How to guide front page 1000+ lives programme

First Episode Psychosis – Intelligent Target

Third DRAFT

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Preface

The 2009/2010 Annual Operating Framework (AOF) included a requirement to develop

Early Intervention in Psychosis (EIP) services, but this has not been advanced

systematically across all Health Boards. EIP services remain under-developed across

Wales, with inequity in the availability, accessibility and provision of high quality,

evidence based care for young people developing psychotic disorders.

To reinforce the national priority for the development of effective EIP services, the

Welsh Assembly Government established an expert clinical group with service

user/carer input to develop an Intelligent Target for First Episode Psychosis (FEP)

under the chairmanship of Mary Burrows – Chief Executive, Betsi Cadwaladr University

Health Board. The development and implementation of the FEP Target first requires the

gathering of baseline normative data in 2010-11 on current service provision in order to

establish future improvement targets for each Health Board for delivery in 2011-12.

This Guide contains the background rationale and key measures for the Intelligent

Target and details the requirements of Health Boards under the 2010/2011 Annual

Operating Framework (AOF section 4c, paragraph 4.93) which states the preliminary

need to establish the baseline position for First Episode Psychosis (FEP) service

improvement.

Acknowledgements

This guide has been produced by Dr Stuart Paynter, Steve Williams, Dr Mike Jackson,

John Baird and Dr Les Rudd, reporting to the National Core Group for Mental Health

Intelligent Targets chaired by Mary Burrows..

We would particularly like to thank PSI Cymru group, with service user and psychiatry

input, and the Betsi Cadwaldr, Hywel Dda and Aneurin Bevin Health Boards and their

teams for their work in designing and piloting the target and feeding back lessons and

experiences gained as a result.

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Date of publication

This guide was published in 2011 and will be reviewed in 2013. The latest version will

always be available online at: www.1000livesplus.wales.nhs.uk

The purpose of this guide

This guide has been produced to enable healthcare organisations and their teams

to successfully implement a series of interventions to improve the safety and

quality of care that their patients receive.

This ‘How to Guide’ should be read in conjunction with the following:

■ Leading the Way to Safety and Quality Improvement

■ How to Improve

Further guides are also available to support you in your improvement work:

■ How to Use the Extranet

■ A Guide to Measuring Mortality

■ Improving Clinical Communication using SBAR

■ Learning to use Patient Stories

■ Using Trigger Tools

■ Reducing Patient Identification Errors

These are available from the 1000 Lives Plus office, or online at

www.1000livesplus.wales.nhs.uk

We are grateful to The Health Foundation for their support in the production of

this guide.

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Making patient safety a priority

The 1000 Lives Campaign has shown what is possible when we are united in the

pursuit of a single aim: the avoidance of unnecessary harm for the patients we

serve. The enthusiasm, energy and commitment of teams to improve patient

safety by following a systematic, evidence-based approach has resulted in many

examples of demonstrable safety improvement.

However, as we move forward with 1000 Lives Plus, we know that harm and

error continue to be a fact of life and that this applies to health systems across

the world. We know that much of this harm is avoidable and that we can make

changes that reduce the risk of harm occurring. Safety problems can’t be solved

by using the same kind of thinking that created them in the first place. To make

the changes we need, we must build on our learning and make the following

commitments:

■ Acknowledge the scope of the problem and make a clear commitment to

change systems.

■ Recognise that most harm is caused by bad systems and not bad people.

■ Acknowledge that improving patient safety requires everyone on the care

team to work in partnership with one another and with patients and

families.

The national vision for NHS Wales is to create a world class health service by

2015: one which minimises avoidable death, pain, delays, helplessness and

waste. This guide will help you to take a systematic approach and implement

practical interventions that can bring that about.

The guide is grounded in practical experience and builds on learning from

organisations across Wales during the 1000 Lives Campaign and also on the

experience of other campaigns and improvement work supported by the Institute

for Healthcare Improvement (IHI).

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Contents

Introduction

Targets for treatment of FEP – Summary

Driver Diagram for 2010-2011 Baseline FEP target Getting Started

Drivers and Interventions

Measuring estimated DUP

Top tips to measure DUP

Top Tips for auditing baseline access to psychosocial interventions

Appendices

Appendix A – Frequently asked Questions

Appendix B - Setting up your team

Appendix C - The Model for Improvement

Appendix D – Driver Diagram for 2010-2012 FEP targets

Appendix E – Glossary of acronyms

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Introduction

Non-affective psychotic disorders are the most severe of all mental health problems, in

terms of their long term costs for the individual and for society. The early years of a

psychotic disorder offer a ‘window of opportunity’ to improve long term outcomes

through the rapid and sustained provision of effective interventions. Yet standard care

often involves substantial delays in providing treatments, and it rarely delivers key

psychosocial interventions such as cognitive behavioural therapy for psychosis, family

intervention, and meaningful vocational support, despite clear NICE guidelines.

A growing evidence base suggests that, compared with standard care, tailored early

intervention services for people developing psychotic disorders (Early Intervention in

Psychosis, EIP) can;

• improve access and engagement with services

• increase access to psychological and psychosocial interventions

• reduce admission rates to in-patient care and length of stay

• reduce detention rates under the 1983 Mental Health Act

• reduce the high attempted and completed suicide rates in early psychosis

• improve the number of people engaged in meaningful educational or vocational

activity

• improve general/social functioning and user satisfaction.

Of particular importance at this time of resource constraint within the NHS is the

evidence of the cost benefits of EIP services. For example, McCrone and Knapp (2007)

found that EIP cost £5,000 per year less than standard care per patient, in terms of

health care costs only including inpatient care costs.

In accordance with the evidence base on the effectiveness of early identification and

treatment of first episode psychosis, the main foci of a national target should be to

reduce the duration of untreated psychosis (DUP) by increasing timely access to

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appropriate evidenced based specialist treatment interventions and to improve clinical

and social/functional outcomes for people with a first episode psychosis. Both of these

aims are clearly indicated in the content of the driver diagram below which outlines the

direction of travel for service improvements in EIP in Wales.

However, because of the low level of development of EIP services in Wales and the

associated lack of baseline data on which to set local improvement targets, the target

for First Episode Psychosis differs from other mental health Intelligent Targets in

adopting a two phase ‘developmental’ approach.

In 2010/11, the required action is to establish routine recording of the baseline

measures for the target, in particular the current duration of untreated psychosis (DUP)

which is not known in Wales. Realistic targets can then be set for each Health Board in

2011-12, using their own baseline data to monitor and drive the implementation of the

required service interventions with priority on improving service capacity, engagement,

response times and provision of optimal interventions, to reduce DUP to 3 months.

Specifically, in 2010/11 the Annual Operating Framework Intelligent Target for First

Episode Psychosis requires as a minimum;

1. The identification of a named lead officer for Early Intervention in

Psychosis/First Episode Psychosis Services in each Health Board

2. Measurement of the duration of untreated psychosis for all people with a first

episode of psychosis

Whilst the Health Board lead officer for EIP/FEP will be responsible for locally delivering

implementation of measurement of DUP, in order to do so where there is a lack of

specialist EIP service capacity it may be necessary to identify a lead EIP care

co-ordinator in each CMHT and CAMHS service. This local CAMHS or CMHT EIP lead

care co-ordinator will be trained and equipped by the Health Board EIP/FEP lead officer

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to measure DUP. The establishment of this basic infrastructure to measure DUP in

CMHT’s and CAMHS may help to develop an EIP service or network at a later date to

respond to FEP/EIP targets for 2011/12. It should also sharpen the focus of attention

on people with first episode psychosis which may begin to improve recognition and

response to people with FEP.

In addition to the above minimum baseline data requirements, services are advised,

where possible, to also measure service engagement, access to NICE compliant

psycho-social interventions such as Cognitive-Behavioural Therapy for Psychosis

(CBTP) and Cognitive-Behavioural Family Intervention in Psychosis (C-B FIP), levels of

meaningful occupational or educational uptake and physical health monitoring for

people with early psychosis.

This data may be more meaningful and valid if collected on a sample of people 2-3

years into their psychosis illness history to allow an appropriate timeframe for

interventions to have been offered and outcomes achieved. The full pilot conducted in

Aneurin Bevin Health Board (see below) indicated that these additional baseline

measures take 30 minutes per patient to complete in most cases.

Baseline data established for these interventions and outcomes can then inform local

improvement targets in all these areas for 2011/12. The initial priorities are likely to be

on improving service capacity, engagement, response times and availability and access

to optimal interventions, with a year on year reduction in the (then known) DUP to 3

months.

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Targets for treatment of FEP – Summary

The targets are described in two main sections

First stage: 2010-2011

Establishment of local baseline for DUP and, if possible service engagement, access to

NICE compliant psycho-social interventions such as Cognitive-Behavioural Therapy for

Psychosis (CBTP) and Cognitive-Behavioural Family Intervention in Psychosis (C-B

FIP), symptom profile, levels of meaningful occupational or educational uptake and

physical health monitoring.

Second stage: 2011-2012

Based on local baseline data established in 2010/2011 where possible, local

incremental improvement target’s should be established in the following areas

(summarised in the appendix);

Clinical outcomes

a. Improved case identification of people with first episode psychosis/reduction

in duration of untreated psychosis

b. Admission, detention and readmission rates

c. Suicide rates

Social functioning/recovery

a. Family satisfaction

b. Meaningful occupational or educational activity

c. Quality of life

d. Service Engagement

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References

Luis Gaite et al, Quality of life in schizophrenia: development, reliability and internal

consistency of the Lancashire Quality of Life Profile - European Version The British

Journal of Psychiatry (2000) 177: s49-s54

McCrone and Knapp (2007, British Journal of Psychiatry)

Priebe S et al. Application and results of the Manchester Short Assessment of Quality

of Life (MANSA). Int J Soc Psychiatry. 1999 Spring;45(1):7-12.

Tait, L., Birchwood, M. & Trower, P. (2002) A new scale (SES) to measure

engagement with community mental health services. Journal of Mental Health, 11, 191 -

198.

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Driver Diagram for 2010-2011 Baseline FEP target (first stage)

The following driver diagram is for measurement in 2010-11 in order to gather baseline data for the establishment of 2011-12 improvement targets. A draft of likely 2011-12 targets is included in Appendix E Content Driver Interventions

To reduce

duration of

untreated

psychosis

(DUP)

Measure access to NICE recommended psychosocial interventions for people with FE/EP and their families

Access to & provision of CBT for Psychosis to people with first episode or early psychosis– NB can be started in acute phase incl inpatient environments (NICE Schizophrenia CG 82 2009)

Measure the duration of untreated psychosis for all people with a first episode of psychosis

Use DUP measurement bundle for all people with a First Episode Psychosis

Other measures Re functioning / social recovery.

Calculate median and mean DUP for each health community

Access to & provision of CB family intervention in psychosis where person lives with or is in close contact with their family (NICE Schizophrenia CG 82 2009)

Use of

• Service engagement scale

• Social functioning questionnaire

• Patient/Family Satisfaction scale

• Quality of life measure

Education/employment status

General health screening

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Getting started

Have you set up your team?

You need to consider three different dimensions:

■ Organisational level leadership

■ Clinical or technical expertise

■ Frontline leadership and team membership

See the ‘Leading the Way to Safety and Quality Improvement’ How to Guide; and

Appendix B for further information.

Do you know how you will measure outcomes?

To ascertain the effectiveness of this work, you should use the following outcome

measures:

• Number of people with FEP accessing NICE recommended psychosocial

interventions

• Number of families of people with FEP accessing NICE recommended

psychosocial interventions

• Number of people with FEP making social recovery

Do you and your team understand how to apply the Model for Improvement?

The Model for Improvement is a fundamental building block for change and you

need to understand how to use it to test, implement and spread the interventions

in this guide.

See the ‘How to Improve’ Tools for Improvement guide and Appendix C for further

information.

How are you going to measure process reliability?

In order to improve outcomes for your patients you need to demonstrate you

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are using these interventions reliably. This means that all the elements of the

interventions are performed correctly on 95% or more of the occasions when they

are appropriate. You need to do this by using the process measures in this guide.

Process measures The case identification of psychosis is predominantly a process target. The 2010/2011

target requires us to identify all people with first episode psychosis and measure their

duration of untreated psychosis. In addition and where possible, the target includes the

collection of baseline data on service engagement, access to NICE compliant psycho-

social interventions such as Cognitive-Behavioural Therapy for Psychosis (CBTp) and

Cognitive-Behavioural Family Intervention in Psychosis (C-B FIP), symptom profile,

levels of meaningful occupational or educational uptake and physical health monitoring

for people with early psychosis. For this content area, you should use the following

process measures in 2010-11:

� Compliance in measuring DUP.

� Compliance in collecting baseline data on service engagement,

access to PSI’s, symptom profile, occupational or educational activity and

physical health monitoring.

How will you share your learning?

Contact 1000 Lives Plus for details of mini-collaboratives and progress of other teams.

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Drivers and Interventions

This section details the 2010-11 baseline measures and then the interventions

highlighted in the driver diagram which evidence has shown to be effective in this

content area for implementation in 2011-12. You should use the Model for Improvement

to test, implement and spread the intervention, using the listed process to monitor

progress.

Please note that tools suggested for use will, where possible, be linked directly from this

document using hyperlinks. They will also be available, in addition to tools developed

locally by frontline teams, on the WHAIP website www.wales.nhs.uk/WHAIP

Driver: Establishing your local baseline for DUP in 2010-11

Aim: To systematically measure the duration of untreated psychosis for people with a

first episode of psychosis (FEP). This should be measured within six months of FEP

being diagnosed or recognised, by a specialist member of staff for each Child and

Adolescent Community Mental Health Team and Adult Community Mental Health Team

who will receive additional training and supervision.

To use this data to calculate current median and mean DUP for each health community

for 2010/11 and establish incremental improvement targets for subsequent years.

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How is the Duration of Untreated Psychosis (DUP) measured?

DUP is determined by calculating the delay between the onset of positive psychotic

symptoms and the client receiving effective treatment; this requires operational

definitions of both time points. Systems need to be able to measure:

i) Date of Onset of Positive Psychotic Symptoms (Onset of Psychosis OP)

The date of onset of positive psychotic symptoms is determined using clients self

report and family report. The date of onset is considered to be the first date at

which the client and/or family retrospectively indicate that the client experienced:

• Any single positive symptom attracting a PANSS

rating of 4 or more

OR

• Any combination of 3 or more positive symptoms (including

at least one of: delusions, conceptual disorganisation and

hallucinations) with a minimum combined score of 7.

This requires some conversance with PANSS criteria. The patient and their

family will need to be interviewed about the sequence of events leading up to the

first treatment and PANSS criteria applied retrospectively.

ii) Effective Treatment- Onset of Criteria Treatment (OCT)

The time point used is the start point of effective treatment when either a)

NICE compliant medication is prescibed and taken or b) NICE compliant

psychosocial interventions are offered and adhered to. The DUP measurement

then, is the length of time between the beginning of Onset and the beginning of

Treatment.

The forms of treatment that will be considered as effective are;

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a) antipsychotic/neuroleptic medication at the minimum dose recommended

by the BNF has been prescribed and taken with good adherence for one

month

OR

b) anti-psychotic medication has been actively considered but not prescribed

and/or the client has refused to comply AND evidenced based psycho-social

therapies in line with NICE guidelines (Cognitive Behavioural Therapy and/or

Cognitive-Behavioural Family intervention in Psychosis) have been provided

in an adequate dose with good adherence.

Rationale for definitions of effective treatment

The industry standard and internationally accepted method of defining effective

treatment for people with early psychosis is the point at which anti-psychotic medication

at least at a minimum BNF recommended dose has been prescribed and taken for one

month with good adherence. It allows for international comparisons to be made and is

widely accepted.

However this definition of effective treatment has been criticised as being too narrow

and restrictive in terms of client choice, clinical pragmatism and the developing

possibility that evidence based NICE recommended psychosocial treatments may be

independently effective treatments in early psychosis.

In recognition of these issues in Wales we will also therefore recognise as the endpoint

of DUP/onset of criteria treatment (OCT) the point at which anti-psychotic medication

has been actively considered but not prescribed or accepted AND an adequate dose of

NICE recommended psychosocial interventions have been provided with good

adherence.

Effectively this means that we will have two data sub-sets in terms of DUP;

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1. A large data set of DUP where the end point of untreated psychosis is defined by

active pharmacological intervention (criteria a above) which will allow

international comparisons to be made and

2. A smaller data set of clients estimated DUP where the end point of untreated

psychosis is defined by consideration (but not prescription and adherence with)

anti-psychotic medication plus provision of an adequate dose of a NICE

recommended psychosocial treatment with good adherence (criteria b above)

which will potentially allow important follow up studies about the independent

effectiveness of psychosocial interventions in early psychosis.

Measuring estimated DUP- establishing Onset of Psychosis (OP)

Onset is determined by a method of "triangulation" from three information sources. That

is 1) the clients perspective 2) the family perspective and 3) the position indicated in the

medical records/notes. Precedence would usually go to the client if there is no

agreement among the three.

1 From medical records, make notes detailing, in chronological order of occurrence

(as opposed to the order in which the facts appear in the medical records)

detailing:

Symptoms, including severity

Life events / significant dates / periods in the client’s life

Diagnoses

Prescriptions

Compliance with medication, and signs of compliance (e.g. side effects)

Signs of recovery

Whilst medical and clinical records are usually the best source of information

available to determine the onset of criteria treatment (OCT), interviews with the

client and a key relative are important and crucial in establishing the onset of

psychosis (OP) and often uncover a great deal more clinically important

information relevant to the onset of psychosis.

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2 Interview the client about the development of their illness. The interview should

be unstructured, and based on the information found in medical records.

Examples of questions may include:

i. Some people tell me that they hear things being said to them when no-one

else is in the room. Have you ever experienced anything like that?

ii. Can you remember the first time that happened?

iii. Can you remember when that was?

Hint: If the client finds this difficult, try and help them rebuild their memory

around the event/period, by asking supplementary questions to help them

work out when it was. For example:

o where they were living

o was it during a memorable period of their life

o were they in a particular job at the time

o what was the weather like

o was it around the time of someone’s birthday,

o was it close to Christmas or another calendar event

o had they recently been bereaved

Repeat the above questions for any other symptoms which you are aware the

client may have experienced.

Use the following as further ‘springboards’ for discussion about symptoms:

iv. Ask about the events that led to the client being admitted to hospital or

home treatment.

v. Ask the client if they think that anyone else had any concerns about

them/their behaviour at any point, and why that might have been.

vi. If the client is a known drug user, ask about when and why they began

using drugs, and when/why they stopped. This may uncover information

about early symptoms

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vii. Similarly, ask about any major life events that may be relevant, and how

the client felt/reacted at the time. Again this may uncover early symptoms

that the client may not have considered relevant so far.

Lastly,

viii. To confirm the onset of criteria treatment (OCT), determine whether or not

the client was prescribed and adhered with anti-psychotic medication at

BNF recommended dose for a minimum of one month OR was considered

for but not prescribed (or would not adhere with) anti-psychotic medication

AND was provided with an adequate dose of a NICE recommended

psychosocial intervention which they adhered with.

To help estimate adherence with anti-psychotic medication ask e.g. ‘Some people tell

me that they are not keen on taking their medication for one reason or another. How do

you feel about taking your medication? Have you ever felt like missing the odd dose?’

OR

To help estimate adherence with NICE recommended psychosocial treatments ask e.g.

“Did you attend your cognitive therapy sessions every week? Was there homework set

and did you do it? Did you have to do anything differently as a result of the therapy such

as a behavioural experiment? Did you feel the therapy helped with your problems?”

From this interview, draw up a set of notes in a similar way to those drawn from

the medical records.

3 Interview a key relative as a further source of information, and draw up a third set

of notes.

4 Compare the three sets of notes, and weighting the information appropriately,

approximate the date of onset of psychosis (OP) and onset of criteria treatment

(OCT). DUP is calculated by subtracting OP from OCT.

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Case example 1

Measurement of DUP in Hywel Dda Health Board

Hywel Dda Health Board’s embryonic and transitional Early Intervention in Psychosis

Service carried out a 4 week pilot to measure the duration of untreated pyschosis (with

onset of criteria treatment traditionally defined) for people currently or recently on their

caseload (n21) in 3 Adult Community Mental Health Teams. A sample (n-9) of

estimated DUP in months for clients as measured by two members of staff is illustrated.

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Case Example 2

Measurement of DUP by Aneurin Bevan Health Board EIP Team

Aneurin Bevan Health Board Early Intervention in Psychosis Team recently measured

the duration of untreated psychosis for 27 of 36 people with first episode psychosis

referred in the six months 1st April 2010- 30th September 2010. They discovered:

• Mean DUP of 24 months

• Median DUP of 6 months

• An outlying sub-group of 4 people with a DUP of more than 48 months

• A concentration of people with longer DUP’s in a particular patch

A second analysis excluding the four people with DUP of more than 48 months

indicated:

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• Mean DUP of 9 months

Staff Training and Engagement

In order to measure DUP accurately staff training is required in the technology of

measurement and the relevance, purpose and ethos of measuring DUP. To measure

DUP with reasonable accuracy identified members of staff will need training in;

• the importance, relevance and underlying ethos in measuring DUP

• use of and familiarity with the PANSS

• definition of psychosis onset criteria and effective treatment criteria

• engagement and interviewing skills to collect DUP data from clients and families

For staff with limited prior experience in this work 2-3 days training may be required.

Engaging clients and families- Clients and families may not initially see the relevance

of measuring DUP once psychosis has been established and may be reluctant to go

over difficult experiences and challenging times. The specialist member of staff

measuring DUP with people with early psychosis and their families will need good

therapeutic engagement skills with this client group and the time to develop a

therapeutic relationship to facilitate this. Measuring DUP requires staff to engage with

families of clients and illuminates the local ‘upstream’ sources of help and support that

clients and their families may have consulted when the psychosis was present but not

recognized or professional referral was not made. This local information concerning key

care pathway players for people with emerging or first episode psychosis will be

invaluable in targeting later efforts to reduce DUP.

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Top tips to measure DUP

1. Staff engaged in measuring estimated DUP need to understand the importance,

relevance and ethos of doing so, as well as the technological aspects of measurement.

2. Clients with early psychosis may need careful engagement to help them collaborate

in measuring estimated DUP due to ‘sealing over’ difficult or traumatic experiences.

3. Clients that ‘seal over’ may need longer to engage in this process.

4. Talking with family members to measure estimated DUP may uncover unmet need

and identify the need for further evidence based family interventions.

5. Measuring estimated DUP will lead to staff having a better understanding of the

clients care pathway, relevant life experiences and history of psychosis and will

increase empathy.

6. Measuring estimated DUP will help staff to develop an upstream, primary care and

community orientated perspective.

7. It can be difficult to differentiate onset of problems from the onset of psychosis; good

supervision and support systems will be required to increase the reliability of the

estimated measurement of DUP.

8. Use anchor points e.g. last Christmas, around the time of your birthday, during the

rugby world cup etc to help clients/families focus on client’s mental health at a particular

point in time

9. Be careful not to underestimate DUP- help client/families review earlier periods to

ensure that onset of psychosis (OP) criteria wasn’t met earlier

10. Allow enough time for engagement and rapport building- clients may be reluctant to

review difficult times in the past and families may have a great need to express feelings

about their experiences with a professional that has not previously been available.

11. Expect a therapeutic benefit- whilst estimating DUP is not intrinsically therapeutic,

helping clients integrate psychotic experiences rather than seal them over and being a

good listener to the families of people with psychosis can be highly therapeutic.

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Driver: Establishing your baseline for other key clinical and social

outcomes.

Aim: To establish a local baseline for key clinical and social outcomes and access to

optimal interventions on which to build incremental service improvement targets in

2011/2012 and beyond.

Case example 3

Measuring access to psychosocial interventions, anti-psychotics, annual medical

review, admissions, section rate, days in hospital and suicide rate in Hywel Dda Health

Board.

In Hywel Dda Health Board the embryonic and transitional early intervention in

psychosis service reviewed the care and treatment of people with a 3-5 year history of

psychosis (i.e. post early psychosis criteria) from one CMHT. The aim of this review was

to assess baseline access to psychosocial interventions and timely and appropriate

management of early psychosis prior to the development of a specialist early psychosis

service in one CMHT area.

An estimate of the number of clients who would meet this criterion was made based on

standard demographic estimates and factoring in that this CMHT covered a largely

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urban and socially deprived community. This indicated that about 10 people per annum

would develop psychosis giving a total potential caseload of 30 clients with a 3-5 year

history of psychosis. However, the audit only uncovered 10 people who met this

criterion. This may indicate that the well reported problems of disengagement from

standard services, where 50% of people with first episode psychosis disengage within

12 months applied in this area. Indicative data in terms of evidence of access to

psychosocial interventions, pharmacological interventions, formal review of

pharmacological interventions, and use of in-patient beds, mental health act and

attempted suicide rate for the 10 clients identified are presented here.

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Case Example 4

Measuring access to psychosocial interventions, anti-psychotics, physical health

screening, admission rate, suicide attempts and assessment of functioning,

engagement and quality of life in Aneurin Bevan Health Board

Data was collected on 36 people with first episode psychosis referred to the early

intervention service between 1st April 2010 and 30th September 2010. This indicated the

following:

Psychosocial Interventions

• CBTp- 10 offered 6 provided

• Relapse Prevention- 17 provided

• Family Intervention 16 offered

Anti-Psychotic Medication

• Offered 36 Received 36

• Medication Review 33

• Side Effects formally monitored (LUNSERS) 30

Physical Health Screening

• Offered 27 Completed 20

Measurement of Engagement, Quality of Life and Functioning

• Use of MANSA V2 24

• Use of GAF 23

• Engagement Scale 23

In-patient care

• People admitted 22

• Number of admissions 34

• Average length of stay 5.5 weeks

Suicide Attempts

• Number of people attempting suicide 7

• Total number of suicide attempts 12

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Top Tips for auditing baseline access to psychosocial interventions

1. Use the target definition of psychosocial interventions (informed by NICE CG82 2009)

so that you are clear about what you are looking for.

2. Develop a written case identification strategy or action plan and record

implementation efforts and problems

3. If conducting an audit on historic data to establish a baseline expect to have to

search hard copy and electronic records to find evidence of what you are looking for

4. Use the definition provided above (in the narrative section for the interventions

relating to this target) to ensure that where psychosocial interventions have been

provided that they have been provided by someone with appropriate knowledge,

education, training, experience, supervision and access to continuing professional

development.

5. With some training in audit and support, frontline clinical staff can conduct the audit

and understand the importance of doing so.

6. Identify and trace first episode psychosis clients via diagnostic codings applied to all

inpatients- in standard services 80% of FEP clients are admitted.

7. Where Crisis Resolution and Home Treatment teams are operational expect some

FEP clients to have been managed there and may therefore not show up via diagnostic

coding of inpatient admissions

8. Go through caseloads of CMHT colleagues and CPA documentation to identify

people who meet early psychosis criteria or recently did so.

9. Historically collected data may not include access to psychosocial interventions- a

brief interview with the clients CPA care co-ordinator and any psychological therapists

active in the area will often be necessary to supplement review of records to establish

baseline data in this area.

10. Work as a team and share good practice/experiences of what works in terms of

where and how to identify cases and locate relevant data to speed up the process.

11. Reduce potential defensiveness by explaining that we are trying to establish a no-

fault baseline to improve access in the future.

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12. Identify historic and current practices of maintaining engagement of people with

psychosis in services.

13. Consider problems with the case finding strategy, implementation of the case finding

strategy and historic and current practices to maintain engagement with people with

early psychosis as potential explanations for identification of low number of cases.

14. Develop a system in an embryonic or transitional specialist early psychosis service

to routinely record and review access to NICE recommended psychosocial

interventions.

Measures and Operational Definitions

Tools have been hyperlinked to this document where possible. Otherwise please go to

the WHAIP website www.wales.nhs.uk/WHAIP for all the improvement tools listed within

this document.

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Appendix A – Frequently Asked Questions

Q. Who should carry out the audits and collection of data?

A. Ownership of the data should be the responsibility of the frontline staff, implementing

improvement is the responsibility of all multidisciplinary staff. If the work is carried out by

a single person it is very difficult to sustain the work over a long period of time.

Q. Who can help me with analyzing the information and measurement?

Within your organisation there will be individuals who have been trained in improvement

methodologies through the Safer Patient Initiative and the 1000 Lives Campaign. In

addition contact DavidL.Williams@nliah.wales.nhs.uk

Q. Do we need retrospective audits to be carried out for compliance with baseline

measurement of DUP and baseline measurement of key clinical and social

outcomes/access to optimal interventions?

A. The recommendation is for implementation sites to identify first episode cases and

baseline measure their DUP within six months of identification. In addition and where

possible, implementation sites should also seek to baseline measure key clinical/social

outcomes and access to optimal interventions. Both should be reviewed and audited on

at least a 3 monthly basis as part of a PDSA cycle.

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Appendix B – Identifying your resources

Achieving improvements that reduce harm, waste and variation at a whole organisation

level needs a team approach: one person working alone, or groups

of individuals working in an uncoordinated way will not achieve it and this applies

equally at all organisational levels.

Whether your improvement priorities relate to 1000 Lives Plus content areas,

national intelligent targets or other local priorities, you need to consider three

different dimensions in putting your team together:

■ Organisation level leadership.

■ Clinical or technical expertise.

■ Frontline leadership.

There may be one or more individuals on the team working in each dimension,

and one individual may fill more than one role, but each component should be

represented in order to achieve sustainable improvement.

Organisation level leadership

An Executive, or equivalent level Director, should always be given delegated

accountability from the Chief Executive for a specific content area; and all staff

working on the changes should know who this is. This individual needs sufficient

influence and authority to allocate the time and resources necessary for the work

to be undertaken. It is likely that accountability will be further delegated to

Divisions, Clinical Programme Groups or Directorates and this can help to build

ownership and engagement at a more local level. However, it is essential that the

leader has full authority over the areas involved in achieving the improvement

aim. As changes spread more widely, crossing organisational boundaries,

appropriate levels of delegation will need to be reviewed.

When working with frontline teams, it is essential for organisational level

leaders to have an understanding of the improvement methodology and to base

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conversations around the interpretation of improvement data. Reporting of

progress to higher organisational levels should also use a consistent data format

so that the Executive level leader can report to the Board on progress.

Clinical/Technical Expertise

A clinical or technical expert is someone who has a full professional

understanding of the processes in the content area. It is critical to have at

least one such champion on the team who is intimately familiar with the roles,

functions, and operations of the content area.

This person should have a good working relationship with colleagues and with the

frontline leaders, and be interested in driving change in the system. It is important to

look for clinicians or technical professionals who are opinion leaders in the organisation

(individuals sought out for advice who are not afraid to try changes)

Patients can provide expert advice to the improvement team, based on their

experience of the system and the needs and wishes of patients. A patient with an

interest in the improvement of the system can be a useful member of the team.

Additional technical expertise may be provided by an expert on improvement

methodology, who can help the team to determine what to measure, assist in

the design of simple, effective measurement tools, and provide guidance on the

design of tests.

Frontline leadership

Each Health Board in Wales will have some specialist staff capacity who are involved in

developing or providing First Episode/Early Intervention in Psychosis (FEP/EIP)

services in a part of their organisation. Frontline clinical leadership needs to become an

integral unit within your team to lead successful change.

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Frontline leaders will be the critical driving component of the team, assuring

that changes are tested and overseeing data collection. It is important that

this person understands not only the details of the system, but also the various

effects of making changes in the system.

They should have skills in improvement methods. This individual must also work

effectively with the technical experts and system leader. They will be seen as a bridge

between the organisation leadership and the day-to-day work.

Frontline leaders are likely to devote a significant amount of their time to the

improvement work, ensuring accurate and timely data collection for process and

outcome measures related to the frontline team.

Characteristics of a good team member

In selecting team members, you should always consider those who want to work

on the project rather than trying to convince those that do not. Some useful

questions to consider are the following:

■ Is the person respected for their judgment by a range of staff?

■ Do they enjoy a reputation as a team player?

■ What is the person’s area of skill or technical proficiency?

■ Are they an excellent listener?

■ Is this person a good verbal communicator within, and in front, of groups?

■ Is this person a problem-solver?

■ Is this person disappointed with the current system and processes and do they

passionately want to improve things?

■ Is this person creative, innovative, and enthusiastic?

■ Are they excited about change and new technology?

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Appendix C – The Model for Improvement

This whole section is generic

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Appendix D

Driver Diagram for 2010-2012 FEP targets

The following driver diagram includes anticipated service interventions, but does not

specify their delivery in 2010-11, rather their preliminary measurement in 2010-11 in

order to gather baseline data for the establishment of likely 2011-12 improvement

targets.

Content Driver Interventions

To improve clinical

and social/functional

outcomes for people

with first

episode/early

psychosis.

To reduce duration

of untreated

psychosis (DUP) to

3 months.

1. Development of access to NICE recommended psychosocial interventions for people with FE/EP and their families

2. Timely & appropriate management of FE/EP

3. Increase functioning / social recovery.

Offer CBT for Psychosis to people with first episode or early psychosis– can be started in acute phase including in-patient environments

Timely/regular provision of medical & PSI interventions including

• general health screening,

• review and monitoring of anti-psychotic prescribing

Use of social functioning questionnaire GAF

4. Increased user/carer engagement & satisfaction

Use of service engagement scale

Offer CB family intervention in psychosis where person lives with or is in close contact with their family (NICE Schizophrenia CG 82 2009)

Outreach to primary care, social services, children’s services, colleges, job centre, CAMHS

60% with FEP in meaningful education/employment after 3 years in MH service

Use of standardised Patient/Family Satisfaction scale

Use of quality of life measure MANSA V 2

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Driver 1: Development of access to NICE recommended psychosocial

interventions for people with first episode/early psychosis and their families

Intervention 1: Offer NICE compliant (CG 82 2009) cognitive-behavioural therapy for

psychosis routinely and systematically to all clients with early psychosis.

Intervention 2: Offer NICE compliant (CG 82 2009) cognitive-behavioural family

intervention for psychosis to people with first episode or early psychosis and their family

(with consent)

Driver 2: Timely & appropriate management of FE/EP

Intervention 1:. Timely/regular provision of medical & PSI interventions including:

- General Health Screening

- Review and monitoring of antipsychotic prescribing

Intervention 2: Outreach to primary care, social services, children’s services, colleges,

job centres, CAMHS etc to reduce DUP

Driver 3: Increase functioning/social recovery

Intervention 1: Routine and systematic measurement of social functioning with GAF

Intervention 2: 60% of first episode psychosis/early intervention in psychosis clients to

be in meaningful employment or education after 3 years contact with mental health

services

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Driver 4: Increased user and carer engagement and satisfaction

Intervention 1: Routine and systematic measurement of service engagement via use of

Service Engagement Scale (SES)

Intervention 2: Routine and systematic measurement of family and client satisfaction

Intervention 3: Routine and systematic measurement of clients quality of life via use of

MANSA V2

Appendix E – Glossary of acronyms

AOF - Annual Operating Framework

BNF – British National Formulary – for prescribing

CAMHS - Child and Adolescent Mental Health Service

CBTp - Cognitive-Behavioural Therapy for Psychosis

C-B FIP - Cognitive-Behavioural Family Intervention in Psychosis

CMHT - Community Mental Health Team

CPA – Care Programme Approach

DUP - Duration of untreated psychosis

EIP - Early Intervention in Psychosis

FEP - First Episode Psychosis

GAF – Global Assessment of Functioning

OCT - onset of criteria treatment

MANSA - Manchester Short Assessment of Quality of Life (MANSA).

NICE – National Institute of Clinical Excellence

PANSS - Positive and Negative Syndrome Scale

SES – Service Engagement Scale (a measure of engagement with community mental

health services)

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