Measurement and MysteryJune 5, 2013
National Association of Catholic ChaplainsDay for Professional & Spiritual Enrichment
Orange, California
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Introduction
Why chose theme? Challenge in the healthcare arena Work that has been done to date Ongoing efforts
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Leadership Issues
Catholic Healthcare • Mission = Business• Financial Realities• Culture• Competition
Mission Leaders
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Mystery
Can one really measure the work of spiritual care? What is the theological basis?
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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
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Theological Grounding Time
• Chronos – Time spent on earth• Chairos – Time of salvation • Doing a time-study of the Jesus of the Gospels
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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?
Challenge: Defining/Demonstrating the Value Proposition
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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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Proce
ss Mea
sures
Outcome
Measures
Performance Against Standards
Integration
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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
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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
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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
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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
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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..
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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
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1. Framework of Spiritual Assessment
2. Chaplain Functions
3. Spiritual Care Outcomes
4. Benefits of Framework
Objectives
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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
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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
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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
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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
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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
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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
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Function Desired Outcomes
2. An Expressing person
• Talks openly• Expresses feelings• Cries• Relaxes• Considers resources
Supportive Validating
3131
4. WaitingUpset feelings from waiting too long in an important situation
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Presence & Networking
• Expresses situation• Prays• Acknowledges limitations• Thankful• Calm
4. A person who is waiting too long
Function Desired Outcomes
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What has this person lost, recently and historically, that still disturbs her/him at times?
Axis Two: Loss and Grief
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7.Prior Grief (Lost
earlier)
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7. Prior GriefMajor past loss being currently grieved
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• 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
Function Desired Outcomes
Grief Counseling
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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 (%)
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How does this person maintain and nurture her own human spirit?
Axis Three: Spiritual Resources
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Religious/ Spiritual
Care
10. Instruction
11. Religious Support
12. Spiritual Support
13. Spiritual Counsel
14. Self Forgiveness
15. Estrangement
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The Need to feel the immediate
positive presence of Transcendence
11. Religious Support
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Religious Support
• Sacrament/ spiritual ritual• Spiritual leader of choice• Religious
questions/problems• Prays
Function Desired Outcomes
Person who is needing God
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15. EstrangementNeed to re-connect with separated loved ones
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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
Function Desired Outcomes
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What does this person need that
may be beyond my relationship with
her/him?
Axis Four: Advocacy and Referral
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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
Function Desired Outcomes
19. People with mental illness or addiction concerns
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21. Love Life PainNeed for listening, advice or referral about one’s love life
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Documentation
Training Resource
Measurement Source
Benefits of the Spiritual Assessment Framework
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What are the needs?
What did we provide?
What is the plan of care?
Spiritual Assessment Form
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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
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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
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Able to Identify the Workload of the ChaplainsPastoral Care Encounters Department
18% 51%
31%
Patients Family Staff
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4%14%
11%
50%
5%
16%
Phone Pager STAR Orders Direct Contact Code Direct Staff
Types of Referrals
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26,116
6,493
12,249
2,297
0
5,000
10,000
15,000
20,000
25,000
30,000 Emotional SupportLoss & AdjustmentSpiritual & Religious SupportAdvocacy/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
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2,518
1,2301,362 1,383
0
500
1,000
1,500
2,000
2,500
3,000Grief SupportGrief CounselingEOL Spiritual CareAdjustment Counseling
Types of Functions to Address Needs- Loss/Adjustment
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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 ConsultationFamily FacilitatingAdvocacyAddiction ReferralFamily ReferralLove 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
Supportive Validating
Informing
Presence & Networking
Resource Enhancing
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1,055
11370
123
-
200
400
600
800
1,000
1,200
Crisis Ministry
Supportive Validating
Informing
Presence & Networking
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
Supportive ValidatingInforming
Presence & NetworkingResource Enhancing
112
480
59
429
8
0
50
100
150
200
250
300
350
400
450
500
Crisis Ministry
Supportive Validating
Informing
Presence & Networking
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
InstructingReligious SupportSpiritual SupportSpiritual CounselingSelf ForgivenessEstrangement
Chaplain Sean Deaconery
Year to Year Comparisons- Spiritual and Religious Support
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2,518
1,2301,362 1,383
-
500
1,000
1,500
2,000
2,500
3,000
Grief SupportGrief CounselingEOL Spiritual CareAdjustment Counsel
594
267239
62
0
100
200
300
400
500
600
Grief SupportGrief CounselingEOL Spiritual CareAdjustment Counsel
Students Chaplains
Students to Chaplains Comparisons- Loss and Adjustment
65
1
25
73
710
7
0
10
20
30
40
50
60
70
80InstructingReligious SupportSpiritual SupportSpiritual CounselingSelf ForgivenessEstrangement
21
293
172
1 12
0
50
100
150
200
250
300
Instructing
Religious Support
Spiritual SupportSpiritual Counseling
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
Supportive Validating
Informing
Presence & Networking
Resource Enhancing
131
1,258
120
428
101
-
200
400
600
800
1,000
1,200
1,400
Crisis Ministry
Supportive Validating
Informing
Presence & Networking
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 AdjustmentSpiritual & 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 InformingPresence & 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
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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
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Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr0
100
200
300
400
500
600
700
800
900
Emotional Support Interventions
Crisis MinistryEmpathic CompanioningInformingPresence & NetworkingResource EnhancingSeries6
Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr0
50
100
150
200
250
300
350
400
450
500
Loss & Adjustment Interventions
Grief SupportGrief CounselingEnd of Life Spiritual CareAdjustment Counseling
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Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr0
100
200
300
400
500
600
700
800
900
Religious & Spiritual Support Interventions
InstructingReligious SupportSpiritual SupportSpiritual CounselingFacilitating Self ForgivenessReconciling Estrangement
Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr0
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
Presence & Networking
Resource Enhancing
Grief Support
Grief Counseling
End of Life Spiritual Care
Adjustment Counseling
Instructing
Religious Support
Spiritual Support
Spiritual Counseling
Facilitating Self Forgiveness
Reconciling Estrangement
Ethics Consultation
Family Facilitating
Advocacy
Addiction Referral
Family Referral
Love Life Pain
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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?
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Data Collection Tool
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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 relaxationSupport person contacted Prayer requested/accepted Realistic PlanningExpressed gratefulness
Summary of Observable Outcome
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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