The aim of the project was to assess current management and treatment by teams serving both working age and older adults against guideline recommendations. A vignette approach allowed the flexibility to assess the extent to which the stepped approach is being applied. Rather than employ a yes/no compliance to standards methodology, the format asked senior team members to report upon likely service response to clients of varying complexity. This allowed implementation to be targeted in a more efficient manner particularly with regard to training and identifying areas for improvement.
Sheffield Health & Social Care Foundation Trust
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
In common with other mental health guidelines a care pathway approach mapped to levels of severity is recommended for OCD and BDD. The aim of the project was to assess current management and treatment by teams serving both working age and older adults against guideline recommendations. A vignette approach allowed the flexibility to assess the extent to which the stepped approach is being applied by asking senior team members to report upon likely service response to clients of varying complexity. Implementation can then be targeted in a more efficient manner particularly with regard to training and identifying areas for improvement. 1] Identification of the extent to which reported practice matched CG31 guidance 2] Identification of any inconsistency in treatment approaches 3] To develop targeted training to enhance compliance with CG31 guidance
In assessing the extent to which the Trust applied stepped care to OCD & BDD in line with the NICE guidance it was unclear how teams managed referrals for this client group in terms of treatment options. A vignette approach, coupled with audit questions taken from the guidelines was constructed. Each vignette described a client with OCD at differing levels of severity. An additional vignette described a client with BDD. Staff were asked to describe how each client would be dealt with within their team by a series of questions directly related to the guidelines. Data submission was carried out via an online web form incorporating the vignettes. A total of 5 vignettes were used. 4 covered case presentations of OCD of increasing severity. These included a vignette for a client over 65 years of age. The 5th covered a case of BDD. The vignettes were composed by professionals trained in the treatment of these disorders. The web form was distributed to the Team Manager, Clinical Psychologist and Consultant Psychiatrist in each team. Results were summarised proportionately using a standard spreadsheet package.
1] Responses indicate general awareness of the use of a stepped care approach to clinical need for this population, both in terms of treatment setting and intervention type. There was appropriate reported use of self-help and CBT approaches, including ERP. Reports of medication use indicated possible over-use for clients with mild problems, and possible under-use for those suffering severe social impacts. This latter finding should be treated with caution, as the questionnaire did not allow responses indicating both CBT and medication approaches, something that was commented upon by a number of respondents. 2] There was noticeable variation between staff in how each case would be managed within their team. This would indicate that increased consistency of approach within and between teams should be an important goal for the OCD & BDD Specialist Team. 3] The Trust Specialist Team for OCD & BDD will be using the information from the audit in the development of Trust-wide training.
The audit will be repeated following implementation of an Action Plan based upon the findings. This work may be published following a repeat audit to determine effects of the intervention.
1] The use of a vignette-based approach is particularly suited to mental health guidelines where cases often present on a continuum of varying severity and duration. Vignettes can be tailored to reflect this. 2] Anecdotally, clinical vignettes engage clinical staff and provide a more coherent grounding point from which to answer specific questions. 3] Use of case vignettes has allowed some insight into the extent that teams within the Trust are implementing NICE guidance for this client group. The limitations of forced choice questions, particularly for the more complex case vignettes were commented upon by a number of respondents and represent a weakness of the method 4] Combining guideline questions with vignettes in order to obtain details of both practice and consistency is a useful approach to auditing NICE guidelines.
Tom Ricketts/Brian Hockley
Nurse Consultant/NICE Implementation Manager
Sheffield Health & Social Care Foundation Trust
Is the example industry-sponsored in any way?