David Dibble, my systems-thinking mentor at New Agreements Healthcare, and I were discussing the challenges of making systems improvement accessible to care providers a few weeks ago. Most times underlying system challenges manifest in the form of symptoms, and it takes some digging to uncover what is actually malfunctioning. I was struck by the similar challenges that care providers face when they are taking care of patients, and it occurred to me that we utilize a tool that organizes our care approach in a consistent manner: the SOAP note. Inherent in that four letter acronym is a very powerful, time tested template for ensuring that all the necessary bases are covered to correctly diagnose and treat a patient, irrespective of their condition. In a lot of ways, however, we have forgotten this system improvement power and SOAP has instead simply become a way of formatting a patient note. Many of the concepts that are now surfacing as new ideas in care improvement, such as patient centeredness, being data driven, and taking a team approach to an evidence-based care plan have all been long embedded in this SOAP acronym. Let’s remind ourselves about this by taking the acronym apart.
“S” is for subjective, or symptoms. The entire care process for the patient begins by the care provider listening to the patient describe their complaint. It’s a frontline driven approach (sound familiar?) – the patient guides the care provider to the health problem. An effective care provider listens with respect, without judgment and asks questions to elicit the complete picture from the patient’s point of view. If additional information is required, a family member may be asked to contribute to the history. Not only is the patient heard and able to describe what it’s like to be experiencing the problem, but he/she is integral to identifying the next step: differential diagnosis and data collection.
“O” is for objective, or data collection. As we know, the most important element to data collection is WHAT is measured and HOW it’s measured. The patient’s subjective input and the care provider’s skilled assessment of the described symptoms direct data collection. This includes physical exam, review of SYSTEMS (interesting how that word shows up!), old records, labs, and studies. We all know what happens when the patient data collected is not focused on the critical elements (remember the Critical 20?) – think about the medical student or intern who orders everything “just to cover the bases.” Not only is it expensive and inefficient, but it frequently sends us all off on wild goose chases with unrelated incidental findings – as Deming would say, “off into the Milky Way we go!” Tight data collection based on the Critical 20 makes it much more likely for us to proceed effectively to the next step: assessment and diagnosis.
“A” is for assessment, or likely diagnosis. When the patient and care provider combine the focused symptoms, signs and data further narrowing of the differential diagnosis is usually possible. We arrive at a working diagnosis, which usually results in a treatment plan. Again, the working diagnosis and treatment plan is only as good as the information collected in the preceding two steps. Think about how many times we go down the less optimal path because we overlooked or were too rushed to recognize a critical input.
“P” is for plan, which leads to action. An effective plan incorporates all of the prior steps, resulting in clear action and improvement to the patient’s condition. An effective plan requires excellent communication, interdisciplinary team work and patient input (if the patient isn’t part of this, implementing a sustainable improvement is not likely to occur! Remember, change is easy until we’re directly affected by it – nobody is closer to the change than the patient).
Once the plan is activated, effective care providers will ideally begin a SOAP "loop" to evaluate and to modify the care process as appropriate. Thus, on a regular basis we check in with the patient to see how they’re doing with the treatment (“S”), we do a physical exam, check labs and studies (“O”), we re-assess our care path (“A”) and continue or modify our plan as necessary (“P”). As the major issues are resolved, we evaluate the patient for any other treatment interventions that might present as important. If we’ve done our job, the patient improves and the patient continues with the care plan or makes lifestyle adjustments such that he/she remains well (sustained improvement).
Food for thought:
- Think about how easy it is for us to cut patients off when they describe their symptoms. Not only are they frequently frustrated with their care providers and disenfranchised from the care process, but we frequently head down the suboptimal care path by jumping to solution. Rather than taking the necessary time to be thorough, we end up course correcting repeatedly in our data collection and treatments, which is an incredible waste of time and resources. Patient and staff satisfaction plummet.
- Think about how we deliver care in silos – every specialist to themselves. Data isn’t shared, frequently it conflicts and the result is a patient who has no idea what’s going on and a care process that’s suboptimal. We can be almost certain that our care interventions will not be sustained when patients are on their own. Instead they continue to cycle through healthcare with the same issues.
- Think about how disjointed we cycle through the SOAP process to make the necessary adjustments to our care intervention. Frequently the patient is excluded from further significant input once we’ve made the initial “diagnosis” and we often transition from proactive to reactive additional data collection, many times at the expense of patient discomfort or harm.
- Think about how the SOAP process relates to improving the systems within which we all work. Who is affected by the broken processes? Who needs to be heard so that the symptoms and relevant data can be collected? Who needs to be part of the solution so that an effective plan resulting in sustainable change is made possible?
Next week we will look at a process improvement tool used in systems improvement at the hospital level and explore its connection to patient care. SOAP is applicable to process improvement and care providers have a lot more to contribute to this than we think.
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