December 2017 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Tartaglia, A., Ford, T., Dodd-McCue, D., Reid, C., Hawley, C. and Hassell, A. "Charting our course: chaplain documentation as a performance improvement project." Journal of Health Care Chaplaincy (2017): published online, November 2, 2017, ahead of print.
[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. Quotations noted below are referenced by manuscript [MS] page numbers.]
SUMMARY and COMMENT: This month's article, out of Virginia Commonwealth University (Richmond, VA), "presents the results of a 30-month process improvement initiative examining the spiritual assessment documentation patterns of staff chaplains as well as CPE residents and interns at an academic medical center" [MS p. 1]. It speaks to issues of chaplain training, professional development, and a culture of quality improvement in a pastoral care department; and it "contributes to the conversation supporting the development of a common tool for chaplain documentation in the electronic health record" [MS p. 9]. The authors include, as an appendix, the spiritual assessment segment of their electronic medical record (EMR) form. Four of the six authors are from the VCU Department of Patient Counseling: Tartaglia, Ford, Dodd-McCue and Hassell. They have partnered here with two members of VCU's Department of Rehabilitation Counseling: Reid and Hawley.
The project built upon the discovery of variances in charting from weekly reviews of chaplains' electronic documentation. Department faculty identified the potential role of biases and patterns in charting that "posed an internal threat to the critical importance of documentation in the medical record," in light of the strong conviction that "[i]n an environment that embraces an inter-professional, medical psycho-social and spiritual model of care, dependable chaplain assessments are critical" [MS p. 3].
Accurate and consistent assessments communicate clear spiritual needs of patients/families to other members of the health care team as well as two other chaplains who share in the care of a particular patient/family. In addition, documentation inconsistencies introduce inter-rater reliability concerns for both clinical practice and training. [MS p. 3]
So, with institutional review board approval for additional study, our authors embarked on the current project, which "focused on three aims:"
The training intervention plan tested here added to an existing orientation process for chaplains' documentation four new components:
- to determine the impact of a comprehensive training intervention on individual and aggregate spiritual assessment patterns of chaplains and CPE students;
- to determine what, if any, benefit the intervention would have on charting consistency; and,
- to explore the benefit of using a comprehensive investigation of chart notes as a method to enhance the training and professional development of chaplains. [MS p. 4]
...(a) a targeted 90 minute review session on documentation for all new CPE interns was conducted one month into the initial unit focusing on differential assessment of spiritual concerns; (b) and additional 60 minute open-ended, student driven seminar focus on assessment and documentation was added to two of the three units in the residency year; (c) weekly documentation reports on each CPE student were provided to the primary CPE supervisor and the service line liaison for individual learning opportunities; and (d) a five-hour annual review of spiritual assessment EMR documentation focused on aggregated findings was offered for all faculty, staff chaplains, and CPE students. [MS p. 4]
Data were collected from EMR system-generated reports for two years (January 1, 2012 to December 31, 2014), from a total of 38,646 charts. Seventeen chaplains documented both before and after the second training intervention. Among the results:
These researchers conclude that the results speak to the "importance of a rigorous, ongoing, and multi-methodological approach to teaching spiritual assessment" [MS p. 8]. "Additionally, the results suggest that the initial patterns of documentation even by experienced chaplains may reflect habit or personal practice, while patterns of students might be attributable to limited experience" [MS p. 8]. "...[S]taff and CPE students alike acknowledged during training sessions that...[some]...categories were convenient default assessments" [MS p. 8]. Regarding the broad effect of the intervention, the authors point to the potential for "overall change in the departmental culture" [MS p. 9]: "Cultural changes in communication among chaplains and between chaplains and other members of the inter-professional team may have become more consistent and dependable" [MS p. 9].
- "Charting patterns remained essentially unchanged for those who attended neither of the annual training events compared to those who attended one or two of the intensive sessions." [MS p. 6]
- "Attendance at both sessions appears to have resulted in broader assessment utilization and reduced documentation of Other." [MS p. 6]
- "Subanalysis of the 'Other/Specify' assessment showed that prior to the first training, only 20.5% of these charts include the phrase 'unable to assess.' After the training, for that same assessment 42.6% of these charts included the exact phrase 'unable to assess.'" [MS p. 6]
- "...[A]nalysis on the effect of the initial training revealed that the most significant predictor of spiritual assessment patterns was whether the charting occurred before or after the training, regardless of whether the chaplain attended the training...." [MS p. 6] "...Residents and Interns (as well as Staff and PRN) decreased their percentage use of the Other category over time, regardless of attendance." [MS p. 8, italics added]
- With the decline of the use of the Other category, there were gains in the use of different assessment categories. For example, there were "near double-digit and above increases" in the use of the category of Meaning by Residents, Staff, and Interns. [--See MS p. 7]
- Significant changes were found according to analysis of the timing of the documentation, the role of the chaplain, and attendance at the trainings.
Generalizability of the findings is hampered by a number of limitations (e.g., analysis is from "a convenience sample of the charting practices of a single academic hospital" [MS p. 9]), and there may be practical impediments to replication at other institutions because of differences in charting systems. Nevertheless, the authors encourage replication efforts elsewhere, in addition to "continued longitudinal study at our own center" [MS p. 9]. The specific Spiritual Assessment Screen used here [--see Appendix A, MS p. 11] may be useful for other program directors to imagine how they could contribute to this line of inquiry.
A final thought: there is an overtone of enthusiasm by the authors for how an EMR "offers opportunities for enhancing quality outcomes by improving communication and coordination in the delivery of patient care" [MS p. 1]. Indeed, they hold that good use of the EMR by chaplains is "critical" [MS p. 3], thus pressing the case for the importance of this research. However, this month's article may be for many chaplains an implicit challenge to value the EMR in the first place. To that point, readers might note especially the positive response of experienced staff chaplains to the intervention in this study, namely: the use of more robust or differentiated spiritual assessments instead of "convenient default assessments" [MS p. 8]. For this reader, the study suggests that focusing on improving assessment and documentation in the EMR may actually help us honor the specificity of a patient's story, experience, and need. That portends well, as we work with progressively refined EMR screens.
Special Comment to the Network by Alexander Tartaglia, ACPE Educator and Katherine I. Lantz Professor of Patient Counseling and Senior Associate Dean for the School of Allied Health Professions, Virginia Commonwealth University, Richmond, VA:
Chaplain documentation in the medical record continues to gain interest. The Network's selection of this article invites others to continue this conversation. I join in that invitation and offer a few observations. 1) This study was originally conceived as a performance improvement initiative. Diane Dodd-McCue and I recently completed the first session of the online course in research literacy as part of the Transforming Chaplaincy grant project. In one of the online modules, I presented the similarities and differences between research and performance improvement. Two of the course participants independently commented that seeing the distinctions side by side took some of the "mystery" and "fear" out of research. Chaplains are familiar with performance improvement, and such projects can serve as the basis for identifying a research question. 2) Our previous study on charting in ACPE residency programs [--see Related Items of Interest, §II, below] identified a lack of consistent and ongoing training for EMR documentation for chaplains at all levels. One of the benefits of this project was the opportunity for a shared learning experience for an entire department. As a result of this study, half-day annual training on documentation has become a standard feature of the department for faculty, staff chaplains, residents, and interns alike. 3) The study greatly benefited from the unanticipated collaboration with our colleagues in Rehabilitation Counseling. This underscored for us the growing circle of professionals with an interest in not only spirituality and health but the role of professional chaplains.
Suggestions for Use of the Article for Student Discussion:
While this month's article may be well suited for ACPE Educators and program directors considering training strategies and "key delivery metrics of chaplain productivity and compliance with scope of service expectations" [MS p. 3], it should have application for general CPE discussion with students who have some practice at documenting in an electronic medical record. In that case, the group could be asked at the outset their feelings about using the EMR. Does it seem a hoop-jumping or pigeonholing exercise or a means of communication for coordinated patient care? Do they conceive of the EMR process in relation to professional practice competencies to "formulate and utilize spiritual assessments, interventions, outcomes, and care plan" [--see MS p. 8]? How does the EMR spiritual assessment screen at their institution compare with the one used in the study [Appendix A]? How did their orientation to the EMR process differ from what is outlined in the article? Do they see in the described teaching/orientation intervention something they imagine would be useful to their work? How do they see themselves fitting into a larger culture of assessment and documentation as expressed through the EMR? The students could discuss what sorts of assessments they find the most difficult to make and communicate. Finally, for students interested in research, the analysis of how the intervention was analyzed to be effective according to time, role, and training should be thought-provoking, and the idea of the CHAID technique for statistical analysis [MS p. 5] could be explored [--and see Related Items of Interest, §V, below.
Related Items of Interest:
I. More extensive dendograms than Figure 2 [MS p. 5] are available freely from the Journal of Health Care Chaplaincy as a Word document. See the journal's page for Supplemental Material. [Note: While the word dendogram may be found in the statistics literature, the Greek-rooted term is often written as dendrogram, with dendro- (δενδρο-) being the common combing form for tree.]
II. The bibliography of our featured article is not large but is quite substantial in content. See especially the two recent items listed below: another study from several of our authors as well as a PhD dissertation from the program in Patient Counseling at VCU.
Adams, K. E. "Patterns in chaplain documentation of assessments and interventions, a descriptive study." Virginia Commonwealth University, Dissertation, 2015. Available online. [(Abstract:) There is increasing emphasis on the importance of evidence-based care provided by all disciplines in healthcare. The Electronic Health Record (EHR) is becoming the standard for communicating assessments, plans of care, interventions, and outcomes of patient care. The spiritual care literature demonstrates the importance of assessing religious/spiritual needs and resources and developing plans of care to address the results of such assessment (Anandarajah & Hight, 2001; Borneman, Ferrell, & Puchalski, 2010; Fitchett, 1999; Fitchett & Risk, 2009; H. G. Koenig, 2007). This literature also suggests that addressing religious/spiritual needs of patients and families in the healthcare context can affect healthcare and adherence outcomes. The purpose of this study was to identify patterns of chaplain assessment and patterns of chaplain provision of services. This descriptive study was an exploratory retrospective analysis of categorical data recorded by clinical staff chaplains in the EHR at a single all pediatric healthcare institution, using contingency tables and frequency tables. The study examined chaplain use of assessment and service descriptors and the patterns of these descriptors when documenting chaplain visits. The results indicate chaplain preference for communicating in the EHR using general themes and concepts. This reveals an opportunity for chaplains to develop and implement a model of professional identity and articulation of care that is broad enough to accommodate the diversity of religion/spirituality chaplains encounter, yet able to articulate the specifics of patient and family religion/spirituality. The results found no consistent patterns among assessments or services provided. Further, the results found no indication of patterns between assessments made and the services provided. This presents an opportunity for chaplains to develop and implement a theory- driven, construct-based model of care that will connect the different facets of spiritual care. The assessments made will lead to plans of care that involve specific interventions resulting in appropriate outcomes related to overall patient and family care.]
Tartaglia, A., Dodd-McCue, D., Ford, T., Demm, C. and Hassell A. "Chaplain documentation and the electronic medical record: a survey of ACPE residency programs." Journal of Health Care Chaplaincy 22, no. 2 (2016): 41-53. [(Abstract:) This study explores the extent to which chaplaincy departments at ACPE-accredited residency programs make use of the electronic medical record (EMR) for documentation and training. Survey data solicited from 219 programs with a 45% response rate and interview findings from 11 centers demonstrate a high level of usage of the EMR as well as an expectation that CPE residents document each patient/family encounter. Centers provided considerable initial training, but less ongoing monitoring of chaplain documentation. Centers used multiple sources to develop documentation tools for the EMR. One center was verified as having created the spiritual assessment component of the documentation tool from a peer reviewed published model. Interviews found intermittent use of the student chart notes for educational purposes. One center verified a structured manner of monitoring chart notes as a performance improvement activity. Findings suggested potential for the development of a standard documentation tool for chaplain charting and training.]
III. Another recent quality improvement project focused on chaplainsí documentation in the electronic medical record:
Stang, V. B. "An e-chart review of chaplains' interventions and outcomes: a quality improvement and documentation practice enhancement project." Journal of Pastoral Care & Counseling 71, no. 3 (September 2017): 183-191. [(Abstract:) In Canada, the spiritual care landscape in health care settings is becoming more regulated and standardized documentation is part of this rigorous environment. Staff chaplains at The Ottawa Hospital participated in a Quality Improvement project that aimed to advance patient-centered care through better charting practices. A sample of 104 spiritual-care assessments that had been posted on the patient electronic health record was examined. This chart review focused on chaplains' activities that were reported as interventions as well as chaplain-reported outcomes for the patient. These interventions and outcomes were coded into discreet categories in order to get a better sense of the activities and the impact of their work. The chaplains' electronic charting content and practices were evaluated. Chaplains found that the Quality Improvement process was beneficial as they updated their electronic templates in order to meet the new reporting requirements of the College of Registered Psychotherapists of Ontario.]
IV. Documentation was also the subject of our October 2016 and November 2011 Article-of-the-Month features.
V. The present study used a software package to analyze data according to Chi-squared Automatic Interaction (CHAID). This sophisticated method provides neatly visible tree diagrams [--see Figure 2, MS p. 8], but it is quite daunting to explain in detail without the reader having a good knowledge of statistics. The authors' brief description [MS p. 5] is an excellent attempt for a typical chaplain audience. Two articles about the method are cited in the bibliography that may be of interest to chaplain researchers, but two other articles may also offer relatively readable explanations:
Milanovic M. and Stamenkovic, M. " CHAID decision tree: methodological frame and application." Economic Themes 54, no, 4 (2016): 563-586. [While this article gives an example of CHAID analysis for leadership studies, but see the first few paragraphs of the Introduction and Part 3: Decision Tree. The language used here tends to be highly technical but not terribly cryptic.] [The article is available freely online].
Song, Y.-Y. and Lu, Y. " Decision tree methods: applications for classification and prediction." Shanghai Archives of Psychiatry 27, no. 2 (2015): 130-135. [This article, in English, covers CHAID only as one example of a decision tree method, but it covers concepts necessary for basic understanding.] [The article is available freely online].