Benchmarking focuses on perfecting pastoral care

Program’s subjective nature posed challenge

Best practices in clinical areas are easy to find. Compare outcomes, costs, and satisfaction of different programs and whichever comes out on top wins. But how do you determine what a good pastoral care program looks like? Research on the spiritual component of good outcomes is only now beginning to trickle out.

For one group of children’s hospitals, finding out what works and what doesn’t has been easier. The hospitals, linked through a benchmarking group put together by Medical Management Planning of Los Angeles, have touched base on issues that are much more ephemeral than immunization rates and how many emergency department patients leave without being seen. They have been able to work with each other to compare pastoral care programs and even to figure out the best way to develop one. (See related story, p. 44.)

Richard Callaway, EdD, MDiv, director of pastoral care at East Tennessee Children’s Hospital in Knoxville oversees a 13-year-old spiritual care program that includes two full-time staff and on-call support.

He says outcry from physicians and staff led the hospital to create the pastoral care program. "There are four major hospitals in this area, and this was the only one without a program," he says. It helped that research in the mid-1980s showed that outcomes improved and litigation decreased at hospitals that had an active pastoral care staff.

It took two years of study before the program got under way, and Callaway says that it really happened because one physician championed the idea and pushed it through.

The program at East Tennessee was featured in the survey of pastoral care programs that Medical Management Planning conducted. (See survey, p. 42.) And that survey helped Robert Flory, MDiv, director of pastoral care at Denver Children’s Hospital, to recreate the pastoral care program at his own hospital.

Prior to Flory’s arrival, students on assignment from a clinical pastoral education program staffed the system. Now, it is a staff-run operation with a half-time chaplain, volunteers, and Flory on board. There are also three clergy members and a pastoral care counselor who staff the 24-hour on-call program. That reevaluation of pastoral care at the hospital is ongoing. Members of the team meet weekly to discuss issues such as how to improve visibility and how to refine the referral process.

The benefits of a computer system

"One problem we have had is that our admissions database form isn’t put into a computer," Flory says. "The only way a referral gets passed on is person to person to person. Since we only have a person and a half, we can’t look at every chart. We are dependent on others to let us know if someone wants to see a chaplain."

At East Tennessee, patients and their families are given cards in their admissions packet that explain the program and how to contact the chaplains. But the records are computerized. Callaway says that any time a patient says he or she wants to see a chaplain, the pastoral care office is automatically notified of that referral.

Flory says he would love such a system. It might help cut the number of complaints that requests for chaplains, as noted on intake forms, are ignored. "It’s hard, because people aren’t here at the hospital to meet a chaplain. But it can be an essential service to a family."

One recent event illustrates the need for organization. A family checked the box to call for a chaplain’s visit, and the referral wasn’t completed. The patient, a young boy, made a request to the nurse, but she failed to make the referral. The father then made a request, and it wasn’t followed through on, either. "And then he came and sat by my door, not knowing that I wasn’t there on the weekend," says Flory. "That boy had a tough recovery period, and he thought God was mad at him because the chaplain didn’t come. Four requests for a referral went unheeded, and that boy took it personally."

When Flory wrote up that story, the staff at the hospital responded. "I get four or five requests a day now," he says. "You see, the problem isn’t that people don’t think a chaplain program is a good idea. The problem is integrating requests for that service into the hospital."

Visibility is vital to the success of a program, says Flory. "But if I’m in oncology, I’m not in the NICU, and people don’t think about making referrals until they see me."

While there are similarities to all the programs in the children’s hospital group, there are also differences. For instance, many have different ways to calculate their success. Callaway uses two methods to evaluate his program. Formally, for hospital administrators, he keeps track of the number of visits, call backs, and the way services are utilized. "On a yearly basis, I have to justify my staff based on those numbers."

But he admits that for most chaplains, that’s a poor way of determining success. "I judge it more by how many notes I get back, when people call for me, how many funerals I’m asked to do. Those are the things that let me know I’ve really made contact with people."

Should you judge success by the numbers?

Flory also objects to looking at the number of contacts as a way to gauge success. "I’ve been at hospitals where they count every person you talk to as a visit," he says. "You can have 50 contacts [a day] if you use that kind of statistic. But is that a meaningful contact? And if you spend five hours with one family, is that just one contact? I spend eight hours of my day on this, so I don’t think counting the hours is the right way to do it, either. It’s a soft discipline, and success can be hard to measure in a way that administrators accept."

The problem with failing to play the numbers game, Flory adds, is it makes the program more vulnerable to cuts. "We aren’t ordering a new medicine and seeing a change in patient health. But there are hundreds of stories I can tell you, where I didn’t know I was affecting the outcome of a patient and I get notes from parents saying they couldn’t have done it without me."

Flory thinks that pastoral care programs are underdeveloped and underutilized, but having a group of highly regarded hospitals at hand with whom he can compare his program and take hard facts and numbers back to his administrators may help him to develop it further in the future. "It’s not that you feel resistance to the idea of pastoral care," explains Flory. "If I did, it might be easier. But thinking that one person can meet the needs of an entire hospital is wrong. The fullness of a program has to be invested in to see the results. The numbers increase as the number of full-time staff increases, not the other way around."

[For more information, contact:

• Robert Flory, MDiv, Director of Pastoral Care, Denver Children’s Hospital. Telephone: (303) 861-6325.

• Richard Callaway, EdD, Mdiv, Director of Pastoral Care, East Tennessee Children’s Hospital, Knoxville, TN. Telephone: (423) 541-8746.]