HCM Benchmarking of Spiritual Care Departments

in Ontario Hospitals

Bob Bond,April 2013

HCM Benchmarking of Spiritual Care – Presentation Outline

A) Data Generation (from our offices, across Ontario)B) HCM Framework:– The Two Ratios– The Benchmark

C) 1st Ratio Dataset: A Comparator Set from HCM– Errors and Holes! – Statistical errors!– Corrected Dataset

HCM Benchmarking of Spiritual Care – Presentation Outline

D) Critical evaluation of the 2nd RatioE) Advocacy for the Profession– Local (to date)– National (to date)– Provincial (to be developed)• Targets• Strategies• Plan

Data Generation (from our Offices)

• The provincial standard: MIS Workload Data by each Spiritual Care-provider tracking – minutes of ‘assessment’, ‘therapy’ and

‘consultation’ patient-work (for the specific patient), and

– group-work (for each group encounter), by Unit or Program.• Conversations with other Hospitals found this

NOT to be standard!

HCM Framework

The two ratios:• #1: Service Hours

Patient Daysin each of (a) Acute Care, (b) Mental

Health, (c) Chronic Care and (d) Emergency,AND, for (e) Outpatient Care, the

Department’s “% Outpatient Workload”

HCM Framework

The ratios• #2: Worked Hours

Attendance

plus Variable non-Labour non-Drug CostsAttendance

HCM Framework

The Benchmark:• It is HCM’s working principle that “efficiency”

is displayed by being at the 25th Percentile in these ratios.

• In other words, a quarter of the hospitals ‘out there’ can deliver this service at this level, and so should you!

Service Hours / Patient Days Datasetfor one of Ontario’s Comparator Groups

Hospital Outpatient Acute Mental Health Chronic EmergencyA 0.103 0.043248 0 0.102036 0.003951B 0.171 0.010106 0.009125 0.01618 0C 0.083 0.029457 0.080733 0 0.000069D 0.125 0.029178 0.017513 0.035749 0.000973E 0.05 0.022515 0 blank 0F 0.226 0.011088 blank blank 0.000091G 0.177 0.038937 0.051871 0.045338 0.000626H 0.039 0.11808 blank blank 0.004016I 0.602 0.011939 0.008651 0 0.000386J 0.094 0.064836 0.03104 0.033722 0.002022K blank blank blank blank blankL 0.121 0.018847 0.011049 0.00095 0.002298M 0 0.040955 0 blank 0N 0 0 0 0 0O 0.022 0.055526 0 0 0P 0 0 0 0 0Q 0.056 0.021728 0.016692 0.021918 0.000576R 0 0 blank 0 0S 0.2 0.012281 0.006568 0.009259 0.003773T 0.408 0.015157 0.021601 0.021467 0.000654

HCM “PerCent Outpatient Workload” Quartiles

0.0000 0.0055 0.0695 0.124 0.602

0 0 0 0

0.022 0.039

0.05 0.056

0.083 0.094 0.103 0.121

0.125 0.171

0.2 0.226 0.602

The Data, arranged in Quartiles:

Lowest data point First Quartile;

HCM’s Goal

Second Quartile (or Median)

Third Quartile

Fourth Quartile

Service Hours / Patient Days DataContributing to the 1st Quartile

Outpatient Acute Mental Health Chronic Emergency R 0 0 blank 0 0N 0 0 0 0 0P 0 0 0 0 0M 0 0.040955 0 blank 0O 0.022 0.055526 0 0 0F 0.226 0.011088 blank blank 0.000091E 0.05 0.022515 0 blank 0B 0.171 0.010106 0.009125 0.01618 0A 0.103 0.043248 0 0.102036 0.003951C 0.083 0.029457 0.080733 0 0.000069I 0.602 0.011939 0.008651 0 0.000386

Hospital

• “R” Hospital has no Chaplain, and hence no service provision;• “P” Hospital laid off its Chaplain some time ago, and is served

by two non-certified spiritual care providers paid for by a local faith community, whose workload is not entered into GRASP because they are not staff;

• “N” Hosptial has a staff coordinator (again, not certified) who manages volunteers, provides no care himself, and therefore yields “zero” care-giving workload;

• All the workload at “M” Hospital and all the non-outpatient workload at “E” Hospital and “O” Hospital gets tracked as “Acute”, and therefore their other categories are “zeroes” even though hospital work is done in those categories;

• “A” Hospital’s SPRC department has no “Mental Health Patient” category in its workload system, so this work is counted as “Acute” and their “Mental Health” column is “zero”;

• “B” Hospital’s SPRC department has no “Emergency” category in its workload system, but it does track its “Rehab” work. So, “Emergency” is “zero” and “Acute” is inflated accordingly;

• “C” Hospital shows “zero” in the “Chronic Patient” category because it has no Chronic / CCC beds.

Many hospital SPRC Departments across the province are not reporting workload data in fashions that align with the HCM attempt to ‘crunch numbers’.

When a second distinct Comparator Hospital Group was interviewed, ‘layered dis-alignment’ in varying methodologies became the major focus of the conversations. Only two hospitals in that whole Comparator Group use the GRASP tool of data measurement. Most SPRC Departments are reporting workload using groupings other than the HCM categories.

As one moves beyond the “zeroes” into the populated zones of the datasets, and conducts conversations with peer hospitals, a singular theme emerges: The SPRC Departments in each of these Hospitals is deciding on how best to serve its local needs, recognizing it could and would do more if there were more resources.

Pertinent here is what stands as a researched and published “best practice” guideline for Spiritual Care Departments across Canada and the United States: staffing levels of one chaplain for the first 50 patients, and one for each 100 patients thereafter. This is SPRC’s benchmark! … our “evidence based” standard … in order to do actual full professional coverage. None of the hospitals in these comparator groups have staffing to this level, and therefore none provides full patient coverage; instead they decide (department by department) how to do the best they can with what they’ve got.

As a given Department emphasizes care in one area (on account of local need and choice), another area necessarily does with less. [One respondent within our survey-of-comparator-hospitals wrote, “Mental Health is particularly unfriendly to Spiritual Care here, even compared to other hospitals in the area. It would take a lot of concentrated work to try to make even small inroads there, which for me would be at the expense of care for patients on other units. … Again, in the E.R., there is no traditional spiritual care presence, and – as in mental health – it would take a concerted effort over time to build that presence.”]

So it becomes clear that service-provision within the first quartile is not to be prized as “efficient” or “best practice”, but rather as “sad”.

HCM “Acute Patient Workload” Quartiles

0.000000 0.010352 0.020288 0.038081 0.118080

0 0 0

0.010106

0.011088 0.011939 0.012281 0.018847

0.021728 0.022515 0.029178 0.029457

0.040955 0.043248 0.055526 0.064836

0.11808

HCM’s Goal

HCM “Mental Health Patient Workload” Quartiles

0.000000 0.000000 0.006568 0.013870 0.080733

0 0 0

0 0 0

0.006568

0.008651 0.009125 0.011049

0.016692 0.017513

0.03104 0.080733

HCM’s Goal

HCM “Chronic Patient Workload” Quartiles

0.000000 0.000000 0.000475 0.020484 0.102036

0 0 0

0 0 0

0.000950 0.009259 0.016180

0.021918 0.033722 0.035749 0.102036

HCM’s Goal

HCM “Emergency Patient Workload” Quartiles

0.000000 0.000000 0.0000802 0.001760 0.004016

0 0 0 0

0 0 0

0.0000693

0.0000911 0.000386 0.000576 0.000973

0.002022 0.002298 0.003773 0.003951 0.004016

HCM’s Goal

Service Hours / Patient Days Datasetfor GNG and WHS Comparators

• Errors and Holes!:– To be statistically correct, the zeroes should not be

included– The Hospital being scrutinized should be included in

the dataset• The biggest statistical issues: – “Efficiency” is not found at the first quartile– The ‘straw dog’ hospital created by cobbling together

‘first quartile’ performers is a figment, and its Spiritual Care department a decimated one!

Service Hours / Patient Days Dataset

Problems with the HCM analysis:1. The clinically least-resourced departments are most represented in the ‘target’ (first quartile) group.2. A department’s “clinical emphasis” will exceed the lowest quartile’s effort and be factored out of the benchmarking focus. To say the same thing a different way: any department’s representation (if at all) is its non-emphasized (due to resource shortage) clinical work.3. A department’s substantive (indeed, sometimes primary) non-clinical work is NOT factored in at all.4. This methodology calls for a reduction to all departments that currently do clinical care. It is not a measure; it is an attack.

Corrected Dataset: “PerCent Outpatient Workload” – Quartiles, pointing out Hospital “T”

0.022 0.054 0.112 0.183 0.602

0.022 0.039

0.05

0.056 0.083 0.094 0.103

0.121 0.125 0.171 0.177

0.2 0.226 0.408 0.602

Corrected Dataset: “Acute Patient Workload” – Quartiles, pointing out Hospital “T”

0.010106 0.012281 0.022515 0.040955 0.118080

0.010106 0.011088 0.011939 0.012281

0.015157 0.018847 0.021728 0.022515

0.029178 0.029457 0.038937 0.040955

0.043248 0.055526 0.064836

0.11808

Corrected Dataset: “Mental Health Patient Workload” – Quartiles, pointing out Hospital “T”

0.006568 0.008888 0.016692 0.026320 0.080733

0.006568 0.008651

0.009125 0.011049 0.016692

0.017513 0.021601

0.031040 0.051871 0.080733

Corrected Dataset: “Chronic Patient Workload” – Quartiles, pointing out Hospital “T”

0.000950 0.010989 0.021692 0.035242 0.102036

0.000950 0.009259

0.016180 0.021467

0.021918 0.033722

0.035749 0.045338 0.102036

Corrected Dataset: “Emergency Patient Workload” – Quartiles, pointing out Hospital “T”

0.000069 0.000386 0.000654 0.002298 0.004016

0.000069 0.000091 0.000386

0.000576 0.000626 0.000654

0.000973 0.002022 0.002298

0.003773 0.003951 0.004016

Worked Hours / Attendance Ratio

• We were given little data here … the provincial quartiles are

Minimum 1st Quartile 2nd Quartile 3rd Quartile

0.2712 0.4935 0.7820 1.3089

Variable non-Labour non-Drug Costs/ Attendance Ratio

• Again, little data here … the provincial quartiles are

Minimum 1st Quartile 2nd Quartile 3rd Quartile

$0.29 $0.96 $1.48 $2.23

Worked Hours / Attendance Ratio

• This ratio’s lack of attention to the time spent within an ‘attendance’ means that an episode of Emergency Room crisis-care (for, say, 2 hours) or an in-depth psychotherapy episode (for, say, a 90 minute block) “counts” the same as a two minute “Hello, I’m here if you want me” encounter.

• Nothing meaningful or helpful was gleaned by talking to the hospitals within this ratio’s first quartile.

Worked Hours / Attendance Ratio

• Having a ratio of Worked Hours / Attendance at the first quartile therefore means exactly what, in terms of efficiency?

Worked Hours / Attendance Ratio

• “What it means” in terms of impact, as applied to a Hospital in this comparator group, is that the Chaplain must generate at least 76 attendances in a week (to fall within the first quartile).

Worked Hours / Attendance Ratio

• The overall impact of the (Service Hours) / (Patient Days) ratio is that this Chaplain must spend less than 630 minutes per week providing care (to fall within the first quartile).

Worked Hours / Attendance Ratio

• Each of the 76 encounters can last no more than 8 minutes, 17 seconds

• (Less time per encounter is preferred; and more overall encounters are preferred)

• [Once again from the (Service Hours) / (Patient Days) benchmarking:] No care is to be given in Emerg, Mental Health or Chronic Care (… in spite of the actual demands there)

Worked Hours / Attendance Ratio

• So, again, let us ask: Having a ratio of Worked Hours / Attendance at the first quartile [76 weekly encounters or more] means exactly what, in terms of efficiency?

Advocacy for the Profession

• At the System which includes Hospital “T”, there have been three rounds (across 2½ years) of critical debate about HCM Benchmarking applied to Spiritual and Religious Care. – System-wide, the Department lost 0.12 FTE in the

first round. – In the third round another 1.6 FTE was lost.

Advocacy for the Profession

• Nationally: This entire concern, and a mathematical model of the Service Hours / Patient Days benchmarking by HCM, were given to the Chair of CASC’s Advocacy Committee at the 2011 CASC AGM, asking for help; then again to the newly appointed Ontario Representative on “Advocacy” in the spring of 2012, asking for help.

• This matter appeared to become of ‘active’ interest to the CASC Advocacy Committee as of October 2012, when Ottawa hospitals began asking questions as well; but nothing “came of it”.

Advocacy for the Profession

• Regionally / Provincially: Possible conversation partners –– OHA (The author’s summer 2012 e-mail enquiry to OHA was never

responded to)– CASCSWONT and CASC-Ontario (Now developing their own

Advocacy interests.)– HCM Itself?– MOHLTC?– Investigative Journalist?– Commission a report from a Statistician?– Other ideas???

Advocacy for the Profession:In the case of the next particular instance of

HCM Benchmarking …

• After a Department is given their comparator data, they are directed to contact comparator departments and “explore efficiencies” (learn “better practices”).

• This is the time for feedback from these fellow professionals.

• So this is the time for the Professional Association to speak its responses to the entire Benchmarking exercise.

HCM Benchmarking of Spiritual Care Departments

in Ontario Hospitals

QUESTIONS?

COMMENTS?

The End!