Rev. Dr. Howard W. Whitaker and Rev. Margaret C. Tuttle on the clinical implications of charting

A PI Project: Chaplain Progress Notes

Pastoral care is such a “soft,” value laden, narrative driven discipline that chaplain observations and interventions are often difficult to chart. However, chaplain progress notes should document pastoral care and interpret the patient’s spiritual concerns to the line staff and treatment team.

Additionally, charting helps chaplains think about the clinical implications of their role, and structure their task accordingly. The progress note can be an effective supervisory tool to track the operational and clinical performance of the chaplain staff.

PLAN

THE PROBLEM
Through 2000 and much of 2004, a review of Pastoral Care progress notes in patient records at Greystone Park Psychiatric Hospital revealed insufficient charting by chaplains. The few existing notes provided little information about pastoral care that would be helpful to either the treatment team or the chaplain supervisor. Several clergy then functioning as chaplains were neither certified nor clinically trained for a psychiatric setting. They seemed unclear and defensive about their role, the role of spiritual care, and its relevance to the treatment process.

The Chaplain Supervisor did not know what the chaplains were doing. The treatment team did not know what the chaplains were doing. It was unclear that the chaplains themselves knew what they were doing.

THE SOLUTION
Writing progress notes should be reaffirmed as a core clinical skill for health care chaplains working in this psychiatric setting.

• Such skill should be sought when hiring.
• Such skill should be taught within the department.
• Such skill should be part of the chaplains' Performance Assessment Review (PAR).

Using our hospital’s Plan, Do, Check and ACT (PDCA) quality improvement plan, we moved ahead.

THE PLAN
“You can’t expect what you don’t inspect.”

• Criteria for chaplain progress notes would need to be established.
• A scoring system based on the criteria would need to be designed.
• Baseline scores would need to be established.
• A training piece would need to be designed and implemented.
• Chaplain charts would then need to be audited on a regular basis with positive and negative feedback to the individual chaplain.
• Scores would be expected to improve with training, feedback, and if necessary, further remedial training.
• Performance would be reflected on the individual chaplain PAR.

DO

A training module titled “Writing the Chaplain Progress Note” was designed and distributed to the chaplain staff in September of 2004. While competency in charting had been included in past PAR’s, it was re-emphasized on the 2004-2005 PAR’s. It was explained at the time of signing off on the new PAR’s that there would be on-going audits of charts and continuous feedback on charting performance.

CHECK

Working with the Office of Quality Assurance, a scoring tool was developed which assigned a numerical value to criteria such as pastoral specificity, data, assessment, plan, brevity, and relevance to the master treatment plan. The conversion of the narrative criteria into a numeric value was an innovative and critical piece.

The first audit was done and a baseline established for each chaplain, and a composite score was established for the department. Data was collected again at 30-day intervals. Continuous feedback was given to the chaplains.

ACT

Data collection, analysis, and feedback continue at 30-day intervals. There are some preliminary observations:

• Scores have risen for each chaplain after education, auditing, and continuous feedback.
• There was utter shock at the February 2005 PAR when it became apparent that charting performance was indeed reflected in PAR ratings. The PAR was reinforced as a tool for professional development.
• Scores rose. Most scores continued to rise. Other chaplains received data with which to make decisions about their career development—one has since retired, another has returned to a medical setting.
• Although there is no formal metric, clinical staffs continue to comment on the chaplain notes. This has usually been positive feedback; however in several cases, negative feedback has added welcome support for further corrective action.
• The increased charting suggests material for clinical supervision and continuing education.
• The chaplains themselves enjoy more collaborative care of patients (they read each other’s notes), work better as a team, and have better clarity about their roles.
• The Chaplain Supervisor enjoys better tracking and increased confidence in the chaplaincy staff.

The data also suggests several areas of interest for an additional PDCA cycle:

• While chaplain progress notes are usually narrative in form, the process is suggesting “check off,” choice fields, and other possibilities for chaplain charting.
• The labor intensity of the project for the supervisor—coupled with the new collaboration between chaplains—suggests that a process of peer review model, rather than one of inspection and grading, may be possible.

The Rev. Margaret C. Tuttle is lead chaplain at Greystone Park Psychiatric Hospital.

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