Wash away your practice management troubles with SOAP

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Whether you regularly use the subjective, objective, assessment, and plan (SOAP) method for medical records, or you haven’t used it since veterinary school, you are likely familiar with its structured approach to identifying problems, adding supporting data, reaching a diagnosis, and formulating a treatment plan. However, have you considered that the SOAP approach can help you effectively manage not only clinical problems but also business problems?

The SOAP format is easy to implement because veterinary professionals are familiar with its structure. The format is simple; it does not require advanced technology or software, and it can be maintained with a simple white board or word processing program. This simple approach allows you to focus on a single issue by identifying a pain point or bottleneck in your workflow—in other words, the root cause of a problem—and focusing on methods for improvement. This allows for cumulative improvements over time, instead of trying to “boil the ocean.”

Think this method can’t work for you? Think again. We have seen tremendous results when the SOAP method is applied to real-life situations. For example, there was a large Arizona practice with a low average per–client transaction, considering the practice type and client base. Using the SOAP method, we identified 2 significant opportunities. Although we targeted a 10% improvement rate, we actually realized a 14% improvement.

Identify an opportunity statement

Begin by defining an opportunity to increase operational efficiency or a root-cause process that needs improvement. Opportunities to improve hospital operations might include the following:

• Number of patients seen per day
• Average transaction amount
• Wellness plan enrollment rate
• Customer satisfaction
• Employee satisfaction
• Cost of goods sold

Basically, any measurable need for improvement can present an opportunity. Focus on one opportunity at a time and ensure measurable results can be yielded in a 2- to 4-week period. An example might be: “Our customers often complain about the amount of time they spend waiting to be seen.”

You might also consider identifying team members who are responsible, accountable, consulted, and informed, according to the RACI model, so the process manager, and everyone who needs to be involved and informed of the process, outcomes, and changes, is clear.

Apply the SOAP template to your practice

Subjective: Gather symptoms

Huddle with your entire team, ask for their ideas about opportunities for improvement, and develop an opportunity statement. Discuss what prevents them from delivering consistent results and apply their answers to the opportunity statement. A great tool for getting to the heart of the opportunity is asking “Why” 5 times. The 5 whys technique comes from lean methodology and, much like young kids, simply asks “Why” at least 5 times to uncover the root cause of a problem. For example:

• Question 1: “Why do you think clients complain about waiting so long?”
• Answer: “Because most appointments don’t start at their scheduled appointment time.”
• Q2: “Why aren’t clients being seen at their scheduled appointment time?”
• A: “Because the team usually isn’t ready when the client arrives.”
• Q3: “Why isn’t the team ready when the client arrives?”
• A: “We are usually still seeing other appointments when the next appointment arrives. We have to finish them before we can start a new appointment.”
• Q4: “Why aren’t we able to finish appointments on time and see the next appointment as scheduled?”
• A: “We always start the first appointments after lunch late because morning surgeries run late, and we have to stagger lunch. Most of the time, we get only a few minutes for lunch before having to see appointments.”
  Q5: “Why do surgeries run into lunchtime?”
• A: “We usually have 5 surgeries scheduled in the morning, but we don’t start them until 9:30 am. We plan to start at 8:30 am, but we always run late.”
• Q6: “Why do we start surgery late?”
• A: “The doctor reviews blood work in the morning to prioritize the surgical cases for the day. We have to collect blood and run lab work before we can prioritize the cases. Once we have results, we prepare for the first case. This usually takes an hour to an hour and a half.”

In this scenario, we asked why clients were waiting to be seen, but we found that the root-cause problem was surgeries starting late in the morning, which led to runover that inhibited afternoon appointments starting on time.

Objective: Perform a physical exam

To identify measurables that support your opportunity statement, consider things you see in hospital reports—while observing workflows—that prevent the team from improving the opportunity. You might look at metrics, compare data with industry standards or previous performance, and watch for signs that offer more clues or provide clarity to some of your subjective thoughts.

To continue our example above, you might look through reports and find that customer satisfaction scores are worse on surgery days. You might also look at appointment data and find that the time from appointment start to appointment finish increases as the day progresses. You may also see that the time between the scheduled appointment time and actual appointment start time increases over the course of the day. You observe appointments for 1 week, confirm your team’s subjective feedback, and gain additional insight through the data you uncovered.

Assessment: Reach a diagnosis

Based on subjective team feedback and objective data review and observations, create a hypothesis—identify the problem and how you want to fix it.

In our scenario, you confirmed that surgeries run long and prevent the first appointments from starting on time. You also recognized that appointment start times become more delayed as the day progresses, and the team ends up staying late to get everything done. They are frustrated because they miss dinner at home, and the hospital is unhappy because the labor for the team to stay late costs a lot extra. Your assessment shows that the team’s original feedback is correct and that they uncovered outcomes in addition to customer frustration.

Plan: Determine the treatment course

Determine a course of action you believe will best resolve the assessed problem. Test the solution, measure the outcomes, and either make the changes permanent or adjust and test again. Create a specific, measurable, attainable, relevant, and time-bound goal to ensure you have clearly defined the change and measured the baseline before you make changes.

Approach the above scenario

Create a specific goal

Which specific factor can you change to test the improved outcomes? Do not change several factors at once, because you won’t know which change is responsible for improved results or whether the results of one change canceled out the results of another.

You decide to have your veterinary technicians start an hour earlier in the morning so they can run the required surgical tests earlier. That way, they can prioritize the surgeries, and the veterinarian can confirm or rearrange the schedule when they arrive at the normal starting time. The technician team will prepare for the first surgery, and although they may sometimes need to adjust, most of the time, your team will be ready to start surgery at 8:30 am.

Create a measurable goal

You must be able to measure potential improvements to recognize and share the results and put controls in place to monitor performance after making the change. Define the measurables you want to improve and record their current results.

Your clients are currently starting their appointments an average 20 minutes after their scheduled time. The first appointments after lunch typically start 15 minutes late, and the last appointments of the day start 30 minutes after their scheduled appointment time. Client net promoter score (NPS) is currently -0.2. By 2 weeks after the test starts, you would like every appointment to start no later than 10 minutes after the scheduled time. You also set a goal of improving client NPS to 0.15 over 1 month.

Create an attainable goal

You want to choose a goal that can be measurably improved in 2 to 4 weeks. A short time frame will allow you to monitor small incremental changes that improve operations over time. However, avoid tackling big process changes with this approach.

You decide to institute the planned adjustments starting Monday, and you expect to see immediate results. You plan to monitor measurable results for 2 weeks to confirm they are permanent.

Create a relevant goal

Ensure the plan aligns with the hospital’s goals and determine whether another goal is more important and should be tackled first.

Your hospital’s goals for the current year include improving customer satisfaction, and this goal aligns well with that overall mission.

Create a time-bound goal

Set a target time to achieve results. You should be able to estimate how long seeing results will take and test whether the plan is working. Schedule a time to review the goal and results with your team and add the date to your calendar for follow-up. If you meet the goal, celebrate the success with your team, and start the process over to identify the next opportunity for improvement.

You will institute changes Monday and monitor results daily. Your practice manager will interview clients as they leave for immediate, direct feedback that reflects improvement in NPS. You will continue for at least 2 weeks before you declare success or adjust the plan.

Take-aways

Using the SOAP approach is empowering, motivating, and engaging for veterinary teams. Involving your entire team in the problem-solving process helps ensure people are on board for change and fosters a culture of continuous improvement. Team members will appreciate being heard, being part of identifying the problem, and seeing their contribution to the solution. Good luck, and enjoy all the incremental improvements you will see over the course of the year.

Emmitt Nantz has been part of the veterinary family for nearly 2 decades and is driven by a personal mission to make the veterinary domain better. Emmitt spent 12 years working at Banfield Pet Hospital, starting out as a single-site hospital manager. Having majored in agriculture management and business, he expanded his education to include an MBA, a Black Belt in Six Sigma, and a Project Management Certification. Emmitt applied these learnings by creating large-scale operational improvements for the entire Banfield network, with a focus on improving employee and client satisfaction. He is now the chief operating officer at Galaxy Vets, a veterinary health care system co-owned by its employees.