Addiction Concerns

20. Family Dysfunction

Concerns

21. Love Life

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19. Mental Health/AddictionsNeed to explore concerns about one’s mental health or mood altering chemical abuse

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Referral• Concern verbalized• Feelings expressed• Calm conversationAccepts consultation


19. People with mental illness or addiction concerns

48

21. Love Life PainNeed for listening, advice or referral about one’s love life

49

Documentation

Training Resource

Measurement Source

Benefits of the Spiritual Assessment Framework

50

What are the needs?

What did we provide?

What is the plan of care?

Spiritual Assessment Form

51

INTERVENTIONS: Advanced Directive Information provided: (Single) __Yes __NoAdvanced Directive Comment:

(Free text) __________________________________________________________________________________________________

EMOTIONAL SUPPORT: (Multi)

__Anxiety reduction initiated __Emotional Health Education provided __Empathic Companioning__ Empowered patient __Established Trust __Family/ Significant Other supported __Guided Imagery provided __Hope” strengths identified __“Hope” struggles identified __Information provided __“Meaning” strengths identified __“Meaning” struggles identified __“Relationship” strengths identified __“Relationship” struggles identified __Other

Emotional Comment (free text)____________________________________________________________________

CHANGE, ADJUSTMENT AND LOSS (Multi)

__ Change, adjustment, loss education provided __End of life discussion/care

__“Hope” with loss addressed __Life review facilitated

__Loss & Grief (current) support provided __Loss and Grief (prior) support provided

__Meaning” of the loss discussed __Referral provided

__Relationships/Community/Support system discussed __Other

Change, Adjustment and Loss Comment (Free text) ____________________________________________________________________________________

Spiritual Interventions

52

SPIRITUAL AND RELIGIOUS multi)

__Anointing of the Sick __ Baptism provided __Beliefs/Values explored __Blessing/Ritual provided __Communion provided __Confession/Reconciliation provided __Ed. on Spiritual/Rel. issues provided __Forgiveness addressed __God/the spiritual strengths identified __God/the spiritual struggles identified__Holy texts/Scripture read/provided __Religious leader/community consulted__ Rosary shared/provided __Prayer shared __Spiritual/Religious life explored __Other

Spiritual and Religious Comment (Free text) __________________________________________________________________________________________________

ETHICS, ADVOCACY AND REFERRAL(Multi)__Addiction discussed/referral/support made __Advocated for patient __Care now and/or in the future discussed __Ethical issues discussed __Ethics Committee called __ Ethics, advocacy or referral education provided __Family Conference facilitated __Healthcare team-Pt./Fam. communication facilitated__Referral provided __Resources provided __Relationship issues/conflict addressed __Other

Ethics, Advocacy and Referral Comment (Free text) __________________________________________________________________________________________________

Intervention Comment/Summary Points (Free text) _________________________________________________

Spiritual Interventions, cont…

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Data Collection Tool

54

Able to Identify the Workload of the Chaplains

Pastoral Care Encounters Department

18% 51%

31%

Patients Family Staff

55

4%14%

11%

50%

5%

16%

Phone Pager STAR Orders Direct Contact Code Direct Staff

Types of Referrals

56

26,116

6,493

12,249

2,297

0

5,000

10,000

15,000

20,000

25,000

30,000 Emotional Support

Loss & Adjustment

Spiritual & Religious Support

Advocacy/Referral/Ethics

Spiritual Care Needs Addressed

57

1,937

10,099

5,026

6,800

2,254

0

2,000

4,000

6,000

8,000

10,000

12,000Crisis MinistrySupportive ValidatingInformingPresence & NetworkingResource Enhancing

Types of Functions to Address Needs- Emotional Support

58

2,518

1,2301,362 1,383

0

500

1,000

1,500

2,000

2,500

3,000Grief Support

Grief Counseling

EOL Spiritual Care

Adjustment Counseling

Types of Functions to Address Needs- Loss/Adjustment

59

1,612

5,068

4,365

529 520

155

-

1,000

2,000

3,000

4,000

5,000

6,000

Instructing

Religious Support

Spiritual Support

Spiritual Counseling

Self Forgiveness

Estrangement

Types of Functions to Address Needs- Spiritual & Religious Support

60

106

857

804

42 29

459

0

100

200

300

400

500

600

700

800

900

Ethics Consultation

Family Facilitating

Advocacy

Addiction Referral

Family Referral

Love Life

Types of Functions to Address Needs- Advocacy & Referral

61

1,937

10,099

5,026

6,800

2,254

-

2,000

4,000

6,000

8,000

10,000

12,000Crisis Ministry


Informing


Resource Enhancing

33

1,055

11370

123

-

200

400

600

800

1,000

1,200

Crisis Ministry


Informing


Resource Enhancing

Chaplain Ima Nun

Chaplain to Department Comparisons- Emotional Support

Department

62

33

1,055

11370

123

-

200

400

600

800

1,000

1,200

Crisis Ministry


Informing


Resource Enhancing

112

480

59

429

8

0

50

100

150

200

250

300

350

400

450

500

Crisis Ministry


Informing


Resource Enhancing

Chaplain Andy Wokswitme

Chaplain to Chaplain Comparisons- Emotional Support

Chaplain Ima Nun

63

5%

19%

5%

35%

39%

44%

33%

13%

43%

7%

13%13%15%

3%2% 2%2%0%0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

FY06 FY07 FY08

Instructing

Religious Support

Spiritual Support


Self Forgiveness

Estrangement

Chaplain Sean Deaconery

Year to Year Comparisons- Spiritual and Religious Support

64

2,518

1,2301,362 1,383

-

500

1,000

1,500

2,000

2,500

3,000

Grief Support

Grief Counseling

EOL Spiritual Care

Adjustment Counsel

594

267239

62

0

100

200

300

400

500

600

Grief Support

Grief Counseling

EOL Spiritual Care

Adjustment Counsel

Students Chaplains

Students to Chaplains Comparisons- Loss and Adjustment

65

1

25

73

7

10

7

0

10

20

30

40

50

60

70

80

InstructingReligious SupportSpiritual SupportSpiritual CounselingSelf ForgivenessEstrangement

21

293

172

1 12

0

50

100

150

200

250

300

Instructing

Religious Support

Spiritual Support


Self Forgiveness

Estrangement

Staff Chaplain Per Diem Chaplain

Per Diem to Staff Chaplain Comparisons- Spiritual and Religious Support

66

173

1,737

1,056

1,587

798

-

200

400

600

800

1,000

1,200

1,400

1,600

1,800

Crisis Ministry


Informing


Resource Enhancing

131

1,258

120

428

101

-

200

400

600

800

1,000

1,200

1,400

Crisis Ministry


Informing


Resource Enhancing

Facility to Facility Comparisons

St. Alan Hospital St. Catherine Hospital

67

71%

25%

3% 0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Spiritual Care Needs AddressedEmergency Department

Emotional Support Loss and Adjustment

Spiritual & Religious Support Advocacy, Referral, Ethics

25%

29% 28%

12%

5%

0%

5%

10%

15%

20%

25%

30%

Emotional Support--ED

Crisis Ministry Supportive ValidatingInforming Presence & NetworkingResource Enhancing

Spiritual Care Needs- Clinical Area

68

65%

8%

22%

4%

0%

10%

20%

30%

40%

50%

60%

70%

Spiritual Care Needs AddressedStaff

Emotional Support Loss and Adjustment

Spiritual & Religious Support Advocacy, Referral, Ethics

5%

35%

39%

15%

8%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Emotional Support--Staff

Crisis Ministry Supportive Validating Informing

Presence & Networking Resource Enhancing

Spiritual Care Needs- Staff

69

Sources of Referrals-CombinedFiscal Year to Date

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr0

100

200

300

400

500

600

700

800

900

PhonePagerSTAR OrderDirect ContactCodesDirect Staff

70

Categories of Spiritual Care Needs Addressed-CombinedFiscal Year to Date

10

5000

10000

15000

20000

25000

30000

35000 31962

9043

17027

2746

Emotional SupportLoss & AdjustmentReligious & Spiritual SupportAdvocacy/Ethics/Referrals

71


100

200

300

400

500

600

700

800

900

Emotional Support Interventions

Crisis MinistryEmpathic CompanioningInformingPresence & NetworkingResource EnhancingSeries6


50

100

150

200

250

300

350

400

450

500

Loss & Adjustment Interventions

Grief SupportGrief CounselingEnd of Life Spiritual CareAdjustment Counseling

72


100

200

300

400

500

600

700

800

900

Religious & Spiritual Support Interventions

InstructingReligious SupportSpiritual SupportSpiritual CounselingFacilitating Self ForgivenessReconciling Estrangement


20

40

60

80

100

120

140

160

Advocacy/Ethics/Referral Interventions

Ethics ConsultationFamily FacilitatingAdvocacyAddiction ReferralFamily ReferralLove Life Pain

73

Division of Mission Operations/Spiritual CareSpiritual Care Interventions-Combined

Fiscal Year to Date / n=60,778

10

2000

4000

6000

8000

10000

12000Crisis Ministry

Empathic Companioning

Informing


Resource Enhancing

Grief Support

Grief Counseling

End of Life Spiritual Care

Adjustment Counseling

Instructing

Religious Support

Spiritual Support


Facilitating Self Forgiveness

Reconciling Estrangement

Ethics Consultation

Family Facilitating

Advocacy

Addiction Referral

Family Referral

Love Life Pain

74

A Means for Examining Effectiveness of Spiritual Care Functions

What are the desired outcomes for rendering a chaplain function?

To what degree do I see the desired outcomes from the services I provide?

75

Data Collection Tool

76

40 (91%) 40 (91%)

36 (82%)34 (77%)

31 (70%)

25 (57%)

21 (48%)

0

10

20

30

40

# of Outcomes

Crisis MinistryN=44

Emotional needs expressed Conversational engagement Increased relaxation

Support person contacted Prayer requested/accepted Realistic Planning

Expressed gratefulness

Summary of Observable Outcome

77

Results Gained from Spiritual Assessment Framework

Improved care to the patient/family/staff

Improved documentation

Identifiers for Growth and Development of

Chaplains

Facilitated discussions in depth by staff chaplains

regarding each of the Chaplain functions

Interdisciplinary Education

Community/Patient Education

Documents

Measurement and Mystery May 31, 2013 National Association of Catholic Chaplains Day for Professional & Spiritual Enrichment Orange, California