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. …