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Implications for Spiritual Care from Recent National Quality Forum Meeting

The National Quality Forum (NQF) is a not-for-profit, nonpartisan, membership-based organization that works to catalyze improvements in healthcare. One of NQF's activities is to convene multistakeholder Standing Committees in topical areas that are charged to review and recommend submitted quality measures for endorsement to NQF’s Consensus Standards Approval Committee (CSAC). NQF endorsement is often a stepping-stone to inclusion on federally required data sets for various levels of health care providers.  These data sets are often tied to reimbursement for those providers. So this endorsement is a big deal.

Recently, Chaplain Margie Atkinson, the current President of the Association of Professional Chaplains (APC) and I were appointed to the End of Life and Palliative Care Standing Committee. It is important to note that while we were nominated by APC and HCCN respectively through both organizations’ membership on the National Coalition for Hospice and Palliative Care, we serve because the NQF staff judged that each of us is qualified to sit on the committee. We do not represent our nominating organizations nor do any organizations have any allocated seats on any standing committee.

Over the years, I have occasionally heard several questions raised within chaplaincy about NQF and why spiritual care and chaplaincy were not represented in its membership or in the measures it endorses.

The membership question is fairly simple. Only NQF member organizations can nominate people to the committees and being a member is very expensive. HCCN and APC get to nominate because both organizations are members of the Coalition that in turn is a member of NQF.  The Coalition submitted a number of nominations in this round many of which were accepted, but some were not.

The question of why there are not NQF endorsed spiritual care measures is also simple in a way. NQF does not itself develop measures. It only considers measures for endorsement that are submitted to it. Further, to be endorsed, measures must satisfy a number of very extensive and very rigidly applied criteria including (1) evidence that the measure improves some specific health care outcomes (2) evidence that the measure measures what it claims to measure and (3) evidence that the measure reliably measures what it claims to measure the same way for everyone, every time. Exceptions to (1) are possible at least at the beginning of the measure's use. The one spiritual care measure of the 35 currently endorsed in EOL and Palliative Care is, in fact, endorsed as an exception and it was not submitted by chaplains but by a research group at Univ. of North Carolina. One result of this gap is that spiritual need and spiritual care are not measured in most required data sets. Thus, one of the major motivators for organizations to integrate spiritual care is missing.

So what do chaplains need to do to remedy this situation? The place that most measurement efforts start is with screening measures that are then paired with treatment measures. By example, one endorsed measure reports the percentage of people admitted to hospice who are screened for pain. The paired measure reports the percentage of people admitted to hospice who screen positive for pain who then are treated for their pain.

Using a chaplaincy example, it might be reasonable to start by proposing the Rush spiritual screening protocol that has some validity testing already done. What would be needed in addition is (1) significantly more validity and reliability testing and (2) research evidence that using the Rush improves some particular health outcomes. It is important to note here that demonstrating that treating spiritual distress improves health outcomes is a contribution and some of that evidence does exist but this evidence is not sufficient for NQF endorsement. The evidence must demonstrate that doing the screening itself leads to improved outcomes.  

It is certainly true that few chaplains have the ability or resources on their own to do this kind of research. However, many have the ability to advocate for this kind of research in their institutions and lend their expertise to the projects. The reality is that unless and until this kind of effort occurs in our field, except in a very few instances, spiritual care quality measures will not take the place they need to occupy to help move spiritual care integration in health care forward.




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