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    Smart goals 2009 Smart goals 2009 Document Transcript

    • Clinical Rehabilitation http://cre.sagepub.comWriting SMART rehabilitation goals and achieving goal attainment scaling: a practical guide Thamar JH BovendEerdt, Rachel E Botell and Derick T Wade Clin Rehabil 2009; 23; 352 originally published online Feb 23, 2009; DOI: 10.1177/0269215508101741 The online version of this article can be found at: http://cre.sagepub.com/cgi/content/abstract/23/4/352 Published by: http://www.sagepublications.com Additional services and information for Clinical Rehabilitation can be found at: Email Alerts: http://cre.sagepub.com/cgi/alerts Subscriptions: http://cre.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.co.uk/journalsPermissions.nav Citations http://cre.sagepub.com/cgi/content/refs/23/4/352 Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • Clinical Rehabilitation 2009; 23: 352–361Writing SMART rehabilitation goals and achievinggoal attainment scaling: a practical guideThamar JH Bovend’Eerdt Oxford Brookes University and Oxford Centre for Enablement, Nuffield Orthopaedic Centre,Oxford, Rachel E Botell Oxford Centre for Enablement, Nuffield Orthopaedic Centre, Oxford and St Mary’s Hospital, Leeds andDerick T Wade Oxford Centre for Enablement, Nuffield Orthopaedic Centre, Oxford, UKReceived 7th November 2008; manuscript accepted 7th November 2008.Objective: To describe a practical method of setting personalized but specific goals inrehabilitation that also facilitates the use of goal attainment scaling.Background: Rehabilitation is a complex intervention requiring coordinated actionsby a team, a process that depends upon setting interdisciplinary goals that arespecific, clear and personal to the patient. Goal setting can take much time and stillbe vague. A practical and standardized method is needed for being specific.Method: A novel approach to writing specific, measurable, achievable, realistic/relevant and timed (SMART) goals is developed here. Each goal can be built upby using up to four parts: the target activity, the support needed, quantification ofperformance and the time period to achieve the desired state. This method can beemployed as part of goal attainment scaling and the other levels can be easily andquickly formulated by adding, deleting and/or changing one or more of the (sub)parts.Discussion: The success of goal setting and goal attainment scaling depends on theformulation of the goals. The method described here is a useful tool to standardizethe writing of goals in rehabilitation. It saves time and simplifies the constructionof goals that are sufficiently specific to be measurable.Introduction team where standard, single-treatment packages are rarely, if ever, appropriate.1 In this context aMany patients attending rehabilitation services goal-planning process should be used to ensurehave multifactorial, complex problems that often that all the people involved, especially the patient,require several or many different interventions to agree on the goals of rehabilitation, on the meth-be given by different people, frequently in a spe- ods to be used to achieve these goals, and on eachcific sequence. Rehabilitation is the archetypical person’s role in this process.2‘complex intervention’, comprising a multitude of It is also well recognized that goal setting is ancomplicated activities and actions. It is a problem- effective way of achieving behavioural change insolving process delivered by a multiprofessional people.3,4 Some of the characteristics of goals that effectively alter behaviour are that the goals: should be relevant to the person concerned, should be challenging but realistic and achievable,Address for correspondence: Thamar JH Bovend’Eerdt,Oxford Centre for Enablement, Windmill Road, Headington, and should be specific (in order to measure them).5Oxford OX3 7LD, UK. e-mail: t.bovendeerdt@brookes.ac.uk There is some evidence concerning the benefits ofß SAGE Publications 2009Los Angeles, London, New Delhi and Singapore 10.1177/0269215508101741 Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • Writing SMART rehabilitation goals 353goal setting in rehabilitation, particularly around service is increasingly expected to show that treat-the use of goal attainment scaling as an outcome ments are having the desired effect.measure.6 Thus the researcher (TB) and the clinical Thus goal setting is an essential part, and indeed service (RB) set out to achieve a process that setsthe central part of the interdisciplinary rehabilita- goals that:tion process. Nonetheless, there is relatively little research on  are individualized to a particular patient;the best way of setting goals in rehabilitation and  can be written without too much effort, time ormany questions on the best method still remain. specific training;For example, does the patient (and family) need  allow accurate, unambiguous determination ofto be present at the goal setting meeting, or is it goal achievement;sufficient to establish their wishes and expectations  are flexible enough to cover most situations.beforehand and to check afterwards that the goalsset are acceptable? What is an appropriate number This novel method for writing SMART goalsof goals? What is an appropriate time frame? can be used as a method simply to write better One particular question is ‘how should one write goals, but it can be expanded to allow the goal(specify) a goal?’. It is generally agreed that a good attainment scaling method to be used at littlegoal is specific, measurable, achievable, realistic/ extra cost.relevant and timed (SMART)7 but defining thecharacteristics of a SMART goal is less easy.Moreover writing SMART goals in rehabilitation Background assumptionsis often perceived as time-consuming and difficult. Well-defined goals are particularly needed for This article is based on four assumptions. First,goal attainment scaling which is sometimes used it will consider rehabilitation as taking placein rehabilitation as way of measuring success. within the pre-eminent (biopsychosocial) modelGoal attainment scaling is a method for evaluating of illness used in rehabilitation, namely anthe attainment of goals. Originally goal attainment expanded version of the World Health Organiza-scaling was developed simply as an outcome mea- tion’s International Classification of Functioning,sure but the process may also be in itself a ther- Disability and Health (ICF) model.9apeutic intervention and a useful tool in case Consequently, it then assumes that rehabilitationmanagement.8 goals will usually be set around observed beha- Goal attainment scaling is particularly depen- viours at the WHO ICF levels of activities and par-dent on defining goals that are measurable,7 ticipation. This does not deny the importance ofwhich is not always easy because each goal other goals concerning the patient’s personalrequires several different levels to be defined. Yip experiences or the patient’s context (personal, phy-and colleagues8 developed standardized goal sical or social). Indeed it should be possible to useattainment scaling menus to address the difficul- or adapt this method for goals in those realms.ties associated with writing multiple goals. However, the method described here focuses onHowever, these menus may be at the cost of activities because they are most easily defined,some of the advantages of goal attainment scaling, and they probably are of most concern both tosuch as its client centred and individual approach. the patient and to those who pay for health care. Locally the rehabilitation service has developed Third, the description assumes that preliminaryand undertaken goal planning for many years but work with the patient (and relevant other parties)there has been a long-standing unease within the has already established necessary backgroundlocal service about the lack of specificity in some information: the patient’s wishes and expectations,goals set. A current randomized trial of a rehabi- and all the additional information needed. Goalslitation intervention (motor imagery) needed to must always be set in realms that are of interest touse individualized specific goals as an outcome the patient. Additionally it may be important tomeasure. Finally, and at the same time, the clinical investigate the wishes and expectations of other Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • 354 TJH Bovend’Eerdt et al.parties such as family members, friends and work The process of goal attainment scaling includescolleagues, whoever is paying for the service, and five steps11 and our method will focus on steps(occasionally) team members. It is also important 1–3, illustrated in Figure 1. It must be emphasizedto know sufficient other information to ensure again that before starting step 1 it is essential tothat the goal is potentially achievable, and to iden- know what the patient’s wishes and expectationstify the actions needed to achieve the goal. In other and goals are and to know enough aboutwords, this method is only a part of the complete the patient’s situation (disease, impairments, con-goal-setting process. text, etc.) to allow the team to set valued and Thus, finally, this method assumes that the team achievable goals.will only set goals that are attainable and realisticfor the patient to achieve. Step 1: Defining the expected goalsGoal attainment scaling – introduction The key innovation described in this article is a structured approach to specifying a goal, andGoal attainment scaling is the term used to describe this is the important first step in goal attainmenta simple method of scoring (quantifying) the achie- scaling. Even if goal attainment scaling is not used,vement of goals. Rather than simply stating that a this method allows one to write a SMART goal.goal has or has not been achieved, attainment scal- The method involves ‘building up’ an expecteding recognizes that sometimes achievement exceeds goal using four parts:expectation, whereas at other times achievement isless than expected but nonetheless there is some pro-  specifying the target activity (a behaviour);gress towards the goal, and (rarely) there may be no  specifying the support needed;progress towards goals set, or even deterioration.  quantifying the performance; and Goal attainment scaling is a structured  specifying the time period to achieve the desiredapproach to recording goal achievement and was state.first introduced in the 1960s by Kiresuk andSherman10 within a mental health service. Theapproach is based on predicting the expectedgoal to be achieved, accompanied by two states Part I. Specify the target activityabove the expected outcome and two states Rehabilitation is, ultimately, concerned withbelow, one of which is usually (but not inevitably) altering behaviour whether that behaviour is (a)the current (or ‘baseline’) state. observed activities or participation in social activ- The process of goal attainment scaling was ities, such as dressing or working, (b) the reportingchosen by us because it is already reasonably by a person of their internal experiences (such aswell researched with evidence that it is at least as pain), or (c) the report of a person about theirsensitive as a measure of change as other standar- interpretation of activities and experiences (suchdized scales,6 and moreover it may in itself as their own assessment of quality of life, orimprove outcome. Furthermore the scoring satisfaction, or social role performance).system can be adapted to take into account vari- In the context of setting specific and measurableables such as the difficulty of achieving a goal and goals it is easiest to focus upon target behavioursthe patient’s priority, and the scoring system can concerned with activity and participation.encompass more than one goal but still give a Common examples include mobility and thesingle outcome value. many activities of daily living (personal, domestic, It is not necessarily easy to write a goal specifi- community, vocational, etc.). The methodcally, but the additional challenge when using goal described here can extend to the reporting ofattainment scaling in particular is to write a series experience and perception, but this article willof five well-defined potential states for each goal, not consider these aspects in any detail; there isand to do so quickly and easily. some discussion later. Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • Writing SMART rehabilitation goals 355 Identify patient’s goals and Identify relevant contextual factors expectations (Environment, resources, etc.) Specify target activity (behaviour) Activity Specify support needed People S Physical aids T E P Cognitive, language or 1 other aids Quantify performance Timing Distance/amount Frequency Specify time period to achieve goal Time period 1 = a little important Weight the goals 2 = moderately important S Importance 3 = very important T E P 1 = a little difficult 2 = moderately difficult Difficulty 2 3 = very difficult Define other levels by adding, –2 much less than expected deleting or changing one or more of ‘support needed’ S and/or ‘quantify performance’ –1 less than expected level T E 0 goal (expected level) P 3 1 better than expected 2 much better than expectedFigure 1 Flowchart for writing goals in goal attainment scaling. Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • 356 TJH Bovend’Eerdt et al. This first part has the largest number of The third subpart of support concerns the waypossibilities and identifies the functional purpose that items in the environment can be set up toof the goal. provide informational support encoded or present The behaviour should be specified as clearly and within the environment; it is the meaning or invo-explicitly as possible: ‘walking indoors’ rather than luntary consequence associated with the object that‘mobilizing’, and ‘cooking a three-course meal’ is important. Examples include lists to prompt therather than ‘preparing food’. Phrases such as person to sequence actions, sign posting for orien-‘using left hand in functional tasks’ are too tation, and barriers that remind the person not tovague and need more detail such as ‘brushing go somewhere.teeth using left hand’. In rehabilitation some activities are commonlytargeted, and one might use a list such as theRehabilitation Activities Profile12 or the ICF Part III. Quantify performancecore sets for stroke13 as a checklist both to Activities can be described both qualitatively,ensure that all relevant activities have been consid- using judgement, and quantitatively in termsered when setting goals and to standardize the of some measurable aspect of the behaviour.behavioural descriptions used, to an extent. The patient’s perception of quality (and, to a lesser extent, the judgement of other people) is of importance but it is not easily standardized. Thus qualitative descriptions have been left out inPart II. Specify specific support this method although an assessment of quality Behaviour is a (goal-directed) interaction with could be used as an option if quantification isthe environment, whether objects or other not possible.people. In rehabilitation it is often necessary to Performance can be quantified in three ways:modify or provide additional environmentalfactors for the behaviour to succeed. There are  by the time taken to achieve a set quantity ofseveral environmental supports to consider, and the activity, and/orthus this part is divided into three subparts.  by the quantity of a continuous activity per- The first subpart concerns support given by formed (e.g. distance) in a set time, and/orpeople in the environment:  by the quantity of a discrete activity occurring in a period of time (e.g. its frequency). hands-on, practical or physical assistance (such as assisting in a transfer, cutting food, doing up Any activity that has a reasonably clear start shoe laces); or and finish can be timed, and timing allows a rea- emotional and stand-by support to increase sonably accurate and sensitive (to change) method self-confidence; or of quantification that, incidentally, will often also cognitive, structural support such as prompting be associated with the quality of performance. and reminding. Timing should be widely used. Examples include time to walk to the post office, time taken to get The second subpart concerns specific objects in up and dressed, and time to complete a shoppingthe environment – extra aids, or particular adapta- trip successfully. Generally (but not inevitably)tions to objects – that need to be present. It covers time will be shortened as performance improves.the field of physical equipment, for example: Distance or amount is commonly used to quan- tify activities, for example the distance walked in 2 specific items that can be moved around (such minutes, or the number of words typed in 5 min- as a walking stick, wheelchair, or hoist); or utes. It could also be the distance walked before adaptation to personal items (such as clothing being stopped by pain, or the amount of time elap- or cutlery); or sing before fatigue supervenes. an adapted fixed environment (such as a ramp, Any activity that occurs repeatedly can also be or a stair rail). counted. If the activity is a desired activity then an Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • Writing SMART rehabilitation goals 357increase will usually be specified (e.g. number of Step 3: Scaling the goalletters filed successfully) but counting can alsoapply to unwanted activities (such as falling, In the goal attainment scaling process, once theswearing, forgetting, needing prompts or dropping initial goal has been set in terms of the perfor-objects) when a decrease will usually be the desired mance level expected at a specified time (which ischange. defined as the level scoring ‘0’), four more perfor- mance levels need to be specified: two that are better than and two that are worse than the goal. The particular advantage of the structuredPart IV. Specify time period to achieve the desired approach to defining a goal outlined above (step 1)state is that it allows easy definition of better than expected The last step is to specify the time period over and worse than expected states. These states arewhich (or date when) the target state is to be achieved by adding, deleting and/or varying oneachieved. In practice many services review pro- or more of the parts or subparts from step 1.gress at set intervals varying from weekly, through Thus, states that indicate exceeding the goal willevery 4–6 weeks, up to every 3–6 months. This involve one or more of:time will vary depending on the rehabilitation set-ting (post-acute or longer term) and the goal set  succeeding with less support from people;(most commonly short- or medium-term goals).  succeeding with a less supportive physical It is important to remember that rehabilitation environment;concerns changing behaviours, which depends  succeeding with a less supportive ‘cognitive’upon learning by the person or people concerned. environment;Behavioural change takes time. Consequently, in  being faster (usually);complex cases it is rarely appropriate to set a  an increase in quantity (e.g. distance); and/orreview point at less than four weeks away.  doing the activity more or less frequently.Moreover, the process described here is probablytoo ‘expensive’ in terms of staff time to warrant its States that indicate underachievement will beuse for shorter term goals. The principles may be the reverse.used by individual therapists, but setting complex The goal that was set in step 1 is level ‘0’; it is themultiprofessional team goals simply for one or level that the team believes can be achieved by thetwo weeks may best be done less formally. specified time. Two states that reflect a better out- come than expected (þ1, þ2) and two states that reflect a worse outcome than expected (À1, À2) need to be specified. Level À1 is somewhat lessStep 2: Weighting the goal than the expected level and level À2 is much less than the expected level. Levels þ1 and þ2 are whenTraditionally in goal attainment scaling, each goal the patient performs somewhat better than expectedis weighted for importance and difficulty. and much better than expected, respectively.However, it is possible not to score importance It is possible for one of these levels to be theand difficulty and simply assign a weight of 1 to current level of performance (see discussionthe goal. If wanted, each goal can be weighted for later), but it will still need accurate specificationimportance and/or difficulty. The importance is using this system.determined by the patient, and the difficulty bythe clinician. Both importance and difficulty areranked on a 3-point scale, ranging from 1 (a littleimportance/difficult) to 3 (very important/diffi- Step 4: Evaluating goal achievementcult). If weighting is used, it needs to be used con-sistently and uniformly for all goals and in all At the appointed review date the level achieved ispatients if any comparison is being undertaken. determined by the patient and the team. Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • 358 TJH Bovend’Eerdt et al.Step 5: Scoring goal achievement with Mr R and will have to supply the long- handled sponge. The physiotherapist will have to practise activity-related balance and the nursingThe score is calculated by applying the formula14, 15: staff will have to implement the techniques in his 10ÆðWi Xi Þ daily routine. ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi GAS ¼ 50 þ qÀ Á ð1 À ÞÆW2 þ ðÆW2 Þ i iwhere Wi is the weight (importance  difficulty) Step 2: Weighting the goalsassigned to the i-th goal; Xi is the numerical value A weight for importance and difficulty isachieved for the i-th goal; and is the expected assigned to the goal. For Mr R the goal is verycorrelation of the goal scales (normally 0.3). important (score 3) and it is moderately Calculating the score is discussed in more detail difficult (score 2). The weight for this goal iselsewhere.11 importance  difficulty; 3  2 ¼ 6.Example 1. An illustration employing steps 1–3 Step 3: Defining other levels Mr R, 73 years old, had a stroke two months ago. The goal is: To wash in the shower with verbalHe used to live independently in an apartment with prompting using a long-handled sponge in 15 min-an adapted shower. The stroke has left him with utes on a daily basis using a checklist within fourslightly reduced balance and some apraxia. weeks (level 0). The other levels are defined byHe has expressed the desire to be able to wash him- adding, removing or changing one or more ofself in the shower on his own. It is anticipated that the (sub)-part (from II and III) that are specificat the time of discharge Mr R will need a small care for Mr R.package to provide some help at home. The inter-disciplinary team will need to write a SMART goal  Level À1 is the current level: To wash in thefor Mr R to work towards washing himself in the shower with physical assistance of one personshower on his own. on a shower chair within four weeks.  Level À2 is less than current: To wash in the shower with physical assistance of one personStep 1: Defining the goal on a shower wheelchair within four weeks. By selecting possibilities from each (sub)-part  Level 1 is somewhat better than expected: Toa SMART goal is created. The occupational thera- wash in the shower with a long-handled spongepist suggests that Mr R needs verbal prompting in 15 minutes on a daily basis within four weeks.(support by people) to perform this activity and  Level 2 is much better than expected: To inde-would be safe doing this if he had a long-handled pendently wash in the shower in 15 minutes onsponge (support by objects). The psychologist sug- a daily basis within four weeks.gests using a checklist (cognitive, structural, com-munication support) to increase his independence.He should be able to do it within 15 minutes(quantifying by timing) on a daily basis (quanti-fying by frequency) within four weeks (time period Practical application – some pointsto achieve state). So the result is the SMART goal:To wash in the shower with verbal prompting We have learned four lessons from our experienceusing a long-handled sponge in 15 minutes on a with goal setting in rehabilitation in general anddaily basis using a checklist within four weeks. with the method described here: This goal is clear for Mr R as well as for theinterdisciplinary team. The psychologist will have  Getting the team to work together as a team.to teach him the strategy of checklists. The occu- When setting goals, aim for them to bepational therapist will have to practise the activity interdisciplinary (i.e. to require collaborative Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • Writing SMART rehabilitation goals 359 working by two or more team members). Discussion Interdisciplinary rehabilitation is effective,16 and creating interdisciplinary goals improves We describe a new, structured method for writing the collaboration of the various disciplines goals that are specific and measurable without too and creates clear aims for the patient and the much effort. Goal attainment scaling is a techni- disciplines (see example 2). que that is increasingly used in rehabilitation, but Making goals relevant and important. This its success depends upon formulating unambigu- should follow on from discussions with the ous goals and the method described here is a useful patient, but we find it is much more likely if tool to achieve this: it is flexible enough to cover goals are based on activities (or social partici- most situations; it is patient-specific; it saves time pation) (see example 2). and effort; and it can easily be taught and used by Scoring goal attainment (a). When scoring the whole team. In this article we have focused on goal attainment (step 4), it is possible that the construction of the target goals and levels of none of the predefined levels precisely repre- achievement (steps 1–3). More detailed informa- sents the patient’s level. However, it is our tion on goal attainment scaling in general is avail- experience that the team can score the appro- able elsewhere.6,10,14,17 Some particular additional priate level without significant difficulty. points that we have considered are discussed here. In example 1, the attainment of the patient Weighting the importance and difficulty of after four weeks is actually: able to wash in goals seems intuitively good, and different meth- the shower with verbal prompts in 10 minutes ods for weighting are available. In the accompany- on a daily basis using a checklist. This level is ing article by Turner-Stokes11 a 4-point (0–3) not one of the predefined levels. However, it is weighting scale is suggested. However, this fairly obvious that the appropriate level is level means that items rated ‘0’ score ‘0’. This may be 0. We suggest that this difference is noted on appropriate in that unimportant goals or goals the score sheet. that can easily be achieved should not be set and Scoring goal attainment (b). When scoring goal should not score at all. However in our view, it is attainment (step 4), occasionally the level inappropriate to waste time setting goals that are achieved is in between two predefined levels. of no importance and/or are very easily achieved. We suggest always choosing the lower Consequently we have restricted the scale to 1, 2 or (less good) level in this case and making a 3 (see Figure 1). note of the actual level on the score sheet. Furthermore, the additional value (information content) of weighting goals is unknown, and it is quite possible that it is an unnecessary complica- tion. Whether importance and/or difficulty are scored or whether goals are always assigned aExample 2. Illustration of an interdisciplinary weight of 1, it is vital that a consistent approachgoal at the activity level is used for all goals given to an individual patient The physiotherapist has identified weak hip and for all patients where aggregation of data isextensor power and poor stability around the contemplated. Comparing patients where impor-hips. An obvious goal for the physiotherapist tance and difficulty are scored with patientswould be: To bridge with verbal prompting to where only importance is scored or without anyclear the bed by 10 cm and hold for 5 seconds weighting at all is completely invalid.within four weeks. This goal complies reasonably The score attributed to the current state whenwell with the SMART criteria: specific, measur- goals are set is also subject to debate. Someable, achievable, relevant and timed. However, a authors set ‘À2’ as the current state, but thisbetter goal that would be interdisciplinary, prob- approach risks missing a deterioration in theably more relevant and at the activity level, would patient’s state15 (i.e. there would be a floorbe: To pull up the trousers independently, using effect). One suggested remedy is to add a furtherbridging, within four weeks. level, ‘À3,’ to indicate deterioration from the Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • 360 TJH Bovend’Eerdt et al.current level (set as ‘À2’).18 Another suggested state such as pain, mood and quality of life becauseremedy is to set the current state as ‘À1,’ but behavioural correlates usually exist. For example aalthough this allows for deterioration it reduces patient’s self-report is in fact a behaviour and, moresensitivity to improvement by removing the importantly, these subjective states usually haveoption of ‘has made some progress, but not as externally observed behavioural sequelae such asmuch as expected’. taking symptomatic treatments (e.g. analgesic Our suggestion is to set the current state at the drugs), reducing or altering other activitiesextreme (‘À2’), and to score (record) any dete- (e.g. sleeping less long, not going to work).rioration as ‘À3’ in the patient’s record but to Two final points must be emphasized. Thescore it as ‘À2’ when scoring, acknowledging method described here has not itself been evalu-that this overestimates their state. Unexpected ated against other techniques for defining differentdeterioration is sufficiently rare to make this a outcome states (such as using a predefined menu).minor problem. However, it is currently being used in clinical prac- Goal setting in general, and goal attainment tice and as an outcome measure in a randomizedscaling in particular, has generally been applied controlled trial, and it is proving to be a userwhen improvement (recovery) is the expected friendly, practical and quick tool in both clinicaldirection of change. However, goals can also be and research practice, without compromising theset in situations where deterioration is the expecta- patient-centred and individualized approach.tion (e.g. in motor neurone disease); under these Second, in this discussion we have outlined sev-circumstances the goal of treatment is to reduce eral variations on the theme of scoring the achieve-the extent or consequences of disease progression. ment of outcome (concerning weighting, scoreThe same general approach to scoring should be attributed to the current state, handling unexpectedused here: ‘þ2’ would represent an outcome state change, etc.). A clinical team or researcher maymuch better than expected and ‘À2’ a state much choose whichever approach seems most appropri-worse than expected. As above, it is probably best ate in their circumstances, but it is imperative thatto set the current state as ‘þ2’, with ‘þ3’ being only one method is used with all patients to beused to record (but not score) a completely unex- analysed in a group, and that the exact methodspected improvement. In patients who deteriorate, used in any report or analysis are specified.the level ‘0’ (‘expected state’) is the state antici-pated as a result of the intervention with ‘À1’and ‘À2’ being worse states. The approach we have put forward depends Clinical messagesupon defining different states at a fixed time. Inprinciple it would be possible to fix a state and to  Goals in rehabilitation can be constructedvary the time taken to reach that state as an alter- using four parts: the target activity, the sup-native means of scoring. For example the state port needed, quantification of performancemight be ‘washing up breakfast dishes without and the time for achievement.being reminded and without breakage’ and one  This method can scale outcome by changingcould aim to achieve this by six weeks, with (sub)parts to give five levels.achievement by five weeks being level ‘þ1,’ four  The method is easy and quick, patient-speci-weeks ‘þ2,’ and seven weeks ‘À1’ and not achiev- fic, and applies to most situations.ing it by 10 weeks being ‘À2’. We are unaware ofthis method being used for goal attainment scal-ing, but recording the time to achieve a state(such as recurrence of a cancer) is a common ana- Acknowledgementslytic technique. We would like to thank all the staff at the The method has been described here primarily in Oxford Centre for Enablement and Claire Guyrelation to activities. These are most easily for their help and effort in developing thisdescribed. The technique should, however, be method. We would also like to thank Joanapplicable to most outcomes, including subjective Warren for her financial support. Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009
    • Writing SMART rehabilitation goals 361References community mental health programs. Community Ment Health J 1968; 4: 443–53. 1 Shiell A, Hawe P, Gold L. Complex interventions 11 Turner-Stokes L. Goal attainment scaling (GAS) in or complex systems? Implications for health rehabilitation: a practical guide. Clin Rehabil 2009; economic evaluation. Br Med J (Clin Res Ed) 23: 362–70. 2008; 336: 1281–83. 12 Jelles F, Van Bennekom CA, Lankhorst GJ, 2 Wade DT. Goal planning in stroke rehabilitation: Sibbel CJ, Bouter LM. Inter- and intra-rater How? Topics Stroke Rehabil 1999; 6: 16–36. agreement of the Rehabilitation Activities Profile. 3 Locke EA, Bryan JF. The effects of goal-setting, J Clin Epidemiol 1995; 48: 407–16. rule-learning, and knowledge of score on 13 Geyh S, Cieza A, Schouten J, Dickson H, performance. Am J Psychol 1966; 79: 451–57. Frommelt P, Omar Z et al. ICF core sets for stroke. 4 Locke EA, Latham GP. Building a practically J Rehabil Med 2004; 44(suppl): 135–41. useful theory of goal setting and task motivation. 14 Tennant A. Goal attainment scaling: current A 35-year odyssey. Am Psychol 2002; 57: methodological challenges. Disabil Rehabil 2007; 705–17. 29: 1583–88. 5 Schmidt RA, Wrisberg WA. Motor learning and 15 Law LSH, Dai MOS, Siu A. Applicability of goal performance: a situation-based learning approach, attainment scaling in the evaluation of gross motor fourth edition. Human Kinetics, 2007. changes in children with cerebral palsy. Hong Kong 6 Hurn J, Kneebone I, Cropley M. Goal setting as an Physiother J 2004; 22: 22–28. outcome measure: a systematic review. Clin Rehabil 16 How do stroke units improve patient outcomes? A 2006; 20: 756–72. collaborative systematic review of the randomized 7 Schut HA, Stam HJ. Goals in rehabilitation trials. Stroke Unit Trialists Collaboration. Stroke teamwork. Disabil Rehabil 1994; 16: 223–26. 1997; 28(11): 2139–44. 8 Yip AM, Gorman MC, Stadnyk K, Mills WG, 17 Rockwood K, Howlett S, Stadnyk K, Carver D, MacPherson KM, Rockwood K. Powell C, Stolee P. Responsiveness of goal A standardized menu for Goal Attainment attainment scaling in a randomized controlled Scaling in the care of frail elders. The Gerontologist trial of comprehensive geriatric assessment. 1998; 38: 735–42. J Clin Epidemiol 2003; 56: 736–43. 9 World Health Organization. International 18 Steenbeek D, Meester-Delver A, Becher JG, classification of functioning, disability and health. Lankhorst GJ. The effect of botulinum toxin type Accessed 23 September 2008, from: www.who.int/ A treatment of the lower extremity on the level of classifications/icf/en/ functional abilities in children with cerebral palsy:10 Kiresuk TJ, Sherman RE. Goal attainment scaling: evaluation with goal attainment scaling. a general method for evaluating comprehensive Clin Rehabil 2005; 19: 274–82. Downloaded from http://cre.sagepub.com at ELON UNIV on March 19, 2009