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The nature of chaplaincy and the goals of QI: patient-centered care as professional responsibility.

Seasoned clinical ethicists have a saying: You cannot bite a wall. The saying refers to that demoralizing moment of taking in the scale of a (really) big challenge in health care. We have two options when we find ourselves up against this wall. One is to ignore it. This means ignoring the needs of people who are sick, or lack access to health care, or could be harmed by care that is not as good as it could be. A health care professional's duty of care is a duty to act in the interests of those for whom one cares. Merely feeling awful--it's a shame about that wall--is the same as ignoring the wall, from the perspective of those who suffer because of the wall's existence.

The second is to be ethical. We can find a crack in the wall and work away at it. The trick is to avoid the temptation to bite off just a bit and declare victory, rather than staying connected to others working on the whole wall. It would be a pity to take down just enough of the wall to build a silo.

Quality improvement in health care can look like yet another unbitable wall. And yet, the Institute of Medicine gave us six ways of looking at the QI wall in its influential 2001 report, Crossing the Quality Chasm. The report described six goals, or "aims," for QI in health care: it should aim to make health care safe, effective, patient-centered, timely, efficient, and equitable. (1)

Different health care professions have focused on one or more of these now-classic six, with particular attention to safety and effectiveness. Health care, as an enterprise, has a fundamental obligation to distinguish safe from unsafe and effective from ineffective. Certain health care professions and clinical specialties--pharmacists and anesthesiologists, among others--have acknowledged safety to be their distinctive QI goal. They have described problems--medication labeling, equipment design--and have recommended solutions intended to increase safety and also effectiveness, given that unsafe care is ineffective care. They have pledged, as a matter of professional ethics, to keep working away on this bit of the QI wall.

It is now time for health care chaplains to step up to this wall. The goal of patient-centered care should be strongly identified with this profession. Patient-centered care is a worthy goal and one that chaplains can contribute to, significantly and measurably.

Why QI? Ethics and Tactics

But why should chaplains choose any QI goal? And why patient-centered care in particular?

If chaplaincy wants to be taken seriously as a health care service--if chaplains want to be taken seriously as health care professionals--then they cannot hold themselves apart from the ethical obligations of the health care enterprise. Doing so would reduce the delivery of spiritual care to something that one does for one's own fulfillment and for the incidental or occasional benefit of others.

It is the nature of chaplaincy to be in solidarity with the suffering person, which in health care is usually the patient or the patient's caregiver. It is also the nature of most chaplains to prefer to be "at the bedside." If chaplaincy cannot identify with patient-centered care as its distinctive QI goal, then it is hard to make the case that another profession ought to. And it's hard to imagine why chaplains would not want to work to make care better for the patients in the other beds, mindful that they themselves cannot be at every bedside.

Also, it makes good tactical sense for the profession of chaplaincy to commit itself to patient-centered care as its QI goal. Thanks to the wide dissemination and discussion of the IOM report, no health care institution can easily argue for a definition of QI that does not include these six. If chaplaincy, as an institutional service, went on record as saying, in effect, "We'll help you with the goal of patient-centered care," then chaplaincy can claim to share the credit for institutional progress, even as it will be held more accountable for showing progress. Good tactics can converge with good ethics.

Defining "QI." If we accept that the price of admission to professional status includes involvement in QI, and if we accept that chaplains, as a matter of ethics and tactics, may have a particular affinity for QI activities aimed at advancing patient-centered care, then how should chaplains go about doing this?

First, they should become familiar with a good working definition of QI. A recent Hastings Center project on the ethical issues raised by quality improvement defined "QI" as "systematic, data-guided activities designed to bring about immediate, positive changes in the delivery of health care in particular settings." (2) Conducting systematic, data-guided activities to advance patient-centered care is different from the desire, however sincere, to provide patient-centered care--or the belief, however sincere, that one is already doing so. (3)

Defining "patient-centered care." Next, chaplains should become familiar with how the most influential organizations within the QI movement define "patient-centered care":

* Institute for Healthcare Improvement: "Care that is truly patient-centered considers patients' cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient and their loved ones an integral part of the care team who collaborate with health care professionals in making clinical decisions. [It] puts responsibility for important aspects of self-care and monitoring in patients' hands--along with the tools and support they need to carry out that responsibility. [It] ensures that transitions between providers, departments, and health care settings are respectful, coordinated, and efficient." (4)

* Agency for Healthcare Research and Quality: "In a patient-centered model, patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals." (5)

* IOM: "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions." (6)

* National Quality Forum: "care [that] is centered on what patients need and want, rather than on what is convenient for providers." (7)

These definitions are not identical, but they are quite similar. "Patient-centered care" encompasses both the individual patient and the coordination of care in the interests of all patients. In a four-hundred-bed hospital, there should not be four hundred customized models of patient-centered care, but rather one model that can reflect the needs and preferences of each patient with respect to his or her diagnosis and treatment goals, as well as how this patient uses health care and receives support from family and other caregivers.

If this institution uses "patient-centered care" only as a marketing slogan for the billboards--"Where you are the center of our care"--but does not show its staff a convincing model of patient-centered care nor give them permission and incentives to make continuous improvements to the working model, then it will be discouraging for this staff to contemplate what the Agency for Healthcare Research and Quality calls the "quality gap": the observable difference "between health care processes or outcomes observed in practice, and those potentially obtainable on the basis of current professional knowledge." (8) This is also, as we say in bioethics, the gap between "is" and "ought." And if any health care professional or profession uses "patient-centered care" to describe an attitude or aspiration, but not an action--then nothing has happened yet that will help these patients. Identifying with patients is not the same as actively looking for ways to bridge the quality gap between their current care and the better care they could be receiving.

From "ought" to "is"--advancing patient-centered care through the work of chaplains. If opinion leaders in chaplaincy were to decide that this field could and should embrace patient-centered care as its collective and distinctive quality improvement goal, what could they then do to help working chaplains bridge the quality gap in their own institutions? And what could this field do within the quality improvement movement?

In addition to the basics--clarifying their own professional practice standards, supplying definitions and examples of chaplains' work that can be easily understood by professionals in other health care fields--chaplaincy would need to go where the QI consensus is. They would need to look for opportunities to join ongoing conversations on patient-centered care organized by the leading QI organizations. They would need to conduct and support research on the chaplain's role in patient-centered care and advocate for better ways to assess chaplains' work and impact in this area. They would need to sponsor workshops to teach chaplains how to design and evaluate QI activities aimed at promoting patient-centered care, or support chaplains' efforts to obtain this training elsewhere. And they would need to nurture visionaries: research-minded chaplains who are passionate about the goal of patient-centered care and who can encourage their colleagues, and the field, to embrace and take pride in collective action toward this goal.

This may seem a bit too much like biting a wall. If so, then chaplaincy--like other health care professions--may want to identify a particular challenge in patient-centered care and work away at it. Improving palliative care offers one such challenge. Chaplains may work on palliative care teams, and palliative care is an interdisciplinary field congenial to chaplains and chaplaincy. The clinical practice guidelines released in 2004 by the National Consensus Project for Quality Palliative Care are notably detailed in their attention to "spiritual, religious, and existential aspects of care" as part of the "patient-and-family-centered-care" that should characterize quality palliative care. (9) The guidelines emphasize that quality in "spiritual, religious, and existential aspects of care," like quality in any other aspect of palliative care, should be evidence-based, consistently practiced, and continuously improved. (10)

There are acknowledged quality gaps in palliative care, and there are acknowledged research gaps, too: practices that are not yet fully informed by evidence or professional consensus. (11) Chaplaincy could partner with researchers--and visionaries--in palliative care to conduct research on quality in spiritual, religious, and existential aspects of care, to disseminate research findings, and to advocate for the application of research to practice. If chaplaincy becomes--and is seen to be--an ally of experts who seek to improve quality in palliative care, then chaplains will be invited to contribute to future clinical practice guidelines. These actions, over time, will improve palliative care, advance patient-centered care, and--not incidentally--add to the stature of chaplaincy as a field. Again, good tactics and good ethics.

Not all of the QI action takes place at the "profession" or "field" level. Working chaplains can also make patient-centered care their institutional QI goal. This will be easier to do if their institution has already made its commitment to patient-centered care clear by encouraging its departments to develop QI projects toward this goal. It may also be easier for chaplains to develop substantive QI projects if their own profession has already embraced patient-centered care as its collective QI goal. If chaplaincy is understood to be a QI-driven profession, then the institutional investment in professional chaplaincy will be understood to bring QI benefits to the institution.

From Theory to Practice

If a chaplaincy department embraced patient-centered care as its QI responsibility, institutionally as well as at the bedside, what would that look like? How does a chaplain take the plunge to design and test a patient-centered model of care? Here's what the chaplaincy director at one hospital did. (12) In the waiting rooms of the outpatient cancer program, posters and brochures invite outpatients and family caregivers to directly contact various social support services--social work, psychiatry, chaplaincy, and patient representatives. Few patients or families did so. Most referrals came from hospital staff, usually after a crisis erupted. Patients and families who were referred to these services consistently reported, via follow-up surveys, that they were highly satisfied with the care they received. The verbal surveys conducted by a team composed of representatives of the supportive services also revealed that these patients and families had not found those posters and brochures to be helpful. It was only after they had met the social workers, counselors, chaplains, or patient reps that they understood what these staff members did and how they could help.

Guided by the survey responses, and working from the hypothesis that introducing patients and families to services they might need and want (and could request on their own) would advance patient-centered care, team members began to talk about developing an orientation session for all new patients in this system. But how to broach this with hospital administration? One team member, the chaplaincy director, took advantage of a training session offered as part of the hospital's QI program. Through this training, she made new contacts in her institution and was able to bring fresh insights to her team on how to develop their idea into a full-fledged QI project.

The orientation sessions, which are optional and open to longstanding patients as well as new patients, are now offered twice a month in the waiting rooms of the outpatient clinics. At each session, at least three members of the project team--consisting of a social worker, case manager, patient representative, chaplain, and psychologist--introduce themselves and describe what they and their departments can do for patients and families, based on what other patients and families have found helpful in managing similar diagnoses and treatments. Team members have noticed that the interactive format of the orientation prompts patients and families to pick up and ask questions about the existing educational material they had previously overlooked, even though it was in plain sight in every waiting room. Team members have also drafted a new brochure describing some of the common issues faced by cancer patients and their families. This brochure is "patient-centered," not "discipline-centered," so patients will not be required to think about their own needs in terms of medical jargon or departmental boundaries.

The project is ongoing, but to date, the outcomes have included:

* immediate and positive feedback from orientation participants, who appreciate the opportunity to meet hospital staff person-to-person, in the outpatient setting, where there is no crisis-driven agenda to increase tension;

* an increase in direct referrals from patients and family members; and

* far greater awareness of supportive services among the oncologists and nurses who work in the outpatient clinics.

These clinicians are now asking members of the orientation team for detailed guidance on making referrals. Team members have collaboratively developed a referral algorithm and referral form to help direct clinicians' referrals to the appropriate departments. These tools are patient-centered in that they allow medical staff to be guided by their patient's expressed concerns and their own clinical observations, rather than requiring them to guess which department should get the referral. The referrals come to the team, whose members collaborate to sort them in terms of the interventions needed. Since the start of this QI project, referrals to supportive services from outpatient medical staff have doubled. As these new referrals are not crisis-driven, they can be managed by existing supportive services staff.

The chaplaincy director and the other project designers have observed another, unanticipated outcome. The same medical staff has begun to ask them for help in talking with another group of patients and families about another problem: the transition from outpatient medical care to hospice. These clinicians had been unsure about when it was appropriate to bring up hospice in the outpatient setting, and they had fallen into a habit of admitting patients with end-stage disease to the hospital for the transition to hospice. By providing patients and families with support at the beginning of their relationship with cancer care providers, and by becoming an ongoing resource to medical professionals, this team is improving the quality of care in their institution in another way, by helping patients near the end of life avoid an unnecessary hospital admission.

Innovation begets innovation. And steadily, the wall comes down.

What Do Health Care Chaplains Think about QI?

There is little data about chaplains' involvement in or attitudes toward QI in the institutions where they work. To fill this gap, the Professional Chaplains and Health Care Quality Improvement project conducted focus groups in 2007 with chaplains in New York, Illinois, Arizona, and California. This IRB-approved study was designed and directed by George Fitchett, director of research in the Department of Religion, Health and Human Values at Rush University Medical Center, with colleagues Clayton Thomason and Kathryn A. Lyndes.

Most focus group participants were board-certified chaplains (74 percent) who worked in hospitals (82 percent); the average participant had worked as a chaplain for thirteen years.

Key findings:

* Chaplains have a strong commitment to providing quality spiritual care. However, they are frequently skeptical about QI as an institutional activity. They may resist QI language and methods that focus on quantity of care--"making the numbers"--rather than quality of care.

* Chaplains who are involved in quality improvement in their own departments may not use QI language or connect their efforts to institutional QI.

* Chaplains are eager to learn more about promising efforts to improve quality in chaplaincy and how to conduct meaningful quality improvement projects.

Research findings will be reported in journal articles. For a summary of this study, go to the project's Web page, id=1212.

(1.) Institute of Medicine, Crossing the Quality Chasm (Washington, D.C.: Institute of Medicine, 2001), 5-6; php?isbn=0309072808.

(2.) M.A. Baily et al., "The Ethics of Using QI Methods to Improve Health Care Quality and Safety," Hastings Center Report Special Report 36, no. 4 (2006): S3.

(3.) Some hospitals use "PI"--performance improvement--methods, which emphasize the role of human performance in the delivery of health care, but both PI and QI are systematic and data-guided, and according to one recent assessment, "there is no discrete boundary between them." T. Bornstein, "Quality Improvement and Performance Improvement: Different Means to the Same End?" QA Brief, USAID-sponsored Quality Assurance Project, Spring 2001. This working definition of QI should, therefore, work for chaplains in "PI" institutions. Similarly, this working definition should work for chaplains in institutions that may use a particular QI method, such as Six Sigma.

(4.) Institute for Healthcare Improvement, "Patient-Centered Care: General," /PatientCenteredCareGeneral/.

(5.) Agency for Healthcare Research and Quality, "Expanding Patient-Centered Care To Empower Patients and Assist Providers," Research in Action, issue 5 (2002), under subtitle, "Health Care Evolves Toward a Patient-Centered Model,"

(6.) Institute of Medicine, Crossing the Quality Chasm, 6.

(7.) National Quality Forum, "NQF Brochure," 2004,

(8.) Agency for Healthcare Research and Quality, "Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies," Technical Review 9 (2005): 1, pdf/qualgap3/qualgap3.pdf.

(9.) National Consensus Project for Quality Palliative Care, Clinical Practice Guidelines for Quality Palliative Care, 5-6, http://www.nationalconsensusproject. org.

(10.) Ibid., 29.

(11.) Ibid., 41-42.

(12.) Unpublished case study supplied to author by a chaplaincy director, May 2008. Some identifying details have been changed.
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Title Annotation:Essays; quality improvement
Author:Berlinger, Nancy
Publication:The Hastings Center Report
Geographic Code:1USA
Date:Nov 1, 2008
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