Spiritual/Pastoral Care Collaborations/Initiatives/Challenges: Some National Perspectives

Spiritual/Pastoral Care Collaborations/Initiatives/Challenges:

Some National Perspectives

June 5, 2013

National Association of Catholic ChaplainsDay for Professional & Spiritual Enrichment

Daly City, California

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What is the Pastoral Care Environment?

Research/Writing Collaboration Challenges/Initiatives

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40 yrs. (Herbert) Benson-Henry Institute for Mind Body Medicine

1998 The Society for Spirituality, Theology and Health at Duke University

2001 George Washington Institute for Spirituality in Health

Research of Farr Curlin et al HealthCare Chaplaincy

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Making Health Care Whole: Integrating Spirituality into Patient Care, Christina Puchalski, MD, and Betty Ferrell, RN, PhD

Professional Spiritual & Pastoral Care: A Practical Clergy and Chaplain’s Handbook, Edited by Rabbi Stephen B. Roberts, MBA, MHL, BCJC

Oxford Textbook of Spirituality and Healthcare, Edited by Mark Cobb, Christina M. Puchlaski, and Bruce Rumbold

Health Progress, May-June 2009, “Do We Care Enough about Pastoral Care?”; March-April 2013 Research

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Collaboration

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CPE Programs Ongoing Education and Training Advocacy Palliative Care The Joint Commission Liaison Network

Collaboration

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CHA / NACC Partnership Summit 2007

◦ Vision for spiritual care◦ Benchmarks and metrics to measure

effectiveness of spiritual care◦ More than 50 participants

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Summit Follow UpTask Forces:

◦ Care Services/Staff Development◦ Metrics◦ Education/Credentialing/Recruitment

Documents:◦ Essential functions of a board certified chaplain◦ Spiritual leadership competencies◦ Communication materials on chaplaincy◦ Shared resources on metrics, Press Ganey

Catalyst for collaboration among Catholic systems

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CHA Pastoral Care Advisory Committee

NACC partnership Representatives from diverse systems Current initiatives

◦ Quality◦ Staff Structure◦ Communication of Value

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SC Challenges/Initiatives1. SC Integrative Challenges2. Common Understanding of SC: how perceived/

understood3. SC Staffing & non-acute care settings4. Defining/demonstrating the value proposition

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1. Integrative Challenges Bedside to Boardroom Silo approaches to spiritual care:

◦ Mission◦ Spiritual/Pastoral Care◦ Workplace Spirituality

Lack of clarity/ownership of roles/responsibilities for spiritual care◦ Screening/spiritual history/assessment◦ Generalists/specialists◦ Primary/specialists

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Mission Integration

Administration

Patient Care

Quality

Human Resources

Mission integration is everyone’s responsibility (Ascension Health)

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Ethics

Spiritual Care

Mission Integration

But certain groups are more responsible for particular elements (Ascension Health)

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1515

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2. Challenge: Common Understanding of Spiritual/Pastoral Care

Pastoral care – mission - sharing in/continuing the healing ministry….

Spiritual care – service – holistic care

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Pastoral? Spiritual? Consensus on SC professional requirements

◦ Standards for certification and code of conduct Consensus on what to expect from SC

◦ Standards of practice Consensus on what they do:

◦ Essential Functions ◦ Diverse Responsibilities

Directors Certified chaplains Non-certified chaplains Volunteers Sacramental ministers

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Common Standards and Code of Ethics◦ Theory of Pastoral Care◦ Identity and Conduct◦ Pastoral◦ Professional

Standards for Certification

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With Patients and Families1. Assessment2. Delivery of Care3. Documentation of Care4. Teamwork and Collaboration5. Ethical Practice6. Confidentiality7. Respect for Diversity

Standards of Practice for Professional Chaplains in Acute Care Settings, Long Term Care Settings

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Staff and Organization8. Care for Staff9. Care for Organization10. Chaplain as Leader

Maintaining Competent Chaplaincy Care11. Continuous Quality Improvement12. Research13. Knowledge and Continuing Education

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1. Provide leadership and education that shapes and supports the culture of spirituality, mission and values of the organization

2. Collaborate within his or her department and organizational setting, aligning spiritual care goals and organizational goals

3. Advocate within their organizations and the communities they serve for justice, human dignity, stewardship of resources, quality, excellence and safety

CHA/NACC Essential Functions

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4. Design, implement and assess a variety of programs across the continuum of care that address diverse religious, cultural and spiritual needs of clients and staff

5. Provide effective spiritual care as part of an interdisciplinary team that contributes to the well-being of staff, patients/clients and their families

6. Document a spiritual assessment, intervention and plan of care

CHA/NACC Essential Functions, cont…

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CHA/NACC Essential Functions, cont…7. Promote the dignity of the human person

throughout ethical decision-making and work within the institutional ethics process to meet the needs

8. Create and facilitate rituals for individuals or groups and to serve organizational needs

9. Facilitate patient/clinic groups to provide support during life/health crises and empower individuals/ families and staff to utilize resources for healing

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With CHA Pastoral Care Advisory Committee sought perceptions of:◦ HC Executives◦ HC Clinicians

Late August-early September 2012

How perceived/understood

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Review of Executive Survey

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182241

3341 42 30

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Board Member/TrusteeCEOCFOCOOCMOCNOOther

*701 Respondents

Q1: Please identify your role in Catholic Healthcare

Largest group of participants are Board Members and CEOs CFO, COO, CMO, and CNO make up about one third of respondents Remember “Other” identifies:

◦ Those who wear multiple “hats”◦ Those who took the survey who were not part of the target

audience

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28

43

21

53

166

151

276

221

0 50 100 150 200 250 300

Other

Important for Healing Process

Spiritual Aid in Dying Process

Essential/Important (Little Clarification)

Essential for Treatment of Whole Person

Provide Staff Support

Provide Patient/Family Support

Part of Catholic Identity/Mission

Q2: How would you describe the purpose & value of spiritual care and professional chaplaincy?

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9

6

4

4

1

3

1

0 2 4 6 8 10

Maintains SpiritualRoutines/Services/Sacraments

Aid in HC Decision-Making

Ethics Consultation/Decisions

SC in HC System (Patient toBoard)

Important for "CurrentGeneration"

Assessing CommunityNeeds/Community Benefit

Aid in Financial Goals ofHospital

Q2, continued – Clarification of “other”

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Open-Ended Response Providing patient and family support was the most

recognized purpose and value of spiritual care and chaplaincy

Second most recognized value was the role spiritual care plays in our Catholic identity and mission

The breakdown by subgroup shows values of spiritual care are similar throughout responding groups (available in the Executive Survey Appendix at the end of the presentation)

Q2, continued – Key Themes

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“Both a strong presence and and wide array of spiritual care services will only enhance our healthcare mission vision and values.”

- Board member/Trustee

“I believe it can be an underrated value, because what happens between a chaplain and the patients is often not going to be revealed, so the value is not seen.”

- Board member/Trustee

“To carry out our mission and ministry by providing spiritual support to residents, families and staff. To act in a leadership role in assisting in the development of a culture of respect and dignity for others, and healing for all.”

– CEO

“I believe this in an integral part of supporting our mission to provide quality care of the whole patient.”

–CFO

Q2, continued – Comments We Are Hearing

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“The purpose and value is many. First, it is to provide a framework for who we are as an organization with our faith based foundation. Second, it is to remind us continually, that our passion and role in life is to live God's will. Third, it is to be supportive to patients and families during times of doubt, need, and grief.” –CFO

“The spiritual dimension is an integral part of our daily ministry to patients, at times of birth and death, joy and sorrow.” – COO

“To lead spiritual healing among patients, families, staff, and physicians. To help organization remain faithful to our mission.” – CMO

“Critical for the success of the hospital and it's mission.” – CNO


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542

407 506

544

486435

536

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Essential role of spiritual care in Catholichealth care.

Integral role of spiritual care, especially intending to the emotional needs of theclients we serve.Orientation, education and integration ofstaff in meeting spiritual care needs.

Positive influence on patient satisfaction.

Impact/involvement in quality initiatives.

Support of staff, especially during criticalincidences.

Influence on overall publicimage/perception of total care.

Other (please specify)

*674 Respondents

Q3: What types of information do you want to have regarding the role of chaplains in your decision making?

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“Check all that apply” Question Most responded: “Integral role of spiritual care,

especially in tending to the emotional needs of the clients we serve” (80.7%)

However, 5 of the answers were within 72% to 80% response range (all important)

Least requested: “Impact/involvement in quality initiative.” (60.4%)

Breakdown by subgroup shows very little variation among individual groups (Appendix).


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Review of Clinician Survey

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98

6

24

12

48

226

18

0 50 100 150 200 250

Other

C N A

Nutritionist

Physical Therapist

Social Worker

Nurse

Physician

Q1: Please indicate your role within the clinical team.

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Nurses make up the largest group of respondents “Other” Responses:

◦ Individuals carrying multiple roles◦ Those outside the target audience

Second largest subgroup are social workers

Q1, continued - Roles

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19

5

3180

163

44

54

45

24

10

23

0 50 100 150 200

Other

Engagement of Faith/Rituals

Part of Catholic Identity

Essential for Treatment of Whole Person

Support Patient/Family

Support Patient

Support Staff

Important (Little Clarification)

Important for Healing

Aid in Ethical Decision Making

Aid in End-of-Life Care

Q2: How would you describe the purpose and value of spiritual care?

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Open-Ended Question Largest Identified purpose/value is Patient and

Family Support (similar to executive survey) Second largest value is the essential need for

treatment of the whole person Breakdown by subgroup does show some

variation due to the number of participants, however, trends are similar within different groups (Appendix) .


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“It is at the essential core of the healing process for patients and their families.” – Physician

“The value lies in the fact that we are not simply physical beings. There is a part of us that, although not physical, requires support and healing during physical illness.” – Physician

“To provide support to the staff, patients, and family. Also, to assist in making funeral home arrangements, organ donor assistance, and morgue management.” – Nurse

“We need to recognize that our patients identify themselves as spiritual beings. Respecting that identity requires we provide care commensurate to their identified needs.” – Nurse


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“The purpose of spiritual care is to encourage the personal active engagement of including God in all we do. The value is the most important aspect of our life.” –Social Worker

“The value and purpose of spiritual care are on the same plane as medical care. Just as important.” - Physical Therapist

“Mindful of dignity to all, Spiritual Care is the carrier of ethics and values within the medical setting, many times just by presence alone and not a word said.” –Nutritionist

“Vital part of care! Our job is to heal body, mind, & spirit.” - CNA


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36

229

184

282

327

381

0 100 200 300 400

Other

EthicalQuestions/Concerns

Personal Support

Supportive Presencefor Staff

Prayer/Ritual forPatient/Family

Supportive Presencefor Patient/Family

Q3: When seeking assistance from spiritual care & professional chaplaincy, what are you asking for?

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“Check all that apply” question Largest response (97.4%) was “Supportive

presence for patient and family” Smallest Response (47.1%) was “Personal

support” Very little variation in subgroups (Appendix).

Meaning: Focus does not vary between the subgroups


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“Feedback from spiritual care about their interaction with unit associates and opportunities for improvement, including more associate engagement in the healing ministry.” - Nurse

“Being available (physically in the building) for 3rd shift as well.” –Nurse

“Advance Directives, help with goals of care, or to help clarify a course of treatment/treatment plan.” - Nurse

“Providing therapies such as music, DVD, simple hand massages, focus breathing etc...” – Nurse


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“I have not thought about consulting the chaplain for ethical questions, thank you for this question.” –RN Case Manager

“Intervention with patients and families at times” – Social Worker

“Teaching for staff on how to meet spiritual needs of patients within the work that we do” – Social Worker

“Help with clarifying needs of patient's from faith backgrounds that we typically do not have experience with. Muslim, Hindu, etc.. and finding support within the community for these patient's and families.”

–Physical Therapist


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49

362

342

369

223

372

314

249

0 100 200 300 400

Other

Family Needs Support

Patient Needs Support with End-of-LifeDecisions

Patient Expresses Need for Spiritual/CulturalSupport (Faith and Beliefs)

Patient Failing to Thrive/Progress with Goals

Patient Expresses/Evidences Emotional/SpiritualDistress

Patient Receives Terminal Diagnosis

Code is Called

Q4: When would you refer a patient and why?

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“Check all that apply” Question Largest response (95.6%): “Patient

expresses/evidences emotional or spiritual distress”

Smallest response (57.3%): “Patient is failing to thrive of progress with goals”

5 responses have 80% or better response rate Little variation by subgroup (Appendix)


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“Many patients have expressed gratitude for spiritual care visits even when no crisis is looming. They like the element of spirituality a visit brings during hospitalization, and they take comfort in access of the service if they need it.” – Nurse

“We need to make these services available for patients seen on an outpatient basis, as they face chronic distress.” – RN Case Manager

“Spiritual Care is much better in addressing the above issues and often has more contacts in the community for helping the resident/family such as calling a priest for Anointing of the Sick, etc.”

– Physical Therapist


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9

2

5

15

23

3

4

5

7

2

2

0 5 10 15 20 25

Other

Chaplain's role in Staff education on SC

Chaplain Support of Other Faiths

Educational Backgrounds/Specialized Training

Specific Roles and Responsibilies of Chaplains

Hours and Availability of Chaplains

How Specifically do Chaplains Provide Support?

Chaplain's Role in Supporting/Comforting Staff

How/When Should Staff Refer Patients to theChaplain?

Catholic vs. non-Catholic Chaplain vs. Priest

When/Where should Chaplains be Visable?

Q5: What more would you like to know to better understand the role of professional chaplains?

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Very small amount of responses (of the 142 replies, most indicated no additionalinformation needed)

Largest response is desire to know more about the specific roles and responsibilities of chaplains

Second largest request was information on educational training of chaplains

Breakdown by subgroup lead to little conclusion due to lack of participation


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“I would like to see them support the staff more during and after a crisis or traumatic event.” – Nurse

“Along with their theological training, do they have social work backgrounds as well? Medical knowledge?” – Nurse

“How does the role of chaplain differ from the role of a local pastor or priest?” - Nurse

“How does someone with a different faith have their support accepted?” - Social Worker


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“We would like information/direction as to how to incorporate more spiritual care in the clinic setting.” - Nurse

“Confidentiality: Can chaplaincy ask if the information can be shared with the professional working on the case?” - Nurse

“What sort of documentation is required for the medical record? Sometimes we don't know if anyone has been to see the patient or not, as there is no documentation.” – Nurse


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How to structure, offer, and deliver spiritual care? What will it look like in other than acute care

settings?◦ Outpatient◦ Clinical settings◦ Medical Home Model◦ Homes

3. Challenge: SC Staffing and Non-Acute Care Settings

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Simple ratio of chaplain to beds/census not sufficient ◦ Does not factor in acuity or

intensity◦ Does not reflect staff

ministry◦ Does not reflect ministry in

the organization (e.g. worship services, blessings, etc.)

What is Not Working in Determining Staffing

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Agreement to Common Unit of Service (UOS) for Chaplain’s Work ◦ Great variation of practice from facility to

facility ◦ Some have tried

Worked days Patient days or patient adjusted days Cost/unit

What is Not Working Perfectly

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Focus on cost savings Recommendations may not

be grounded in verifiable data

Ask questions

When Consultants Come to Town

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Concern about sharing models for fear that “floor” (minimum) does not become “ceiling” (maximum)

If we don’t develop a model soon, consultants will and staff will be cut

Fears

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Develop multiple models simultaneously

Share models Test across systems Evaluate from tests

R&D Model

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Approaches

Justifying value of chaplains

Determining appropriate staffing levels

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Chaplains’ Role When Census Lowers

Who? Providence Everett, WA

What? Model that shows when census goes down, attention to staff ministry goes up

Results? Demonstrates to administrators that chaplains work beyond patient care

Helps chaplains understand shifts in their work

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Chaplains’ Role in Population Management

Who? Providence Oregon

What? Initial work with population management care showing acuity outside of hospital and hospice

Results? Just beginning work with ALS clinic

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Focused Reports on Chaplains’ Work

Where? Franciscan Health System/ CHI Tacoma, WA

What? Reports visually show Needs served Number of people served Services provided

Results? Visually appealing Clear for chaplains and administrators Allows for coaching of chaplains regarding

productivity

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Conceptual Framework for Discussion

Where? Dignity Health San Francisco, CA

What? Conceptual piece of three-legged stool (next slide)

Results? Invites pastoral care leaders to consider what is important to their administration

Provides system formula that captures both core staffing and local expectations for spiritual care

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Spiritual Care is who we are. (Mission Integration)

Spiritual Care is a factor in improved outcomes. (Strategic Integration)

Spiritual Care can account for a core staffing standard.

(Stewardship)

Dignity - The Three Legged Stool

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Where? Mercy St. Louis, MO

What? Conceptual discussion starters about acuity and how it influences staffing levels, e.g., 100-bed NICU staffed more robustly than medical-surgical area

Results? Provides talking points for discussion about how much is needed

Does not provide easy formula

Consideration of Acuity in Determining Staffing Levels

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Tool to Assess Rural or Critical Access Hospital Where? Mercy

St. Louis, MO

What? Simple process to gather information about needs and resources within the community

Results? Provides organized way of assessing Honors local tradition and community Provides information for making

recommendations

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Rural or Critical Access Hospital Assessment of Need Interview key leaders

◦ History, traditions, needs

Identify Current State of Pastoral Services/Attention to Spiritual Needs◦ Coverage by chaplain or clergy? When? How? ◦ Relationship with local clergy? ◦ Training for staff or volunteer clergy? ◦ Chapel space? ◦ Tradition of prayer in facility? ◦ Other resources for spiritual needs?

Develop recommendations

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Multi-level Model

Where? Trinity Health Livonia, Michigan

What? A tiered model to staffing dependent upon geography, resources, and services provided

Results? Allows for various configurations of teams Allows for various levels of coverage Accounts for local culture

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Tie Chaplains’ Work to Hospital Performance

Where? Oakwood Hospital Dearborn, MI

What? Use results of HCAP question to show value of chaplaincy in

Results? Simple process

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GRASP Model – Orin NewberryGrant-Riverside Acuity Staffing Process

Where? Ohio Health Columbus, OH

What? • Unit by unit assessment of need• Approach utilized to determine staffing for

organization.

Results? “Very helpful to the pastoral care department at Grant Medical Center and Riverside Methodist Hospital”

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Inpatient assessment of patient care areas using three criteria:

◦ visibility◦ ability ◦ urgency

Score each unit on criteria: 1 (High) to 4 (Low) Sum of scores designates unit acuity

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Things to Consider

• Need both numbers AND stories

• If we were given blank slate, what would we create?

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Potential Groups to Learn From

Other departments who are doing some chronic disease management

◦ Care managers◦ Social workers◦ Palliative care early interventions

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“Intrinsic good” vs. “instrumental good”◦ ERDs define pastoral care as a means to an

end: “promote health and relieve human suffering.” (Introduction to Part 2)

◦ Metrics that make the case Demonstrating value to CEO,

physicians and others

4. Challenge – Defining/ demonstrating the “Value Proposition”

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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?

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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

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A measure which focuses on a process that leads to a certain out come

◦ ? Did you do it (services complete)? ◦ ? Did you do it right? Process measures

can be isolated to a particular activity.

Examples: ◦ Newly admitted patients seen within 2hrs of admission◦ Time of charting within 30 minutes after encounter◦ Chaplain notified within 60 minutes…..

Process Measures

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A measure of the results of a system, relative to aim

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

◦ Standardize it, measure it, assess outcome, and improve it.

Examples:◦ To what extent is the chaplain meeting your spiritual

need (outcome measure). Did the spiritual well-being change- what does the patient report?

◦ To what extent is the chaplain meeting your emotional need… Did emotional well-being change? what does the patient report?

◦ Chaplain called to comfort anxious patient. Was there a change- what does the patient report?

Outcome Measures

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

◦ Standards of Practice for Professional Chaplains in Acute Care (SOP-AC)

◦ Standards of Practice for Professional Chaplains in Long-Term Care (SOP-LTC)

◦ Performance against one of the (SOP-AC) Standard 3 - Documentation of care Set a measure to do a chart audit on a specific

number of patient charts each month to review that charting was timely, appropriate, and accurate.

◦ SC Standards of a system, department

Performance against Standards

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Challenges ◦ Identifying clearly expected behaviors for each

standard that will indicate performance being met

◦ Putting in place accountability measures First attempt at Core Elements

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Gratitude for Gathering Today Collaborative Spirit of CHA members Ongoing work of the CHA Pastoral Care Advisory

Committee ACA, 2014, and beyond

The journey continues…