Medical Practice Standard Operating Procedures: Expect Exceptions

Standard operating procedures (SOPs) are essential to any well-run enterprise, but wisely deviating from them is the mark of a truly effective operation. Ralph Waldo Emerson was onto something when he wrote, "A foolish consistency is the hobgoblin of little minds." I would add, however, that slavish consistency often trips up great minds, too.

A well-crafted and implemented SOP will work well about 95 percent of the time. The task or situation will be adequately addressed with maximum reliability and minimum resources. Unusual situations - the other five percent - require some flexibility.

Some examples from my own experience:

Complete all charting during the patient encounter.

With well-designed paper forms or EHRs, a provider can document most visits efficiently. It is a matter of choosing phrases and checking boxes for most of the documentation. Specific notes are required only for unusual observations and are generally brief.

A very unusual circumstance can, however, require research, reflection, and/or consultation.
Disrupting patient flow to finish the task right now inconveniences several people and wastes resources if the sole motivation is to finalize the encounter. Some research earlier this year reported that the most efficient physicians were those who completed 95 percent of their charts during the patient encounter. A higher percentage was associated with significantly lower productivity.

Reschedule appointments accordingly.

When a move took me more than an hour's drive from a wonderful dentist, I continued to rely upon him for dental care. As I was on my way to an appointment for a regular cleaning, I received a call to inform me that one of the hygienists had called in sick and my appointment was cancelled. I explained that I already had 30 minutes of drive time invested and asked if a more local patient could be cancelled instead of me. The receptionist did not even consider the request.

The receptionist was focused on a task, as opposed to an objective, and had no criteria for deviation. She was cancelling the appointments of one of the hygienists, and it happened to be the one assigned to me. I now have a different dentist and am not nearly as happy with the care. Everybody lost.

Divert attention from the objective to make sure all the boxes get checked.

One of my clients provides a very well defined, high value service. Judgment and expert knowledge are required, but the steps in the process are the same in almost all cases. Client interactions are regularly audited for compliance to the protocols. An average audit score of 95 is the threshold. Averages below that require more research and explanation. One leader and, consequently, her entire team were fixated on scoring 100 percent on each audit. The protocols are specifically designed to gather information in a way that makes sense to the client. This team was so focused on acing the audits that they reordered the steps in the protocol so that they captured all of the audit data before letting the client tell his story.

In the absence of clearly defined measures of success, people will develop their own or latch onto whatever measures are available to them. Management must develop measures of success that are tied to the objectives as well as the tasks.

Well-defined SOPs are necessary and include more than documentation of the procedure. A good SOP includes statements of the objective, what likely circumstances require deviation, what deviations are acceptable, and who has the authority to make an exception.

Find out more about Carol Stryker and our other Practice Notes bloggers.