7.3 SMART and SMARTER Goals

When developing a programme’s goals, it helps to consider the SMART framework (44). While all elements are not necessarily relevant in all situations, the SMART framework can be used to help a surveillance team develop and critically examine the stated goals of their programme. For our purposes, the SMART acronym features the following attributes:

• Specific – targets a specific outcome, indicator, or area for improvement
• Measurable – quantifies the indicator(s)
• Achievable – states what results can realistically be achieved with available resources
• Relevant – provides meaning and importance to the community
• Time-related – specifies when the result(s) can be achieved.

Going through the exercise of setting specific and measurable goals not only clarifies to everyone in the programme what must be achieved, but begins to provide a basis for quality assessment and improvement. A few basic examples can illustrate this point.

Specific. A programme that sets out to “monitor all birth defects” does not have a specific goal – what are “all” birth defects? A more specific goal would be to monitor an explicit list of selected birth defects (e.g. spina bifida, omphalocele, gastroschisis, and so on – together with clear case definitions), among well-defined birth outcomes (e.g. all live births, all live births plus stillbirths plus pregnancy terminations, etc.) in a well-defined source population (e.g. births delivered in a hospital network, or from mothers living in a defined geographic area).

Measurable. A measurable indicator of such a specific goal could be prevalence at birth, maternal age-specific prevalence at birth (important for conditions such as Down syndrome or gastroschisis), perinatal mortality, infant mortality, and so on – with each indicator having its explicit definition and the means to access the appropriate data on denominators.

Achievable. Having achievable and realistic goals is extremely important. The goal can be a stretch but should be doable given available resources. For example, programmes that are starting or have limited resources would want to strongly consider focusing, at least in the initial stages, on a shortlist of birth defects that can be reliably ascertained and evaluated with simple means: typically, a shortlist of external birth defects, visible at birth, of significant clinical and public health impact. Likewise, the type of data to be collected for each case will need to be carefully calibrated so that they serve the specific goals of the programme. Such sets of conditions and variables have been developed by several organizations and networks (e.g. list from NBDPN, PreSurv database of the ICBDSR, and the list provided in Chapter 4 of this manual). These resources are good starting points that can be tailored to a programme’s need.

Having achievable goals also serves as a reminder that a programme must have trained staff to do the work well. In birth defects surveillance, this means, for example, having both the epidemiologic and clinical capacity to identify, describe, code and classify relatively rare and sometimes complex conditions. In practice, a programme needs to think about appropriate training for front-line staff (e.g. nurses in the birthing centres) and having expert clinicians for case review and classification (e.g. at the central or coordinating programme office), in addition to data managers, analysts and epidemiologists.

Relevant. Good goals are meaningful to the programme and to the community. This shared belief and commitment will drive a programme forward in good and bad times. A relevant goal is one that seems worthwhile, that is applicable to the community’s social and cultural environment, and that is relevant for the times. For example, a relevant goal might be to conduct surveillance on clinically important birth defects with known modifiable risk factors (e.g. NTDs) and to link a birth defects surveillance programme with programmes that monitor and intervene in such risk factors (e.g. nutrition and fortification programmes, diabetes screening programmes, etc.). Programmes operating in settings with specific concerns or risk factors (e.g. high use of concerning medications) might include those concerns when deciding on their goals.

Time-related. Finally, a good goal is time-related or time-bound. Having a defined time horizon helps meet goals and keep track of progress. A good time-related goal is not too ambitious but also not too diffuse; for instance, having a goal of monitoring spina bifida in 10 years is too far in the future to be useful. One can have long-term goals, but in such cases, these need to be associated with shorter-term goals that can be used to track and assess progress.

Two additional points deserve emphasis. First, thinking carefully about data and data quality from the perspective of the end product – the goals of the surveillance programme – is not an academic exercise but a necessity. Time spent in this phase will save much time and effort later on. In the planning phase, the planners should realize that data are expensive – it takes time and resources to gather, check, store and analyse data, and such time and resources are limited. There should be no “recreational data collection” – all data to be used should be collected; all data collected should be used. A simple exercise once a proposed list of data elements has been created is to develop a set of tables in which those variables will be used. If there is no use for certain data elements, or if a programme is unable to collect those data accurately, then an argument can be made for not including them in the surveillance system.

Second, a well-planned programme will be forward thinking and have an explicit plan for expansion. For example, a programme might begin operations focusing on a core set of conditions and data elements. Depending on resources and the success of operations, a programme can then develop and implement an expansion plan to add conditions and data elements.

In fact, a variant of the SMART acronym is SMARTER – goals are also to be Evaluated and Reviewed. This extension speaks to the dynamic nature of goals. Everything can be improved, including goals. Regular evaluation and review is critical to ensuring the best use of a programme’s resources for the benefit of the community.

With goals set in place and having developed a first list of data elements to serve those goals, a programme will need to implement broad strategies and good practices to start embedding quality into such data elements.