Implementing SMART goals into daily clinical reasoning

Incorporating the SMART-Goal Evaluation Method (SMART-GEM) into daily clinical practice can be a powerful yet simple tool to empower your patients motivation and enhance their compliance to your treatment protocol.

The success of goal setting and goal attainment scaling depends on the formulation of the goals and effective communication between the healthcare professional and the patient.

The SMART-Goal Evaluation Method (SMART-GEM) described here is a useful tool to standardize the writing of goals in rehabilitation.

It saves time and simplifies the construction of goals that are sufficiently specific to be measurable.

And the SMART-GEM demonstrated good construct validity and very good inter-rater reliability in a recent study from august 2015 and shows promise as a standardized method to writing and evaluating goals in clinical practice for healthcare professionals working with patients and clients on a daily basis.

A practical guide to the SMART-Goal Evaluation Method (SMART-GEM): 

SMART is short for Specific (S), Measurable (M), Attainable (A), Relevant (R), and Time-bound (T).
GEM is short for Goal (G), Evaluation (E), Method (M).

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Specific (S)

The goal has to offer an specific and relevant solution to the patients problem. So the first goal in a clinical setting is to understand what problem that has to be solved.

First ask the patient: “What can I help you with?”, then listen actively, perform your anamnesis and map out the size and character of the problem.

During this process ask yourself: ”What specific problems are presented and has to be solved?”.

Then perform a physical assessment and examination of the patient with relevant tests, and reflect: “What do these tests tell me on how I can help the patient to solve the specified problem?”.

Illustrate and explain your findings on the nature of the specific problem of which you discussed and assessed with the patient and then present your suggestion for a treatment plan, including step-goals to be set on the process towards the main goal.

Discuss the suggested treatment plan with the patient and offer sufficient patient education when questions are asked.  Achieve agreement on these goals with the patient before beginning the treatment protocol.


Measurable (M)

The goal has to specific enough to be measured over time. This means that your second consideration in your clinical reasoning process should be: “How do I test and re-test a baseline for the patient in order to measure the outcome of my treatment intervention?”. And thirdly: “Should I plan to test and re-test a baseline every treatment or plan structured re-tests with suitable time in between?”.

A general rule to follow on these questions would be only to test when a plausible improvement can be expected.

Example given of a test and re-test of a baseline during the same treatment session:

  • Examining pain during lumbar flexion and testing for less pain during lumbar flexion after performing an intervention, such as an mobilization technique in a treatment session.

Example given of the test and re-test of a baseline after multiple treatment sessions:

  • Testing MVC in a 1RM test before beginning a strength training protocol and then measuring the MVC again in a 1RM test following 6 weeks of structured strength training.

Do not overdo the testing as this can confuse the patient and can give cause for concern of the professionalism of the therapist. Plan and structure the tests to evaluate the treatment outcome.


Attainable (A)

The goals set has to offer an specific solution to the patients problem and has to be measurable but it also has to be realistic and attainable taken the patients resources and physiological state into consideration. Therefore the main concern here is not to set unrealistic goals which are unlikely to be reached. It will cause disappointment and frustration for the patient, and give the therapists a bad rumor. An easy tip for gaining compliance with your patients is to set an easy attainable short term goal, which can be expected to be achieved upon the next consultation.


Relevant (R)

The goal has to make sense in the context for the patient and has to be as relevant as possible in order for your proposed solution to seem purposeful for the patient to comply with your treatment protocol.

Do not insist on treatment goals that seem irrelevant or incomprehensible for the patient. If you strongly believe in a goal then offer sufficient patient education until mutual understanding and agreement has been obtained. Reconsider, reflect and discuss expectations before setting new goals with the patient.

Testing and re-testing a baseline to illustrate an relevant improvement for the patient in your first assessment and examination of the patient can be a strong tool to utilize in clinical practice in order to illustrate the relevance of your suggested treatment protocol and in that way empower motivation and enhance compliance to your suggested treatment protocol. When the patient experiences an improvement and you professionally illustrate this for the patient, the patient will start to put trust and hope in you and will be willing to invest time, money and effort into reaching the agreed goals as they now can be seen as meaningful and obtainable for the patient.


Time-bound (T)

The goal has to be time-bound, in such a way that the outcome of the treatment intervention is measured structured and systematically.

Structuring and systematizing the treatment intervention can also offer an easy overview for the therapist and a therapeutic tool that the patient can use to keep track of their own process.

Make sure to have short term goals or step goals that are specified and defined and explained to the patient in the process of reaching the main goal. Set dates in the calendar for when what has to be tested and keep track of the process from treatment to treatment.


I hope you will enjoy my articles and that you share my content with your friends!

Sincerely

Alexander Hummelshøj Kringelbach,
Physiotherapist & founder of Physio-excellence.net


 

REFERENCES:

http://www.ncbi.nlm.nih.gov/pubmed/19237435 GUIDE

http://www.ncbi.nlm.nih.gov/pubmed/26286379 VALIDITY

1 Shiell A, Hawe P, Gold L. Complex interventions or complex systems? Implications for health economic evaluation. Br Med J (Clin Res Ed) 2008; 336: 1281–83.

2 Wade DT. Goal planning in stroke rehabilitation: How? Topics Stroke Rehabil 1999; 6: 16–36.

3 Locke EA, Bryan JF. The effects of goal-setting, rule-learning, and knowledge of score on performance. Am J Psychol 1966; 79: 451–57.

4 Locke EA, Latham GP. Building a practically useful theory of goal setting and task motivation. A 35-year odyssey. Am Psychol 2002; 57: 705–17.

5 Schmidt RA, Wrisberg WA. Motor learning and performance: a situation-based learning approach, fourth edition. Human Kinetics, 2007. 6 Hurn J, Kneebone I, Cropley M. Goal setting as an outcome measure: a systematic review. Clin Rehabil 2006; 20: 756–72.

7 Schut HA, Stam HJ. Goals in rehabilitation teamwork. Disabil Rehabil 1994; 16: 223–26.

8 Yip AM, Gorman MC, Stadnyk K, Mills WG, MacPherson KM, Rockwood K. A standardized menu for Goal Attainment Scaling in the care of frail elders. The Gerontologist 1998; 38: 735–42.

9 World Health Organization. International classification of functioning, disability and health. Accessed 23 September 2008, from: www.who.int/ classifications/icf/en/

10 Kiresuk TJ, Sherman RE. Goal attainment scaling: a general method for evaluating comprehensive community mental health programs. Community Ment Health J 1968; 4: 443–53.

11 Turner-Stokes L. Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clin Rehabil 2009; 23: 362–70.

12 Jelles F, Van Bennekom CA, Lankhorst GJ, Sibbel CJ, Bouter LM. Inter- and intra-rater agreement of the Rehabilitation Activities Profile. J Clin Epidemiol 1995; 48: 407–16.

13 Geyh S, Cieza A, Schouten J, Dickson H, Frommelt P, Omar Z et al. ICF core sets for stroke. J Rehabil Med 2004; 44(suppl): 135–41.

14 Tennant A. Goal attainment scaling: current methodological challenges. Disabil Rehabil 2007; 29: 1583–88.

15 Law LSH, Dai MOS, Siu A. Applicability of goal attainment scaling in the evaluation of gross motor changes in children with cerebral palsy. Hong Kong Physiother J 2004; 22: 22–28.

16 How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials. Stroke Unit Trialists Collaboration. Stroke 1997; 28(11): 2139–44.

17 Rockwood K, Howlett S, Stadnyk K, Carver D, Powell C, Stolee P. Responsiveness of goal attainment scaling in a randomized controlled trial of comprehensive geriatric assessment. J Clin Epidemiol 2003; 56: 736–43.

18 Steenbeek D, Meester-Delver A, Becher JG, Lankhorst GJ. The effect of botulinum toxin type A treatment of the lower extremity on the level of functional abilities in children with cerebral palsy: evaluation with goal attainment scaling. Clin Rehabil 2005; 19: 274–82.

6 thoughts on “Implementing SMART goals into daily clinical reasoning

    1. Your welcome Loretta!
      Im glad the post was useful to you.

      Alexander Hummelshøj Kringelbach,
      Physiotherapist & Founder of Physio-excellence.net

    1. Dear Dwain Kuehner. I believe your question is a bit off the topic discussed in the post. But to answer your question I believe that the application of early manual therapy can provide a window for opportunity to move into a more active approach afterwards. Manual therapy has a neurophysiological analgesic effect which can provide quick and easy pain relief early on in a case with acute back pain and build compliance for the proposed treatment plan which should incorporate an active approach tailored to the individual in accordance or atleast inspired by the SMART-GEM principles to improve patient adherence and clinical outcomes. Most patients wont comply if exercise is painful therefore if manual therapy can deminish this, we might get the patient active.

      Alexander Hummelshøj Kringelbach,
      Physiotherapist & Founder of Physio-excellence.net

  1. I really like what you guys are usually up too. This sort of clever work
    and exposure! Keep up the amazing works guys I’ve added you guys to my personal blogroll.

    1. Thank you for your comment! I’m glad you found the blog-article useful.

      Alexander Hummelshøj Kringelbach,
      Physiotherapist & Founder of Physio-excellence.net

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