borderline personality disorder (bpd) audit support
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Audit supportIssue date: [Year]Short title of guidelineNICE clinical guideline [XX]
Borderline personality disorder
Audit supportImplementing NICE guidance
2009
NICE clinical guideline 78
This audit support accompanies the clinical guideline: Borderline personality disorder:
treatment and management (available online at www.nice.org.uk/CG078).
Issue date: 2009
This is a support tool for measuring and monitoring local practice against the
NICE guidance.
It is not NICE guidance.
National Institute for Health and Clinical Excellence
MidCity Place, 71 High Holborn, London WC1V 6NA; www.nice.org.uk
© National Institute for Health and Clinical Excellence, 2009. All rights reserved. This material
may be freely reproduced for educational and not-for-profit purposes. No reproduction by or
for commercial organisations, or for commercial purposes, is allowed without the express
written permission of the Institute.
Audit support: borderline personality disorder (2009) 2 of 15
Using audit supportThe audit support document can be used to measure current practice in the treatment
and management of borderline personality disorder against the recommendations in
the NICE guideline. Use it for a local audit project, by either using the whole tool or
cutting and pasting the relevant parts into a local audit template.
Audit criteria and standards are based on the guideline’s key priorities for
implementation. The standards given are typically 100% or 0%. If these are not
achievable in the short term, set a more realistic standard based on discussions with
local clinicians. However, the standards given remain the ultimate objective.
The data collection tool can be used or adapted for the data collection part of the
clinical audit cycle by the trust, service of practice. The tool is based on the key
priorities for implementation relating to clinical activity and on organisational priorities.
Data may be required from a range of sources, including policy documents and
service user records. Suggestions for these are indicated on the tools, although this is
not an exhaustive list and they may differ in your organisation.
The sample for this audit should include adults and young people (under the age of
18) with borderline personality disorder in primary, secondary or tertiary care. Select
an appropriate sample in line with your local clinical audit strategy.
Whether or not the audit results meet the standard, re-auditing is a key part of the
audit cycle. If your first data collection shows room for improvement, re-run it once
changes to the service have had time to make an impact. Continue with this process
until the results of the audit meet the standards.
Audit support: borderline personality disorder (2009) 3 of 15
Clinical criteria for ‘Borderline personality disorder’
Criterion 1 Percentage of people with borderline personality disorder who have been excluded from any health or social care services because of their diagnosis or if they have self-harmed
Exceptions None
Standard 0%
Definitions None
Criterion 2 Percentage of people with borderline personality disorder with whom the healthcare professional has worked in partnership to develop their autonomy and promote choice
Exceptions None
Standard 100%
Definitions This should be done by ensuring that the person with borderline personality disorder remains actively involved in finding solutions to their problems, even during crises and/or encouraging them to consider the different treatment options and life choices available to them.
Criterion 3 Percentage of people with borderline personality disorder who have explored their treatment options with their healthcare professional and have had it explained that recovery is possible and attainable
Exceptions None
Standard 100%
Definitions None
Criterion 4a All people with borderline personality disorder who have had the withdrawal and ending of treatment or services, or the transition from one service to another should have had these changes discussed carefully with them beforehand.
Exceptions None
Standard 100%
Definitions Discussion should involve family or carers if appropriate.
Criterion 4b Any ending and withdrawal of treatments or services, or the transition from one service to another should be undertaken in a structured and phased way.
Exceptions None
Standard 100%
Definitions Healthcare professionals should anticipate that these changes may evoke strong emotions and reactions.
Discussion should involve family or carers if appropriate.
Audit support: borderline personality disorder (2009) 4 of 15
Clinical criteria for ‘Borderline personality disorder’
Criterion 4c Percentage of service users with a care plans that supports effective collaboration with other care providers during endings and transitions and includes the opportunity to access services in times of crisis
Exceptions None
Standard 100%
Definitions None
Criterion 4d If referral for assessment in other services is made, the person should be supported during the referral period and any arrangements for support are agreed beforehand with them
Exceptions None
Standard 100%
Definitions Other services include psychological treatment.
Criterion 5a Percentage of service users who have a comprehensive multidisciplinary care plan developed in collaboration with the service user (and their family/carers, where agreed with the person)
Exceptions None
Standard 100%
Definitions None
Criterion 5b Percentage of service users who have a care plan, as referred to into criterion 5a, that:
identifies roles and responsibilities of all health and social care professionals involved
identifies manageable short-term treatment aims and specific steps that the person and others might take to achieve them
identifies long-term goals that the person would like to achieve
sets out a crisis plan, that:
– identifies potential triggers that could lead to crisis
– specifies self-management strategies likely to be effective
– establishes how to access services if self-management strategies alone are not enough
is shared with the service user and their GP
Exceptions None
Standard 100%
Definitions Long-term goals should include those relating to employment and occupation. They should underpin the overall long-term strategy and should be realistic, and linked to short-term treatment aims.
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Clinical criteria for ‘Borderline personality disorder’
Criterion 6 Percentage of service users who receive brief psychotherapeutic interventions (of less than 3 months’ duration) specifically for borderline personality disorder or for the individual symptoms of the disorder, outside a service that has the characteristics outlined in criterion 11
Exceptions None
Standard 0%
Definitions The service characteristics that should be in place are:
an explicit and integrated theoretical approach used by both the treatment team and the therapist, which is shared with the service user
structured care in accordance with this NICE guidance
provision of therapist supervision
Criterion 7 Percentage of people who receive drug treatment specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder
Exceptions None
Standard 0%
Definitions Examples of behaviour associated with this disorder include repeated self-harm, marked emotional instability, risk-taking behaviour, and transient psychotic symptoms.
Criterion 8 Percentage of service users offered written information about:
their illness or condition
the treatment and care they should be offered, including being made aware of the ‘Understanding NICE guidance’ booklet (http://guidance.nice.org.uk/CG78)
the service providing their treatment and care
Exceptions None
Standard 100%
Definitions Service users should be offered written information to help them make informed decisions about their healthcare. This should cover the condition, treatments and the health service providing care. Information should be available in formats appropriate to the individual, taking into account language, age, and physical, sensory or learning disabilities.
Criterion 9 Percentage of carers offered written information about:
the service user’s illness or condition
the treatment and care the service user should be offered, including being made aware of the ‘Understanding NICE guidance’ booklet (www.nice.org.uk/CG078)
the service providing the service user’s treatment and care.
Exceptions A If there is no carer involved
B If sharing information may compromise the service user’s confidentiality or wishes
Audit support: borderline personality disorder (2009) 6 of 15
Clinical criteria for ‘Borderline personality disorder’Standard 100%
Definitions If the service user agrees, families and carers should have the opportunity to be involved in decisions about treatment and care.
Number of criterion replaced:
Local alternatives to above criteria (to be used where other data addressing the same issue are more readily available)
Exceptions
Settings
Standard
Definitions
Audit support: borderline personality disorder (2009) 7 of 15
Organisational criteria for ‘Borderline personality disorder’
Assessment
Criterion 10 Community mental health services should be responsible for the routine assessment, treatment and management of people with borderline personality disorder
Exceptions None
Standard Met/unmet
Definitions Community health services include community mental health teams, related community-based services, and tier 2/3 services in child and adolescent mental health services (CAMHS)
Psychological treatment provision
Criterion 11 When providing psychological treatment the following service characteristics should be in place:
an explicit and integrated theoretical approach used by both the treatment team and the therapist
structured care in accordance with this NICE guidance
provision of therapist supervision
Exceptions None
Standard Met/unmet
Definitions None
Multidisciplinary specialist teams
Criterion 12a Mental health trusts should develop multidisciplinary specialist teams and/or services for people with personality disorders
Exceptions None
Standard Met/unmet
Definitions The specialist teams should have specific expertise in the diagnosis and management of borderline personality disorder
Criterion 12b The multidisciplinary specialist teams referred to into criterion 12a should:
provide assessment and treatment services for people who have complex needs and/or high levels of risk.
provide consultation and advice to primary and secondary services
offer general psychiatric services a diagnostic service if they are unsure about the diagnosis and/or management
develop systems of communication and protocols for information sharing among different services and collaborate with all relevant agencies within the local community
provide and/or advise on social and psychological interventions, including access to peer support, and advise on the safe use of drug treatment in crises and for comorbidities/insomnia
Audit support: borderline personality disorder (2009) 8 of 15
Organisational criteria for ‘Borderline personality disorder’
work with CAMHS to develop local protocols to govern arrangements for the transition of young people from CAMHS to adult services
establish and maintain clear lines of communication between primary and secondary care
support, lead and participate in the local and national development of treatments for people with borderline personality disorder, including multi-centre research
develop/provide training programmes that cover diagnosis of borderline personality disorders and the implementation of this NICE guideline
oversee the implementation of this NICE guideline
monitor the provision of services for minority ethnic groups to ensure equality of service delivery
Exceptions None
Standard Met/unmet
Definitions None
Number of criterion replaced:
Local alternatives to above criteria (to be used where other data addressing the same issue are more readily available)
Exceptions
Standard
Definitions
Audit support: borderline personality disorder (2009) 9 of 15
Service user data collection tool for ‘Borderline personality disorder’Complete one form for each service user or episode.
Service user identifier: Sex: Age: Ethnicity:
No.Data item no.
Criteria Yes NoNA/Exceptionsa
NICE guideline ref.
Assessment
1 1.1 Has the person been excluded from any health or social care services because of their diagnosis or because they have self-harmed?
1.1.1.1
If ‘Yes’:
1.2 From which service were they excluded?
1.3 What reason was given for exclusion?
Autonomy and choice
2 Was a partnership working approach taken to develop autonomy and promote choice by:
1.1.3.1
2.1 actively involving the person in finding solutions to their problems
2.2 encouraging the person to consider different treatment options and choices available?
Developing an optimistic and trusting relationship
3 When working with the service user:
3.1 were the treatment options explored
3.2 was it explained that recovery is possible and attainable?
Managing endings and transitions
4 4.1 Was a treatment or service withdrawn or ended, or did the person make a transition from one service to another? Please state details:
1.1.7.1
If 4.1 answer was ‘Yes’:
4.2 Were changes discussed beforehand with the person?
4.3 Were the changes structured and phased?
Audit support: borderline personality disorder (2009) 10 of 15
No.Data item no.
Criteria Yes NoNA/Exceptionsa
NICE guideline ref.
4.3
4.4
Did the care plan:
document the need for collaboration with other care providers during endings, withdrawals and transitions?
Include the opportunity to access services in times of crisis?
4.5 Was the person referred for assessment in other services? Please state details:
If 4.4 answer was ‘Yes’:
4.6 Was the person supported during the referral period?
4.7 Were arrangements for this support agreed with the person beforehand?
Care planning
5 5.1
5.2
Did the person have a multidisciplinary care plan?
If ‘Yes’:
Was it developed with the service user?
1.3.2.1
Did the care plan:
5.3 identify roles and responsibilities of all health and social care professionals involved
5.4 identify manageable short-term treatment aims and specific steps that the person and others might take to achieve them
5.5
5.6
5.7
5.8
identify long-term goals that the person would like to achieve
were these goals:
– underpinning the overall long-term strategy
– realistic
– linked to short-term treatment aims
set out a crisis plan, that:
– identifies potential triggers that could lead to crisis
– specifies self-management strategies likely to be effective
– establishes how to access services if self-management strategies alone are not enough?
5.3 Was the care plan shared with the service user?
Audit support: borderline personality disorder (2009) 11 of 15
No.Data item no.
Criteria Yes NoNA/Exceptionsa
NICE guideline ref.
5.4 Was the care plan shared with their GP?
Psychological treatment
6 6.1 Was brief psychotherapeutic intervention (of less than 3 months’ duration) used specifically for borderline personality disorder or for the individual symptoms of the disorder?
1.3.5.7
Please state details:
6.2 If ‘Yes’, was the intervention carried out in a service that had the following characteristics: an explicit and integrated theoretical approach
used by both the treatment team and the therapist structured care in accordance with this NICE
guidance provision of therapist supervision?
Drug treatment
7 7.1 Did person receive drug treatment specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder?
1.3.5.1
Please state details:
Person-centred care
8 Was the service user offered evidence-based written information about:
Person-centred care
8.1 their illness or condition
8.2 the treatment and care they should be offered
8.3 including being made aware of the ‘Understanding NICE guidance’ booklet
8.4 the service providing their treatment and care?
(Data source: service user records)
9 Were carer(s) offered evidence-based written information about:
A / B Person-centred care
9.1 the service user’s illness or condition
9.2 the treatment and care the service user should be offered
9.3 including being made aware of the ‘Understanding NICE guidance’ booklet
9.4 the service providing the service user’s treatment and care?
(Data source: service user records)
Audit support: borderline personality disorder (2009) 12 of 15
Organisational data collection checklist for ‘Borderline personality disorder’
Organisation/service:
NoData item
Criteria Yes No NA/CommentsNICE
guideline ref.
Assessment
10 10.1
Systems are in place to ensure that community mental health services are responsible for the routine assessment, treatment and management of people with borderline personality disorder.
1.3.1.1
Psychological treatment provision
11
The following service characteristics are in place when providing psychological treatment:
1.3.4.3
11.1 an explicit and integrated theoretical approach used by both the treatment team and the therapist
11.2 structured care in accordance with this NICE guidance
11.3 provision of therapist supervision
Multidisciplinary specialist teams12
12.1Multidisciplinary specialist teams and/or services for people with personality disorders provided.
1.5.1.1
If these specialist teams are provided do they:
12.2 provide assessment and treatment services for those
people who have complex needs and/or high levels of risk
12.3 provide consultation and advice to primary and
secondary services
12.4 offer general psychiatric services a diagnostic
service if they are unsure about the diagnosis and/or management
12.5
develop systems of communication and protocols for information sharing among different services and collaborate with all relevant agencies within the local community
12.6
provide and/or advise on social and psychological interventions, including access to peer support, and advise on the safe use of drug treatment in crises and for comorbidities/insomnia
12.7 work with CAMHS to develop local protocols to
govern arrangements for the transition of young people from CAMHS to adult service
12.8 establish and maintain clear lines of communication
between primary and secondary care
12.9 support, lead and participate in the local and national development of treatments, including multi-centre research
Audit support: borderline personality disorder (2009) 13 of 15
NoData item
Criteria Yes No NA/CommentsNICE
guideline ref.
12.10 develop/provide training programmes that cover
diagnosis of borderline personality disorders and the implementation of this NICE guideline
12.11 oversee the implementation of this NICE guideline
12.12 monitor the provision of services for minority ethnic
groups to ensure equality of service delivery?
Audit support: borderline personality disorder (2009) 14 of 15
Further informationClick here for further information on reporting and monitoring the audit of NICE
guidance in your organisation.
NICE is committed to promoting through its guidance race and disability equality
and equality between men and women, and to eliminating all forms of
discrimination. One of the ways we do this is by trying to involve as wide a range
of people and interest groups as possible in the development of our guidance on
interventional procedures. In particular, we aim to encourage people and
organisations from groups in the population who might not normally comment on
our guidance to do so. We also ask consultees to highlight any ways in which
draft guidance fails to promote equality or tackle discrimination and give
suggestions for how it might be improved.
Supporting implementation NICE has developed tools to help organisations implement the clinical guideline
on borderline personality disorder (listed below). These are available on our
website (www.nice.org.uk/CG78).
Costing tools:
costing report to estimate the national savings and costs associated with
implementation
Slides highlighting key messages for local discussion.
Implementation advice on how to put the guidance into practice and national
initiatives that support this locally.
Audit support for monitoring local practice (this document).
A practical guide to implementation, ‘How to put NICE guidance into practice: a
guide to implementation for organisations’, is also available to download from the
NICE website.
The guidanceYou can download the guidance documents from www.nice.org.uk/CG78. For
printed copies of the quick reference guide or ‘Understanding NICE guidance’,
phone NICE publications on 0845 003 7783 or email publications@nice.org.uk
and quote N1765 (quick reference guide) and/or N1766 (‘Understanding NICE
guidance’).
Audit support: borderline personality disorder (2009) 15 of 15
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