Spiritual/Pastoral Care
Collaborations/Initiatives/Challenges:
Some National Perspectives
May 31, 2013
National Association of Catholic Chaplains
Day for Professional & Spiritual Enrichment
Orange, California

Research/Writing

Collaboration

Challenges/Initiatives
2
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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
3

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

Health Progress, May-June 2009, “Do We Care Enough
by Mark Cobb, Christina M. Puchlaski, and Bruce
Rumbold
about Pastoral Care?”; March-April 2013 Research
4
5
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CPE Programs

Ongoing Education and Training

Advocacy

Palliative Care

The Joint Commission Liaison Network
6
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Summit 2007
◦ Vision for spiritual care
◦ Benchmarks and metrics to measure
effectiveness of spiritual care
◦ More than 50 participants
7
Task 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
8

NACC partnership

Representatives from diverse systems

Current initiatives
◦ Quality
◦ Staff Structure
◦ Communication of Value
9
1.
2.
SC Integrative Challenges
Common Understanding of SC: how perceived/
understood
3.
SC Staffing & non-acute care settings
4.
Defining/demonstrating the value proposition
10
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
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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
11
Mission integration is everyone’s responsibility
(Ascension Health)
Administration
Human
Resources
Mission
Integration
Patient
Care
Quality
12
But certain groups are more responsible for
particular elements
(Ascension Health)
Ethics
Mission
Integration
Spiritual
Care
13
14
14
15


Pastoral care – mission - sharing in/continuing the
healing ministry….
Spiritual care – service – holistic care
16

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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
17

Common Standards and Code of Ethics
◦ Theory of Pastoral Care
◦ Identity and Conduct
◦ Pastoral
◦ Professional
18

With Patients and Families
1.
Assessment
2.
Delivery of Care
3.
Documentation of Care
4.
Teamwork and Collaboration
5.
Ethical Practice
6.
Confidentiality
7.
Respect for Diversity
19

Staff and Organization
8.
Care for Staff
9.
Care for Organization
10. Chaplain as Leader

Maintaining Competent Chaplaincy Care
11. Continuous Quality Improvement
12. Research
13. Knowledge and Continuing Education
20
CHA/NACC Essential Functions
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
21
CHA/NACC Essential Functions, cont…
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 wellbeing of staff, patients/clients and their families
6. Document a spiritual assessment, intervention and
plan of care
22
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
23

With CHA Pastoral Care Advisory Committee sought
perceptions of:
◦ HC Executives
◦ HC Clinicians

Late August-early September 2012
24
Review of Executive Survey
25
25
Q1: Please identify your role in Catholic Healthcare
*701 Respondents
182
241
Board Member/Trustee
CEO
CFO
COO
CMO
33
41
132
42
30
CNO
Other

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
26
Q2: How would you describe the purpose & value
of spiritual care and professional chaplaincy?
221
Part of Catholic Identity/Mission
276
Provide Patient/Family Support
151
Provide Staff Support
166
Essential for Treatment of Whole Person
53
Essential/Important (Little Clarification)
21
Spiritual Aid in Dying Process
43
Important for Healing Process
28
Other
0
50
100
150
200
250
300
27
Q2, continued – Clarification of “other”
Aid in Financial Goals of
Hospital
1
Assessing Community
Needs/Community Benefit
3
Important for "Current
Generation"
1
SC in HC System (Patient to
Board)
4
4
Ethics Consultation/Decisions
6
Aid in HC Decision-Making
Maintains Spiritual
Routines/Services/Sacraments
9
0
2
4
6
8
10
28
Q2, continued – Key Themes




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)
29
Q2, continued – Comments We Are Hearing
“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
30
Q2, continued – Comments We Are Hearing
“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
31
Q3: What types of information do you want to
have regarding the role of chaplains in your
decision making?
Essential role of spiritual care in Catholic
health care.
435
103
Integral role of spiritual care, especially in
tending to the emotional needs of the
clients we serve.
486
544
536
Orientation, education and integration of
staff in meeting spiritual care needs.
Positive influence on patient satisfaction.
Impact/involvement in quality initiatives.
407
506
542
*674 Respondents
Support of staff, especially during critical
incidences.
Influence on overall public
image/perception of total care.
Other (please specify)
32
Q3, continued – Key Themes





“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).
33
Review of Clinician Survey
34
Q1: Please indicate your role within the clinical
team.
18
Physician
226
Nurse
48
Social Worker
12
Physical Therapist
24
Nutritionist
6
CNA
98
Other
0
50
100
150
200
250
35
Q1, continued - Roles

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
36
Q2: How would you describe the purpose and
value of spiritual care?
23
Aid in End-of-Life Care
10
Aid in Ethical Decision Making
Important for Healing
24
45
Important (Little Clarification)
54
Support Staff
44
Support Patient
163
Support Patient/Family
80
Essential for Treatment of Whole Person
31
Part of Catholic Identity
5
Engagement of Faith/Rituals
19
Other
0
50
100
150
200
37
Q2, continued – Key Themes

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) .
38
Q2, continued – Comments We Are Hearing
“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
39
Q2, continued – Comments We Are Hearing
“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
40
Q3: When seeking assistance from spiritual care &
professional chaplaincy, what are you asking for?
Supportive Presence
for Patient/Family
381
Prayer/Ritual for
Patient/Family
327
Supportive Presence
for Staff
282
184
Personal Support
Ethical
Questions/Concerns
229
36
Other
0
100
200
300
400
41
Q3, continued – Key Themes




“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
42
Q3, continued – Comments We Are Hearing
“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
43
Q3, continued – Comments We Are Hearing
“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
44
Q4: When would you refer a patient and why?
249
Code is Called
314
Patient Receives Terminal Diagnosis
Patient Expresses/Evidences Emotional/Spiritual
Distress
372
223
Patient Failing to Thrive/Progress with Goals
Patient Expresses Need for Spiritual/Cultural
Support (Faith and Beliefs)
Patient Needs Support with End-of-Life
Decisions
369
342
362
Family Needs Support
49
Other
0
100
200
300
400
45
Q4, continued – Key Themes



“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)
46
Q4, continued – Comments We Are Hearing
“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
47
Q5: What more would you like to know to better
understand the role of professional chaplains?
When/Where should Chaplains be Visable?
2
Catholic vs. non-Catholic Chaplain vs. Priest
2
How/When Should Staff Refer Patients to the
Chaplain?
Chaplain's Role in Supporting/Comforting Staff
7
5
4
How Specifically do Chaplains Provide Support?
3
Hours and Availability of Chaplains
23
Specific Roles and Responsibilies of Chaplains
15
Educational Backgrounds/Specialized Training
5
Chaplain Support of Other Faiths
2
Chaplain's role in Staff education on SC
9
Other
0
5
10
15
20
25
48
Q5, continued – Key Themes

Very small amount of responses (of the 142
replies, most indicated no additional



information 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
49
Q5, continued – Comments We Are Hearing
“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
50
Q5, continued – Comments We Are Hearing
“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
51
3. Challenge: SC Staffing and Non-Acute Care
Settings


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
52

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.)
53

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
54



Focus on cost savings
Recommendations may not
be grounded in verifiable
data
Ask questions
55

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
56

Develop multiple
models
simultaneously

Share models

Test across systems

Evaluate from tests
57
Approaches

Justifying value of chaplains

Determining appropriate staffing levels
58
58
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
59
Who?
Providence
Oregon
What?
Initial work with population management care
showing acuity outside of hospital and hospice
Results?
 Just beginning work with ALS clinic
60
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
61
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
62

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)
63
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
64
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
65



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
66
66
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
67
Where?
Oakwood Hospital
Dearborn, MI
What?
Use results of HCAP question to show value of
chaplaincy in
Results?
 Simple process
68
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”
69
 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
70
70
•
Need both numbers
AND stories
•
If we were given
blank slate, what
would we create?
71

Other departments who are doing some chronic
disease management
◦ Care managers
◦ Social workers
◦ Palliative care early interventions
72


“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
73




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?
74




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
75

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…..
76

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 changewhat 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?
77

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 LongTerm 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
78


Challenges
◦ Identifying clearly expected behaviors for each
standard that will indicate performance being
met
◦ Putting in place accountability measures
First attempt at Core Elements
79




Gratitude for Gathering Today
Collaborative Spirit of CHA members
Ongoing work of the CHA Pastoral Care Advisory
Committee
ACA, 2014, and beyond
80