BY: RANDY SHOOK and LAURIE FOJUT
Mr. Shook is director of media relations, Catholic Health Initiatives, Denver; Ms. Fojut is a freelance writer based in Rochester, MN.
In 2001, Catholic Health Initiatives (CHI), Denver, launched an 18-month study of chaplain performance and productivity. The findings—including a widespread lack of clarity and consistency in the understanding and measurement of what chaplains do—led CHI, one of the nation's largest Catholic health care systems, to make a set of recommendations to the spiritual/pastoral care departments at its hospitals and long-term care facilities in 19 states. As CHI's facilities act on those recommendations, their chaplains are learning to better define their roles, to articulate their duties, and to foster recognition of their contribution to patient care.
"Chaplains are often exhausted by the demands of their daily work, yet unable to explain exactly what they do or how they make a difference to patients or to their organizations," said Fr. Gerard T. Broccolo, STD, CHI's vice president of spirituality. "The inability to articulate what you do in a way that others can understand can be terribly harmful. Chaplains need to understand their value to their organizations and to the health of the patients and coworkers they serve."
Jim Gunn, clinical/pastoral education supervisor at Penrose-St. Francis Health Services in Colorado Springs, CO, has studied spiritual assessment for 20 years and believes that many chaplains are not fully aware of how their activities contribute to their organizations. "As a result, they often underreport what they do," he said. "In addition, administrators are often content with the symbolic nature of the chaplain's role—the fact that they represent the values of the organization. The role of a chaplain is far greater, but that won't be widely understood until chaplains learn to report the full scope of their activities."
Cathy Wendt, mission leader and director of spiritual services at Franciscan Villa, a long-term care facility in South Milwaukee, WI, uses a metaphor to explain the perception of chaplaincy in many health care organizations. "There is still an idea that we're the icing on the cake, not part of the batter," she said. "Nurses refer residents to us because they know we can help them deal with many issues. But they don't see us as part of a patient's therapy—as professionals who deal with a resident's spiritual care needs while they deal with physical care needs. Fortunately, perceptions can change."
Study Goals
In instigating its study, Measures of Chaplain Performance and Productivity (published in June 2002), CHI's Task Force on Chaplain Performance and Productivity Measures sought to define:
- A common language to describe what chaplains do
- The typical outcomes of their work
- The most appropriate ways to measure their productivity
"Organizations measure what they value, and they value what they measure," Fr. Broccolo said. "Catholic health organizations value spiritual care. The question is: What is the best way to measure it? We know how to count, but do we know what to count?"
Fr. Broccolo noted that most measures of chaplain productivity are based on volume statistics, such as the number of patient visits made each day. "The problem is, that type of measurement cannot capture the depth and breadth of the competencies chaplains need to serve patients, families, and their fellow caregivers," he said. "It also cannot account for the complexity or time required to deliver specific chaplaincy services, which range from giving sacraments to supporting individuals through the last days of life. It is entirely possible that the chaplains who see the greatest number of patients in a day are not able to provide the quality of spiritual care that they or their patients would like."
To begin to answer the measurement question, the CHI study team surveyed chaplains to determine their daily tasks and their ideas for appropriate productivity and performance measures. "We saw widespread diversity and subjectivity of perception about what chaplains do and how it should be measured," Fr. Broccolo said. "In addition, we saw that many chaplains have a difficult time articulating what they do, which makes it very difficult for other health care professionals to understand their role."
In the study's second phase, the team surveyed family members of patients who had recently died in CHI facilities to determine their satisfaction with chaplaincy services at the time of the patient's death. "As far as we know, this is the first time a health provider has gathered this type of chaplain performance data," said Fr. Broccolo. "The data clearly show that families see chaplains as surrogate family members who help them cope with the death of a loved one. This affirmed the value of chaplains as care team members who tend to patients' needs for comfort and spirituality."
The survey also had some findings that Fr. Broccolo found startling. "Many of the people surveyed didn't know if they actually met a chaplain or not," he said. "We saw that chaplains had to take part of the responsibility for fuzzy perceptions of their roles. The problem is that fuzzy perceptions are not conducive to clear productivity and performance expectations or assessments for chaplains."
However, the study found that even when performance expectations are unclear, there is a strong consensus that chaplains add value to health care organizations. "Patients and employees like the fact that chaplains are available to meet others' needs with no agendas of their own; to provide comfort and support in a variety of circumstances; and to facilitate an individual's journey toward peace and wholeness, among other things," Fr. Broccolo said.
Measurement Recommendations
The study's findings, combined with the collective thinking of task force members, led the CHI task force to make four recommendations to directors of spiritual/pastoral care for the improvement of chaplain performance and productivity measurement:
- Engage staff chaplains in a reflective process of role clarification, to identify and prioritize the most common key activities and competencies expected of them.
- Engage colleagues from other disciplines to help chaplains articulate performance expectations (outcome measurements) in a behavioral, common language.
- As a starting point for an improved and locally customized approach to measuring chaplain productivity (efficiency), create a template to define levels of task complexity for each of five to 10 key chaplain activities.
- Make a firm commitment to continuing education in order to develop the skills and competencies highlighted by the study, which will make a difference in the quality of spiritual/pastoral care.
In October 2002, CHI sponsored what it called a National Telephone Forum to enable its facility-based directors of spiritual/pastoral care to discuss the study report and the recommendations. "This live dialogue was absolutely critical to understanding and acceptance of the study report," said Fr. Broccolo. "I think that, during the telephone forum, many people began to understand for the first time how they could use the study's findings."
After the forum, every director of spiritual/pastoral care within CHI developed and submitted an action plan for implementing at least one of the four recommendations. As of May 2003, nearly 30 facilities had begun to implement action plans for at least one of the recommendations. "Most are working on the first recommendation, which is sensible, because chaplains really need to start this process by clarifying their roles," Fr. Broccolo said. "They are developing more complete and specific job descriptions, which is an excellent step toward educating others about what they do."
New Tools and Initiatives
Some facilities have used the study as fuel for existing initiatives and to create new tools for chaplain productivity and performance measurement. The spiritual/pastoral care staff at St. John's Regional Medical Center in Joplin, MO, carefully considered the tasks performed by its chaplains and broke them down into specific competencies required for cases with low, moderate, or high acuity. "We listed the knowledge and skills required for each level of acuity and estimated the chaplain time required in each instance," said Mary Ann Soerries, director of pastoral/palliative care for St. John's. "This is something the study recognized—that chaplains face more than one degree of task complexity, and that calls for more than one degree of chaplain competency."
An example of a task involving a lower degree of complexity is a patient death that is anticipated by both the patient and his or her loved ones. A more complex situation arises in the case of the death of a patient who is unprepared for it or whose family members are in conflict about the wishes of the deceased. "In either case, a chaplain must respond to the patient's death, but many more skills and competencies are needed to deal effectively with the complex situation," said Soerries. "We have developed algorithms for this and other chaplain tasks to clarify roles, ensure quality spiritual care, and eliminate rework. These are useful tools not only for our chaplains but also for the orientation and development of new employees."
At Penrose-St. Francis Health Services, the study supported the development of a form that helps chaplains perform detailed assessments of patients' spiritual well-being. "We hoped to make the form part of the medical record, but in working with our physicians we found that they want only very succinct spiritual assessment notes on patient charts," said Gunn. "Still, the forms are very valuable to us because they gather and preserve important information about the spiritual condition of our patients."
The chaplains at St. Joseph Medical Center in Towson, MD, are currently developing a tool that will measure their productivity in terms of outcomes. "We're also studying our chaplains' nonproductive time to determine whether we have the right people doing the right things and using the right tools in spiritual care," said Nancy Conner, the facility's director of spiritual/pastoral care. "We may find that reassigning some tasks will make things more efficient and help us improve the quality of our care." In addition, each of St. Joseph's six chaplains has "adopted" a specific chaplain competency mentioned in the study—for example, the ability to negotiate mutually acceptable outcomes among diverse viewpoints or the ability to help others manage their inner resources—and are developing training sessions for their peers.
At Marymount Medical Center in London, KY, Sr. Catherine Arnold, SCN, is developing a tool that will serve a dual purpose: to enable patients, families, and caregivers to evaluate chaplain performance and, at the same time, educate those populations about the role of chaplaincy. "The very process of completing the evaluation will educate the user about what they can and should expect from a chaplain," said Sr. Catherine, who is the only chaplain in this 100-bed hospital, which serves a mainly other-than-Catholic population.
Other spiritual care departments within CHI are using the list of chaplain competencies contained in the study report as a checklist for self-evaluation, or to identify areas for training and development or reinforce the value of chaplains as members of multidisciplinary care teams. The chaplain competencies, summarized in an appendix to the study report, include care coordination and systems management competencies, as well as direct caregiving skills. CHI is also assisting its chaplains with in-house resources to help develop the competencies emphasized in the study report.
Organizational Diversity
Because CHI is such a large and diverse health care system, the task force took care to ensure that the study of chaplain productivity measures would be useful to facilities of different sizes and geographic locations. The study also had to be meaningful for both acute care centers and for long-term care facilities, where chaplains often spend substantial amounts of time supporting residents as they prepare for death.
"The long-term nature of the care we provide gives us an opportunity to build relationships with our residents and their families," said Franciscan Villa's Wendt. "Many of our residents conduct life reviews, looking back to assess the things they did or did not do. As chaplains, we can help them achieve closure and let go of guilt or regret. We can help them decide what they want to happen in their lives now as well as during and after their funerals. We also work with families to help them deal with the decline of a loved one.
"For me," she said, "the study justified the time we spend tending to our resident's spiritual care needs, and the importance of gathering qualitative rather than quantitative data about that time."
Welcome Affirmation
CHI chaplains and their leaders agree that one of the most significant results of the study was the sense of pride and affirmation it gave them.
"I'm proud that the study brought out the professionalism of chaplains, and the fact that chaplains are accountable for their actions just like other professionals in the hospital," said Sr. Catherine. "It gave me confidence that chaplains do have an impact on health care. Though what we do is difficult to measure, it is an important piece of a holistic approach to care."
Soerries agrees that the study validated the importance of chaplaincy. "Our staff is very proud of their work, and the affirmation they received is one of the most important outcomes of the study," she said. "It just made them feel more professional."
"The study helped our chaplains name and claim their profession by identifying some common language, levels of practice, competencies, and standards of care to which they can be held accountable," said Conner. "It's a big step forward in the evolution of our profession."
Fr. Broccolo said that the ultimate outcome of the study will be realized when CHI's facilities develop their own individual, customized lists of chaplain competencies as a basis for performance measurement as well as training and development. At least 15 facilities are already engaged in that work.
Fr. Broccolo said he is impressed and encouraged by this progress, but recalls having to overcome some significant initial resistance to the study from chaplains themselves. "Chaplains are intuitive and not naturally measurement-oriented," he said. "They establish close relationships with patients and with God, which some believe simply cannot be measured. The task force members and I had a lot of face-to-face dialogue with chaplains throughout our system to gain their acceptance of the study. We persuaded many chaplains that it is much harder to add value to an organization when no one understands what you do. It is important to our mission, and to the advancement of the Catholic health ministry, that patients, co-workers, clinicians, and administrators understand the role of chaplains, their contributions, and how to evaluate their work."
CHI is currently working to develop outcome measures that accurately and effectively capture and evaluate chaplain performance. "I suspect that many health providers do as we used to do, and include a question about chaplain performance in their general patient satisfaction survey instruments," Fr. Broccolo said. "We dropped the chaplain-specific question from our survey for a number of reasons, but primarily because the chaplains' ministry today is so multidimensional that no single question can adequately capture their impact on patient satisfaction.
"In place of such a question in the general patient satisfaction instrument," Fr. Broccolo continued, "chaplains in several of our facilities are receiving more helpful and detailed feedback from routine internal surveys of sample groups of nurses, physicians, family members, and other key stakeholder recipients of their ministry."
Fr. Broccolo is pleased with the progress that CHI and its facilities have made toward new measures of chaplain performance and a new understanding of their vital role in Catholic health care. "We see this as a three-to-five-year project," he said. "We are very encouraged by the way our chaplains have responded to our recommendations. What they do is often of immeasurable value to those they serve, but by attempting to measure their effectiveness we can give them some of the recognition and understanding they deserve."
The report of the Catholic Health Initiatives Task Force on Chaplain Performance and Productivity, Measures of Chaplain Performance and Productivity, is available to interested parties upon request. To request a copy, contact Catholic Health Initiatives at 303-383-2696.