SOAP-Q: An innovative curricular intervention to promote quality improvement behaviors within the clinical learning environment
Physician competency in quality analysis is necessary to optimize the quality and safety of patient care, yet current undergraduate medical education in these areas remains highly variable. The University of Washington School of Medicine (UWSOM) introduced a novel, pre-clinical phase curriculum (the Ecology of Health and Medicine- EHM- course) encompassing health systems, advocacy, equity, quality, and patient safety beginning in the academic year 2017-2018. To facilitate experiential learning opportunities within the clinical environment, we created an innovative curricular intervention: the SOAP-Q framework. Medical communication and documentation conventionally rely upon the SOAP format (Subjective, Objective, Assessment, Plan). We add a fifth element to this format, “Q,” triggering students to assess and advocate for quality patient care. We now disseminate this framework to all medical students as they enter the clinical phase and now pilot clinical integration within the Family Medicine clerkship. We hypothesize that students and faculty will respond positively to the framework and student confidence in advocating for quality patient care and in addressing quality gaps will increase. Subsequent assessment phases will examine impact on student behavioral metrics including documentation of quality assessment, participation in error identification and reporting, and performance on quality measures. The multiphase project will utilize the framework as scaffolding for student quality improvement project charter design, implementation of projects for fourth year students participating in a quality improvement pathway, and creation of a project catalogue with tiered implementation and mentoring throughout the medical education and faculty continuum. In utilizing SOAP-Q, the University of Washington offers opportunities for students to build competency in the newest of the AAMC’s Entrustable Professional Activities for Entering Residency, EPA-13. This EPA calls for the student to identify system failures and contribute to a culture of safety and improvement.
A similar tool, SOAP-V, has demonstrated utility in assessment of high-value, cost-conscious care within the clinical encounter (3). Initial studies indicated that SOAP-V increased comfort with discussing value and considering cost when providing care. SOAP-Q utilizes a quality-driven focus rather than cost focus, but is similarly intended to help the learner communicate effectively. The clinician considers the following in every patient encounter:
- Safety- Conditions contributing to unsafe practice and systems solutions
- Timeliness– Issues contributing to delay or process lead time
- Efficiency- Value conscious utilization of resources with minimal waste
- Efficacy- Evidence-based approaches to improve health outcomes
- Equity – An approach to care that recognizes sociodemographic drivers of health inequities and actively advocates for equitable outcomes
- Patient-Centeredness- Patient engagement and patient experience.
An oral case presentation using the SOAP-Q framework integrates an assessment of one of the six STEEEP aims within the body of the presentation. It calls attention to the aim in a single line callout at the conclusion of the presentation beginning with identification of the aim. A progress note written in the SOAP-Q framework similarly embeds discussion within the text and delineates the issue in a single line at the conclusion of the note beginning with aim identification. As faculty, please encourage student use of SOAP-Q format and where appropriate utilize the quality call out as a prompt for discussion and teaching (see the one minute preceptor models for examples).
Faculty resources are below. Thank you for your support of student programs. Please help us evaluate SOAPQ by completing a baseline faculty survey at the following link:
- One-Minute Preceptor SOAP-Q Teaching Models:
- Video of student and preceptor modeling SOAP-Q
- Exemplary Progress Note in SOAPQ Format
- CLIME cast- Do No Harm: An introduction to equitable teaching
- Choosing Wisely Family Med Guidelines
- Institute of Health Improvement (IHI) Online Open School Certificate Program in Quality Improvement and Patient Safety
- The Center for Scholarship in Quality Improvement and Patient Safety.
- QI Bootcamp Flyer 2019
- QIPS Cross Continuum competencies
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Washington, DC: National Academies Press, 2001.
- The Core Entrustable Professional Activities for Entering Residency Drafting Panel. Core Entrustable Professional Activities for Entering Residency. Association of American Medical Colleges 2014.
- Moser, EM, Huang, GC, Packer, CD et al. SOAP-V: Introducing a method to empower medical students to be change agents in bed in the cost curve. J of Hosp Med 2016; 11: 217-220.