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:
You now have experience developing PICO questions and have learned about different study designs including their strengths and weaknesses. During your clerkship experiences you and your team will have many questions about how to best care for your patients. Throughout your career you will need to seek evidence on best practices to make clinical decisions and will have to sort through journal articles, practice guidelines and evidence summaries to determine how to proceed with diagnostics and therapies. Understanding different ways to appraise literature will help you answer your questions and make decisions based on evidence.
There are many resources available to you through the University of Washington Health Sciences Library to assist in this process.
For this session, please reflect on your case study. Consider possible interventions or therapies that may be beneficial to the patient. Develop a PICO question before the session as you will be reviewing and appraising literature in order to answer this in class.
This article was written by a medical student (who is now faculty in the Department of Medicine at UW) who describes feeling uncomfortable with a patient care task he was asked to perform. He felt silenced by the medical hierarchy and didn’t speak up at the time due to fear. He emphasizes the importance of changing the culture of medicine to one that respects open communication and respectful advocacy to promote safety in the learning environment and patient care.
In an article published in the American Journal of Public Health in 2003, Kindig and Stoddard defined population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Population health aims to improve the health status of entire human populations, and includes efforts by organizations and institutions at the local, state, federal, national, and global levels to measure the distribution of outcomes and link them to health policies and interventions. More information can be found in that article [READ this linked article by Kindig and Stoddard].
Many organizations involved in public health in the US support the overall goals of population health and fill important roles such as surveillance, national registries, health surveys, and collection of administrative data that can help decision-makers form effective policy. For an overview of how organizations in the US Public Health system provide core functions and essential services, please see the powerpoint at [READ this linked presentation – US Public Health 101]. For a description of the different US government agencies involved in supporting public and population, please see the brief descriptions posted by the US Public Health Service, describing agencies within the Department of Health and Human Services (https://www.usphs.gov/aboutus/agencies/hhs.aspx) and those in other departments of the federal government (https://www.usphs.gov/aboutus/agencies/non-hhs.aspx).
Value-based payment models aim to increase value by improving outcomes and lowering costs. Though there are many possible approaches to achieve this aim, most models use some combination of care coordination and financial incentives/penalties tied to quality metrics. The reading provides a general overview of the types of value-based payment models.