SMART was developed by George Doran in a two-page article to help business managers develop objectives / goals.1 Since then, it has been subject to interpretation and alteration. SMART originally represented "Specific," "Measured," "Assignable," "Realistic" and "Time-related."
Since then, variations have emerged. The "A" has represented "Achievable" or "Attainable" and the "R" has represented "Relevant."2
Applying SMART in the Clinical Setting
Specific: What is the specific outcome the patient or prospective patient wants from the clinician-patient relationship? Do they want to achieve a vague goal as "improved well-being"; a specific objective such as "reduced knee pain"; or a combination such as "improved well-being by "reducing knee pain," "reducing anxiety" and "weight management"?
Specificity may necessitate prioritization and consolidation of goals / objectives. Patients presenting with multiple unrelated complaints that have different treatment diagnoses, strategies and plans require deciding which is most important. However, a clinician might identify multiple complaints as elements of a single diagnosis.
Measured: Select the most appropriate measurement tools to determine achievement of the goal / objective. Some relevant characteristics of measures in the clinical setting are validity, convenience, difficulty, frequency of administration, ease of scoring, interpretation, objectiveness / subjectiveness and expense ... and the willingness of the patient to participate.
A patient who is personally financially responsible for their medical fees may prefer the less expensive VAS and orthopedic testing than an MRI. A clinician may use subjective tests as quality of life (QoL) and activity of daily living (ADL) surveys on the premises for generalized goals; or refer elsewhere for objective imaging to evaluate specific body structures.
Determine the target measurements. The clinician may consider natural progression of the patient's condition without intervention as a reference. Options include shortened healing time, slowing of progression, improved quality of life or function. Both clinician and patient have a role in determining the measure and target score. The clinician determines target scores and the patient consents (or not) and expresses their concerns.
Ideally, pre-treatment and post-treatment measures are scored and compared using a single treatment protocol.
Assignable: Both clinician and patient have a role in the attainment of the goal / objective. The roles and responsibilities of each are documented. For example, the clinician provides weekly treatment to increase cervical range of motion, and the patient performs prescribed cervical stretches daily at home and receives treatment as scheduled. Each is accountable to the other regarding success or failure in attaining the goal.
Both clinician and patient are to retain a copy of a SMART note. Appending additional information such as exercises and other directives for the patient to follow is appropriate.
Realistic: This is a review and assessment of the other elements of the SMART goal / objective. Both clinician and patient will honestly consider if the other elements (specific, measured and time-related) are realistic. If either party believes any of the other elements is unrealistic, then the goal / objective is no longer SMART. Therefore, modification of the unrealistic elements is necessary.
Time-related: A date that one may mark on a calendar or a specific duration of care defines the end of treatment for the patient's specific complaint. A specific date gives the patient and clinician an expectation there is a decision to continue, discontinue or change treatment strategy. For the clinician, this is the day to re-evaluate and consider changing treatment, retaining, referring or releasing the patient from medical care. This is a formal opportunity for either party to discontinue the clinician-patient relationship.
Examples of SMART Notes
SMART objective: reduce neck pain. Clinician provides weekly acupuncture to treat neck pain to achieve a two-point reduction on a visual analog scale (VAS). Patient is to perform prescribed cervical stretches daily and receive scheduled treatment until re-evaluation on Sept. 21.
SMART goal: reduce pain. Clinician provides weekly acupuncture treatment according to any of the following SMART objectives: 1. Reduce neck pain, 2. Increase cervical range of motion, 3. Reduce anxiety. 4. Reduce seasonal allergy symptoms. Re-evaluation is scheduled for Sept. 21 and the goal is considered achieved if two objectives have been satisfied.
Post-SMART Note
Regardless of success or failure of the course of treatment, this an opportunity for assessment. Both clinician and patient may assess themselves and each other. Did each adhere to their agreed-upon roles? If not, then why? Were confounding factors discovered or arise? Was the goal / objective unrealistic? Were there errors in any components of SMART?
Appending the post-SMART note to the original SMART note benefits both clinician and patient. It describes the rationale for the continuation or discontinuation of the clinician-patient relationship. Giving a copy of the SMART and post-SMART notes to the patient serves as an aid for their personal contemplation.
When to Use SMART Notes
1. When a prospective patient seeks a consultation. Simply explaining the use of SMART goals / objectives as part of medical care should give the prospective patient the impression that a patient-centered approach is practiced.
2. As part of the initial evaluation. This establishes the environment, expectations and duration for which treatment / medical care is to occur.
3. As part of the re-evaluation. The re-evaluation is the occasion to determine if it is most appropriate to continue, discontinue or refer to another clinician for additional care.
Take-Home Points
When SMART notes are written in accordance to the original associations of the acronym (Specified, Measured, Assignable, Realistic and Time-based), a clearly documented clinician-patient relationship emerges.
The clinician may use the SMART note to convert prospective patients into patients and aid patient management. The SMART note documents the clinician's and prospective or established patient's role, responsibilities, time commitment and expected expense.
Both clinician and patient know they have an important role in the clinician-patient relationship; and that regardless of success or failure relative to achieving the goal / objective, neither is alone.
References
- Doran GT. There's a S.M.A.R.T. way to write management's goals and objectives. Management Rev, 1981 Nov;70:35-36.
- Stonehouse D. How SMART are your patient goals? Brit J Healthcare Assist, 2018;12(5):233-235.
- MacLeod L. Making SMART goals smarter. Phys Exec, 2012;38(2):68-72.
Lawrence Howard, LAc, MSAc is a New York State-licensed acupuncturist in practice since 1998, specializing in pain management. He is currently an acupuncture doctoral student at Pacific College of Health and Science.