a quality improvement clinical
audit of the Journey day service
completed as part of
MSc Working with Personality Disorder:
Extending Expertise and Enhancing Practice
BIGSPD – Leeds 5th March 2015
Alan Hirons – Occupational Therapy Clinical Specialist
Leeds Personality Disorder Services
alan.hirons@nhs.net
● overview of Journey
quality improvement clinical audit
- dedicated Occupational Therapy group work programme
- focussed on facilitating adaptive goal directed activity:
around control and regulation, and identity
- commenced 2006, now on 26th cycle
- evaluation and outcomes consistently positive
- but, seemingly high ongoing attrition rate of 50%
● why clinical audit?
quality improvement clinical audit
- a pragmatic response to
- Trust rationalisation of services in response to economic
environment
- Trust identification of quality improvement as main vehicle for
achieving efficiency savings
- Francis Report recommendations for engagement with quality
assurance processes
● clinical audit methodology
quality improvement clinical
audit
- Measurement of effectiveness
against proven standards of high
quality
- Action taken to bring practice
into line with standards
- Improvement in quality of care
and health outcomes
quality improvement clinical audit
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
- conceptual shift:
traditional quality assurance model to quality improvement model
● stage 1 - sources of criteria
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
- NICE clinical guideline – BPD (2009)
- NICE clinical guideline – Service user experience in adult mental
health care / Access to care (2011)
- Treatment Readiness Model – PD (Tetley et al, 2010; McMurran,
2012)
- Local Commissioner requirements
● stage 1 - standards
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
- Section 1:
Assessment and entry / 13 standards
- Section 2:
Facilitating attendance / 4 standards
- Section 3:
Managing endings and transitions / 6 standards
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
● stage 2 - data collection
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
- x49 ‘referrals’ (from 16.1.13 – 13.6.13)
- represents 45% of referrals in 2013
- written and electronic data collected between 20.1.14 to 31.1.14
- data processed by Trust Clinical Audit Department
● stage 2 - data analysis
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
- Phase 1: Clinical Audit Lead –
overview
- Phase 2: Reference Group
tasked with reflecting and commenting upon data and
making recommendations
Membership:
• ex service users • CCG Commissioner • Journey staff • Directorate AHP Lead
• Trust Clinical Audit Department representative • PD Services group programme lead
● stage 2 - general findings
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
- n11/16 (69%) of service users completed their programmes
- n10/43 (23%) of service users dropped out of assessment process
before meeting a Journey staff member
● stage 2 - specific findings
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
Impact of procedural factors – ‘basics’
- Lack of clear instruction on assessment form – 61%
- Not enough prompts on assessment form – 97%
- Record keeping not complete – 75%
Impact of contextual factors – ‘wider issues’
- The apparent complexity and ‘busyness’ of the assessment process
- Mismatch of expectations around ‘recovery’ processes
● stage 3 - changes implemented
- Section 1: Assessment and entry
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
To improve information given to service user and documentation
• Service leaflet included in assessment appointment letter
• Assessment summary letter to be placed on electronic recording system
• Assessment summary letter to be sent to GP
• Assessment form redesigned
- Section 2: Facilitating attendance
To improve recording of interactions and improve provision of
written information about personality disorder
• Instruction given to staff team to record all interactions
• Reference copy of NICE BPD clinical guideline made available
● stage 4 - re audit
Stage 4 –
Sustaining
Improvement
(including
re-audit)
Stage 1 –
Preparation
and Planning
(including
re-audit)
Clinical
Audit
Cycle
Stage 3 –
Implementing
Change
Stage 2 –
Measuring
Performance
(Adapted from Burgess, 2011)
- Late 2015
- Journey 25 programme had n7/8 (88%) completion
● reflections and learning
quality improvement clinical audit
• heightened anxiety
• sense of isolation
• sense of ‘defending’
• closed system
• ‘authoritarian’ style
reference group
- ‘paranoid schizoid’ position to ‘depressive’ position
• engagement with
anxiety
• collective endeavour
• clarity of primary task
• open system
• ‘authoritative’ style
● overall learning
quality improvement clinical audit
- worthwhile – direct evidenced based information
- immediate engagement with quality improvement
- organising and focussing of energy and endeavour
- invigorating