Borderline personality disorder (bpd) audit support

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.


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.



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.



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


http://guidance.nice.org.uk/CG78/PublicInfo/pdf/English

http://guidance.nice.org.uk/CG78

http://guidance.nice.org.uk/CG78/PublicInfo/pdf/English

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


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


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


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?


No.Data item no.


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?


No.Data item no.


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)


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


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?


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 [email protected]

and quote N1765 (quick reference guide) and/or N1766 (‘Understanding NICE

guidance’).


mailto:[email protected]

http://www.nice.org.uk/usingguidance/implementationtools/auditadvice/audit_advice.jsp

Borderline personality disorder (bpd) audit support

Health & Medicine

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