Blog Creating a SMART Plan of Care for Physical Therapy By Jerry Henderson, PT, 02.27.14 FacebookTwitterLinkedin Nearly every successful business is driven by clearly set and articulated goals. Whether you run a Fortune 500 business, small business, or are just starting out, it’s important to know that your success often relies on your ability to achieve your own defined goals. What’s the secret to effective goal setting and hitting those goals? Getting SMART. Luckily, SMART goal setting isn’t difficult, and even better, the framework of SMART can be implemented in nearly every aspect of a physical therapy business. From goal setting, to project management, to – you guessed it – effective care plans. I started to realize this after I recently read an article devoted to SMART project management and think it is a great tool to consider using as your guide to great documentation. What does SMART stand for? Let’s first start out defining SMART. Specific: The goal should target a specific area of improvement or answer a specific need. Measurable: The goal must be quantifiable, or at least allow for measurable progress. Achievable: The goal should be realistic, based on available resources and existing constraints. Relevant: The goal should align with other business objectives to be considered worthwhile. Time-bound: The goal must have a deadline or defined end. The objective with setting SMART goals across your organization is that every aspect of a project goal must adhere to these five criteria in order to be effective. It’s also important to understand when to formulate SMART goals. Often times, early isn’t always better since it’s not feasible that you have every aspect of your business, project, or goal figured out. As it pertains to a care plan, creating SMART goals prior to the initial visit won’t do you much good. In that situation, it’d be highly likely that you’d be back to the drawing board before long – plus you would be setting yourself up to fail. Now, let’s look at how the SMART criteria can be factored into creating a SMART plan of care. Specific Using “decreased pain and improved strength” as a goal is neither specific nor tied to function, but that phrase is written thousands of times every day. Instead, I encourage you to think outside of the box. What does the patient need to reach their goal and stay in line with their care plan? An example of a specific goal might be: “the patient needs to be able to walk two blocks to the grocery store and ascend and descend stairs safely and with less pain to continue living independently.” Measurable You need to make sure that the set goals are measurable and relate to the patient’s function, since you will be measuring their progress throughout the duration of treatment. Lack of specificity is often paired with lack of measurability. If a test has poor validity it isn’t worth including in your documentation. My favorite example is Passive Intervertebral Mobility Testing (PIVMs), often used in manual therapy. We know that inter-rater and test-retest validity of PIVMs is non-existent, so why bother? If I were a chart reviewer and I saw documentation of PIVMs, I would go right past that drivel and look for something that is measurable and relates to the patient’s function. Here is a recreation of a typical conversation I’ve heard from past staff doing a discharge interview: Therapist Dave: “So, Joe, are you doing better?” Patient Joe: “Yes, I sure am!” Therapist Dave: “How much better do you think you are?” Patient Joe: “Gosh, I don’t know.” Therapist Dave: “Would you say that you are 70-80% better?” Patient Joe: “Uh, sure, I guess. Yea, I am about 70-80% better.” Then, therapist Dave would write something in the chart like “Patient reports he is 70-80% better.” But what does that even mean? Instead, opt for something more concrete, like “patient is able to walk 5 blocks without feeling knee pain” or “patient can maintain stability for [x amount of time].” Specificity is critical as the PT world moves to a pay-for-performance model. Achievable Goals should be realistic and achievable. While you can set stretch goals, do not set goals for your patient that are unachievable. Impractical goals can create unrealistic expectations and cause frustration for the patient. So ask yourself: Are the goals you are describing achievable, given the patient’s condition? And how do you know? Be descriptive, while also maintaining room for flexibility as the patient completes their care plan. Relevant Make sure your documentation describes the functional problem and why it is impacting the patient’s well-being and lifestyle. Your writing should tell a story about how fixing the problem at-hand will better improve the patient’s independence or lifestyle. Make it concise and do everyone a favor…forget the fluff! If a detail is not important to the care plan, leave it out. (Does the reader really need to know that the patient is “pleasant?” While it’s nice, the note is irrelevant to the patient’s care plan.) The quality and usefulness of your documentation is often inversely related to the length of the report. Time-Bound Propose a detailed timeline for the plan of care. Give a realistic time estimate as to how long the treatment plan will take for the patient to reach their functionally-based goals. Your treatment proposal should include the number of times a day, number of visits per week, and the number of weeks of treatment. When documenting, answer the following questions: Is there an end to this plan of care, and when is it? How many visits is it going to take? What is the patient’s end-goal for functionality once treatment is completed? Great Documentation is a Road Map A well-organized plan of care and good documentation is like a great road map. It not only informs you when you are on course and when course corrections need to be made, but it also informs everyone else involved in the patient’s case: the referring physician, the insurance auditor, and, most importantly, the patient. Your plan of care should be shared with the patient and reviewed with them routinely. It can be used as an educational tool, a source of motivation for your patient, and a powerful tool for establishing medical necessity and demonstrating the value of your services. Poorly done, and it serves little purpose other than keeping chart auditors employed. A well written evaluation, plan of care, daily notes, progress reports, and other written communication will help you deliver even better care. Look at your documentation objectively using this SMART criteria. It will make your great care even greater.