The SOAP Cycle: Collaborative Quality

Over the past two posts we looked at the care provider’s approach to quality at the level of the patient using the SOAP method, and the hospital approach to systems improvement using the PDSA Cycle. We noted that both methods are very effective when used conscientiously and how easy it can be to deviate from their intended use. It is interesting to observe that each method by itself, even when followed to the letter, understates key elements about their effective use.

The effectiveness of the SOAP format requires that the care provider and patient cycle through the process continuously, and the assumption is made that this will occur on a regular basis. As we have seen, there is a tendency for care providers to come up with a care plan and to make modifications to the plan only when a significant unanticipated outcome occurs. Adjustment is more reactive than proactive, and the adjustments that do occur frequently skip elements of the preceding “SOA” steps: we jump to solution and perpetuate suboptimal results.

The effectiveness of the PDSA Cycle, while emphasizing the continuous nature of an improvement process, makes the assumption that the initial plan is on target and meaningful. However, we have seen how frequently an improvement plan begins without thorough preparation. If we cycle a poorly conceived improvement initiative we get an “improved” poorly conceived improvement, which is not the same as a good result. Again we get a misguided, data-driven result that is suboptimal.

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What happens if we were to combine both cycles? Suddenly we have a way of making visible these key assumptions for each individual method, creating a complementary formula for complete quality. The common element to both methods is “P” or plan. When SOAP is inserted into the “P” of the PDSA cycle a unifying message is made clear. To the care provider, the message is that a care plan must continuously be evaluated and adjusted, even when things may appear on the surface to be going well. It is also a reminder that a care plan may be a subset of other issues that may be going on with the patient. Cycling through a care plan does not mean that the patient as a whole becomes secondary – we are reminded that on top of the treatment there is a patient whose other “systems” are being affected by our intervention. We need to maintain oversight of the big picture as well.

From the hospital systems improvement perspective, SOAP inserted into the “P” emphasizes that a successful PDSA Cycle outcome depends on a well thought out plan based on the input from patients and staff experiencing the challenge, the collection of meaningful data to validate and to narrow down the possible causes of the challenge, and a joint assessment to define the critical intervention points, from which a collaborative plan is developed. The message is to look at the challenge from big picture to small, to be inclusive, data driven and collaborative.

Not only does the SOAP Cycle serve care providers and hospitals in their respective areas of focus in quality care, but it can also serve to unify the language of quality in a way that enables care providers to become part of care process and system improvement at the hospital level. Although SOAP is used at the level of the individual patient, it is in essence a method of continuous improvement when properly used. In the context of SOAP, care providers can understand the PDSA Cycle with ease, and vice versa for hospital QI teams. Care providers bring invaluable expertise to hospital quality improvement, and in many ways the SOAP Cycle can align incentives and eliminate the barriers to entry into process improvement that result when outside methodologies such as Lean and Six Sigma are introduced. Indeed, if you look at any successful quality program you are likely to find that all of the SOAP Cycle elements have been incorporated into the process, regardless of quality program label. In that regard the SOAP Cycle can serve as a diagnostic tool to identify the weaknesses in any quality initiative that is not achieving the desired results. Very cool!

Food for thought:
Think about quality improvement initiatives that you are participating in or are a recipient to the results. What made them successful? What was missing from those that didn’t work out as intended?

Next post will incorporate universal systems principles into the model, completing the core elements for any QI process: The Universal SOAP Cycle.