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BY: PATRICK GAUGHAN

The Catholic health care ministry finds itself at a critical juncture, confronted with rapidly changing business models, razor-thin margins and a brand that is being challenged by the complexities of public perception and the realities of health care delivery. We have worked hard to change incrementally — and to transform where possible. But is this sufficient to continue as healers like those that have come before us? Are we fully capable of serving as agents of Jesus and his healing ministry to those who come to us, and for those we seek out, to fully engage in the promise of the healing ministry?

The preceding paragraph was paraphrased from "Leadership Formation: A Call to Action," written just shy of a decade ago.¹ Not only does the author's take on the signs of the times still ring true, his questions are still applicable, as the ministry has worked over the past 45 years to expand and strengthen formative opportunities to all who participate in the ministry. Unfortunately, intense focus on current challenges and opportunities may tempt leadership to neglect the distinctively Catholic vision that inspired the founders.²

Not all leaders recognize that the temptation to neglect is occurring, and not all who see it care. Some appear to be concerned exclusively with market-oriented aspects of their mission; for others, "Catholic" is an artifact, a heritage to be remembered at particular times of the year. Many express doubts that the specifically "Catholic" legacy of a mission can have significant impact in their institutions, let alone help them thrive in the future.

Are these reasonable doubts in the current environment? Possibly, yet they also may be founded less on managerial and economic realities and more on the leaders' own limited understanding of the Catholic tradition — spiritual, social and intellectual — and of the understated, but potent, character of the Catholic missions that they now steward.

That potent character is our cumulative effort to make the presence of God and the healing power of Christ seen, heard and felt. This is a remarkable opportunity that points to the essence of formation. However, there is little evidence-based data to indicate the positive return on investing in formation, when reduced resources for this vital, foundational element of our ministry are suggested. In these fiscally challenging times, such an approach compromises the ministry's long-term ability to adapt our potent character at the expense of short-term financial gains.

HOW TO MEASURE OUTCOMES?
It is a well-known axiom that what is not measured cannot be managed or improved. Management may turn to quick-fix strategies such as across-the-board cuts in services, compensation and labor. But imposing arbitrary spending limits on discrete components of care, or on specific line-item expense categories, achieves only marginal savings that often lead to higher total system costs and poorer outcomes.³

Increasing efficiencies and reducing expense is not only about changing care delivery models but also about transforming the operational functions that support such models. As value-based care takes hold, operational leaders must scrutinize the value of every resource, including formation. Across the ministry there is no question, anecdotally or qualitatively, that formation is valuable. In the absence of evidence-based, comparative metrics, departments are sometimes held to productivity numbers dictated by consultants.⁴ Sadly, such micromanagement of costs at the individual organizational unit level does little to reduce total cost or improve value — and may, in fact, destroy value by reducing the effectiveness of care and driving up administrative costs.⁵

The need to demonstrate positive, measurable outcomes or risk discontinuation of mission-related programs always comes up.⁶ This need prompted the Catholic Health Association's Ministry Leadership Formation Advisory Committee to learn more about outcomes — especially those patterns and practices that measure the effectiveness of formation beyond the individual's own self-assessment.⁷

Recent survey efforts conducted by the committee indicate that education is still needed to fully understand what is meant by objective metrics when it comes to formation, and that establishing an effective assessment framework remains not only important, but also desired. The survey highlighted concern regarding the cost to develop a tool that can isolate and attribute the impact of formation on measurable organizational improvements.

A few formation programs are making advances in assessing the value between formation and operational outcomes. Still, significant questions remain. Would or could such a tool be used or modeled by the ministry as a whole? Variables such as utilization expense, integration with existing organizational metrics, differences of concept definition and essential content in such a tool abound.

So what evidence needs to exist to indicate that formation is an effective approach to advancing the ministry and preventing serious loss of Catholic identity and ministerial integrity? Perhaps the profession of formation could look to the profession of medicine to posit a not-so-common perspective on this question.

THE PARACHUTE STUDY
For many practitioners, it is tempting to criticize or ignore methods of medical practice that aren't supported by rigorous scientific evidence. Several years ago, the BMJ (formerly the British Medical Journal) published an almost infamous satire on naïve implementations of evidence-based medicine that demonstrated the pitfalls of doing so.⁸ The authors set out to determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Their design and study selection included the systematic review of randomized controlled trials showing the effects of using a parachute during free fall. The key outcome measure was death or major trauma, defined as an injury severity score greater than 15. Their results: They were unable to identify any randomized controlled trials of parachute intervention.

Their conclusion is of most interest. As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomized controlled trials. The paper carries the concept of parachute efficacy through the typical mechanisms of evidence-based medicine, all the way to the ridiculous conclusion: We think that everyone might benefit if the most radical protagonists of evidence-based medicine organized and participated in a double-blind, randomized, placebo-controlled, crossover trial of the parachute.

The desire for evidence-based data to determine whether formation is effective in protecting the integrity of, and creating sustainability of, the ministry in relation to organizational and leadership challenges and metrics remains formation's elusive Holy Grail.

Applying the insight gleaned from the parachute parody, one could posit the question for Catholic health care: "Without protecting the integrity of and creating sustainability of the ministry through and with formation, will we be able to turn around, look and say with integrity in three, five or 10 years that what we have created is Catholic?"

The physics of falling bodies has been understood for a long time, and a properly designed parachute increases the scientific likelihood of survival to virtually 100 percent. Therefore, persons are willing to take their chances with a parachute during a plunge from a height — randomized controlled trials or no randomized controlled trials. They simply understand and trust the parachute is manufactured with strong materials according to designs that have been well-tested.⁹

Just as persons need parachutes based on solid design, Catholic health care needs formation rooted in Christian spirituality and Catholic theology and constructed using adult learning principles. Nobody willingly accepts the risk of using a placebo parachute. Catholic health care cannot willingly accept the risk of using a placebo for formation when it comes to advancing a ministry.

THE POWER OF WHY
Enhancing one's awareness and expanding one's capacity to effectively lead in ministry requires practicing a discipline to hear, discern and respond to the invitation of the Holy Spirit as it calls people to cooperate with God's healing activity. That invitation is present in the richness of challenge, accomplishment, diversity, conflict and demand found in our daily work.

The work of formation, then, is to help those who participate in the ministry tap into the power of "why" as core to the meaning, identity and role they serve in the health care ministry.

Connecting with the power of "why" produces opportunity to enhance our mission and advance our legacy. We do this by practicing a discipline that encourages a "transformation" in personal and organizational spiritual growth aimed toward greater consistency in behaviors congruent with core values and mission.

Consistency in such behaviors and culture are fundamentally intertwined, so most organizations have analytical tools to measure competency and cultural efficacy. Could use of these tools move the ministry closer to grasping formation's elusive Holy Grail? Decades of research have gone into development drawing upon psychology, anthropology, sociology and statistics, to name a few disciplines. These tools have undergone a multitude of analysis, tests of reliability and studies of validity to provide data related to individual and organizational actions, decisions and behaviors — the results of which are often met with mistrust, question and misinterpretation of analyses. Even with such rigor supporting these tools, skepticism remains.

Evaluation models and approaches for adult education and training seem relatively straightforward and could perhaps shed light on formation's elusive Holy Grail, however ideological, curricular and political rethinking has fundamentally undermined this seeming simplicity.¹⁰ Take for example the Kirkpatrick Model, the most recognized and widely used training and education evaluation model in the world.¹¹ Researchers have asserted several fundamental limitations of the model and have outlined potential risks those limitations raise, arguing that the risks — plus the inability of the model to effectively address both the summative question (Was training effective?) and the determinative question (How can training be modified in ways that increase its potential for effectiveness?) limits the capacity of training, and those facilitating the training, to fulfill the ethical duty of beneficence.¹²

This principle increasingly is being used to assess risk versus benefit, and it has been argued that the limitations of the Kirkpatrick model may prevent evaluators from adequately addressing this principle. Kirkpatrick's level four New World Addition moves in this direction.¹³ Other models like Phillips, Jacobs, and Kaufman and Keller, have made significant evaluative enhancements, yet limitations remain.^{14, 15}

RISK OF MISLEADING JUDGMENT
When no determinative data is collected about why the training was or was not effective, or when key input factors are left out, the potential of misleading judgment about the effectiveness of the training program increases. Such judgments can be significant risks when they lead to the cancellation of what may be truly useful training programs. It is therefore a benefit to the organization to know whether the success or failure of the program has been attributed to contextual factors or other input factors.¹⁶

Although formation is not training, such information can provide a foundation upon which decisions can be made. So should a survey or a control group be used to evaluate effectiveness? Survey research is popular because it is versatile and efficient, and the results are generalizable. However, as noted above, other influences or factors may contribute to improved performance. Is it realistic to isolate for such influences or factors? Some researchers have argued that if a control group cannot be used, attempting to isolate the effects of training efforts would be invalid and should not be used.¹⁷

Given the magnitude of these limitations, Edgar Henry Schein, former professor at the MIT Sloan School of Management who has made a notable mark on the field of organizational development and culture, depends more on careful observation, group interviews and focused inquiry.¹⁸ He relies on face validity and on the fact that feedback from others illuminates this complex evaluative phenomena.

He uses what he calls "replication," specifically, would others see the same cultural phenomena that he sees if they were to enter the situation or environment? Could this concept have insight for formation? For Catholic health care? That is, do persons we serve or serve with — or even accreditors evaluating our organizations — feel a difference when they enter our facilities or when they encounter our care? Do they say aloud that there is something different about this place? Through our service, do persons experience our religious and spiritual values?

That cultural phenomenon, that spiritual and benevolent difference, existed in Catholic health care long before there was a desire to prove it with evidence-based data. And so, in an environment where risks threatening Catholic health care's survival are reaching daunting heights, perhaps lessons can be drawn and stewardship questions can be raised. Is the use of resources to create evidence-based data to prove the effectiveness of mission-related programs, such as formation, effective stewardship? Could effective stewardship be bewitched by the lack of evidence-based data and thus favor reducing or eliminating formation? Is protecting the integrity and sustainability of the ministry through formation — as Catholic health care has done throughout most of its existence, without formally calling it such and without evidence-based data — effective stewardship?

MULTIFACETED EVALUATION OF FORMATION
Reading the signs of our times, we are challenged to move beyond a single narrative or single language of what Catholic identity means. Instead, we use hints and guesses, intuitions and fragments, as a bricolage weaving a tentative vision together from multiple insights into a dynamic whole. In this process, the power of humility and vulnerability come to the surface. It is akin to Paul's struggle in 1 Corinthians (12:12-14) to envision a gentile Christianity. The ministry must be multilingual, comfortable with some degree of chaos and ambiguity, aiming primarily to change the conversation of what it means to be a ministry and protect its integrity. Likewise, rather than seek a single or set of metrics, evaluation of formation will need to be multifaceted.

Formation can help translate the ministry into these new times; it can help encourage the ministry to leave the familiar and venture into the new — that is, to be, to act. Formation creates deeper meaning, facilitates recognition of grace and nurtures belief in why we do what we do, and how we do it, beyond data and business norms.

When the why is a deep personal belief, healing becomes more than curing. Healing rightly enfolds the realm of mind, body and spirit. But the why must transform from more than a mere common understanding to a personal belief — a conviction that is deeply important and inspires action.

In conversations with leaders, many talk about how formation helps them to be a better CEO, a better leader, better at translating strategies in light of who we are as a ministry. They talk about how our Catholic history is tightly woven into the fabric of who we are as a company. They articulate that we must be healing ministers in every way and through God, that we are called to continue the legacy of our mission and that formation helps put into business practice and decisions the value of each person and the need to put the person/patient at the center of all we do in our decisions, actions and behaviors.

Persons willingly share how formation touches their core, their hearts, and how it changes not only their understanding of work, but of themselves. Participants share how they have put principles into practice in their daily work, try to help staff connect more strongly with our mission and see the Christ in everyone we serve.

GREATER FUTURE CLARITY
The profession of formation must and will continue to learn and make a difference amid organizational and leadership challenges. The pain of discontent in the area of evidence-based metrics propels us to greater future clarity, and we dare not be discouraged when confronting such questions juxtaposed with all the other demands of today's health care environment.

The spiritual energy that was the foundation for the sponsoring religious founders was not superior knowledge, skills or even raw courage. It was the Holy Spirit called upon daily in support of their efforts.¹⁹ Our times promise to continue changing the nature and complexity of health care. As a ministry, we must call upon that same Holy Spirit for support and stay committed to formation and its ability to influence leadership and organizations.

We have the privilege and the responsibility of leading at this critical time in Catholic health care's ongoing story. Therefore, we must revitalize the ministry's rich heritage in contemporary health care and draw upon formation as we come down from the dizzying heights of present-day risks. So in three or five or 10 years, after we have carefully gathered our parachute, we will be able to turn around, look, and say with integrity and certainty that what we have created is Catholic.

PATRICK GAUGHAN is system vice president, Center for Formation, Catholic Health Initiatives, Englewood, Colorado.

NOTES

1. Jon C. Abeles, "Leadership Formation: A Call to Action," Health Progress 89, no. 2 (March-April 2008): 32-37.
2. Michael J. Naughton and Jeanne Buckeye, "The Importance of Leadership Formation" Health Progress 89, no. 2 (March-April 2008): 38-42.
3. Robert S. Kaplan and Michael E. Porter, "The Big Idea: How to Solve the Cost Crisis in Health Care," Harvard Business Review 89, no. 9 (September 2011): 47-64.
4. Brian P. Smith, "We Know What We Value. Measuring It Is Up to Us," Health Progress 94, no. 3 (May-June 2013): 88-90.
5. Kaplan and Porter.
6. Brian Yanofchick, "Leadership Formation: What Difference Is It Making?" Health Progress 91, no. 4 (July-August, 2010): 74-76.
7. Smith.
8. Gordon C.S. Smith and Jill P. Pell, "Parachute Use to Prevent Death and Major Trauma Related to Gravitational Challenge: Systematic Review of Randomized Controlled Trials," BMJ 327 (Dec. 18, 2003): 1459-61.
9. "A Call for Randomized Clinical Trials of Parachutes," Not Totally Rad blog, Aug. 8, 2008. http://nottotallyrad.blogspot.com/2008/08/call-for-randomized-clinical-trials-of.html
10. G. McNamara, P. Joyce and J. O'Hara, "Evaluation of Adult Education and Training Programs," in International Encyclopedia of Education, Volume 3, ed. Penelope Peterson, Eva Baker and Barry McGaw, (Oxford, U.K.: Elsevier Science, 2010), 548-54.
11. Kirkpatrick Partners, "The Kirkpatrick Model," website. www.kirkpatrickpartners.com/OurPhilosophy/TheKirkpatrickModel.
12. Reid Bates, "A Critical Analysis of Evaluation Practice: The Kirkpatrick Model and the Principle of Beneficence," Evaluation and Program Planning 27, no. 3 (August 2004): 341-47.
13. Kirkpatrick Partners.
14. McNamara, Joyce and O'Hara.
15. Travis K. Brewer, "Use of Phillips's Five Level Training Evaluation and Return on Investment Framework in the U.S. Non-profit Sector," (PhD diss., University of North Texas, 2007). https://mdi.missouristate.edu/assets/mdi/Training_ROI_Non_Profit_Sector_dissertation.pdf.
16. Bates.
17. Brewer.
18. Edgar H. Schein, Organizational Culture and Leadership (San Francisco: Jossey-Bass, 2010).
19. Andre L. Delbecq, "Identity and Catholic Healthcare: The Challenge of Leadership Formation: A Call to Action," abstract.