a quality improvement clinical audit of the journey day service completed as part of msc working...
DESCRIPTION
- 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 ● why clinical audit? quality improvement clinical auditTRANSCRIPT
a quality improvement clinical audit of the Journey day service completed as part of MSc Working with Personality Disorder: Extending Expertise and Enhancing Practice
Alan Hirons – Occupational Therapy Clinical Specialist Leeds Personality Disorder Services
BIGSPD – Leeds 5th March 2015
- 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%
● overview of Journeyquality 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
● why clinical audit?quality improvement clinical audit
● clinical audit methodology
Stage 1 –Preparation
and Planning (including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(Adapted from Burgess, 2011)
- conceptual shift: traditional quality assurance model to quality improvement model
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
- 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 - sources of criteria Stage 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(Adapted from Burgess, 2011)
- Section 1: Assessment and entry / 13 standards
- Section 2: Facilitating attendance / 4 standards
- Section 3:Managing endings and transitions / 6 standards
● stage 1 - standards Stage 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(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 collection Stage 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(Adapted from Burgess, 2011)
- Phase 1: Clinical Audit Lead – overview
- Phase 2: Reference Group tasked with reflecting and commenting upon data
and making recommendations
● stage 2 - data analysis
Membership: • ex service users • CCG Commissioner • Journey staff • Directorate AHP Lead • Trust Clinical Audit Department representative • PD Services group programme lead
Stage 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(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 - general findings Stage 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(Adapted from Burgess, 2011)
● stage 2 - specific findings
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 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(Adapted from Burgess, 2011)
- Section 1: Assessment and entryTo 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 attendanceTo 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 3 - changes implemented Stage 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(Adapted from Burgess, 2011)
- Late 2015
- Journey 25 programme had n7/8 (88%) completion
● stage 4 - re audit Stage 1 –Preparation and Planning
(including re-audit)
Stage 2 –Measuring
Performance
Stage 3 –Implementing
Change
Stage 4 –Sustaining
Improvement (including re-audit)
Clinical Audit Cycle
(Adapted from Burgess, 2011)
- ‘paranoid schizoid’ position to ‘depressive’ position
● reflections and learningquality improvement clinical audit
• heightened anxiety• sense of isolation• sense of ‘defending’• closed system• ‘authoritarian’ style
refe
renc
e gr
oup
• engagement with anxiety• collective endeavour• clarity of primary task• open system• ‘authoritative’ style
- worthwhile – direct evidenced based information- immediate engagement with quality improvement
- organising and focussing of energy and endeavour- invigorating
● overall learningquality improvement clinical audit