Introduction to TAPPPS...

The development of the 'Team Approach to Positive Practice in Psychosis Standards' (TAPPPS) is in response to the well-reported and documented evidence that the transfer of knowledge and skills from educational and training courses is dependant on a number of critical organisational factors, many of which operate at the team level within organisations. The tool has been developed for use as part of a peer review process for individual, team and organisational development in support of positive practice for psychosis care. The practice standards are broken into eleven sections, each with their own indicators and supported by a values and evidence based approach.

The eleven standards are:

The standards may be used individually or together to form a comprehensive approach to local benchmarking. The rationale behind the adoption of a peer-based approach is to promote local ownership of positive practice approaches to psychosis care at the team level, so that individual team members already trained or about to be trained in Psychosocial Interventions (PSI) will have maximum support in the successful transfer of their new knowledge and skills by their colleagues and peers.

Evidence suggests that trainees returning to work in teams and services whose local systems do not change or modify existing mental health practice to support newer evidence based approaches quickly lose their enthusiasm and confidence for the new approaches. They may stop using the new approaches altogether, or else leave the team to another that they perceive as more ready and willing to support them.

One of the central aims of mental health policy initiatives was to ensure that 'what matters is that staff are trained, organised and managed properly to ensure that the effective interventions are delivered where they are most needed and where they can have most impact' (Department of Health, 1998: pp46 - 47). The TAPPPS has been developed by a group of clinicians and educators to support the widespread adoption of evidence based approaches to psychosis so that individuals and families have a much greater chance of recovery. The TAPPPS standards are informed by this evidence base, clinical experience and a willingness to listen to what service users and carers want from mental health services. It is anticipated that the use of the TAPPPS will help teams focus on their local strengths, as well as enable agreement to be reached on a range of further developments to support positive practice.

Guidelines for Peer Assessment

Phase 1: Orientation and agreement of practice area(s)

The Practice Standards may be used as a whole or individually for specific areas of practice. The more you choose to review the longer the time required. Obviously, it would be useful to review the full spectrum of interventions at least annually, and this may be done as part of a whole team away day or broken down across several meetings.

The TAPPPS can be used for self-assessment but, where possible, a peer review approach is recommended. The peer reviewers and the team being reviewed should agree one or more areas of practice for the peer assessment. Identify and share strengths and concerns around the chosen area(s) of practice from the initial analysis of information received and from other organisational performance assessments (such as local audits). The purpose of this is to orientate the peer assessors to the area of practice and familiarise them with local history and context.

Phase 2: Establish comparison group

Establish a comparison group. Examples of comparison groups are;

Practitioners within the team.
Different teams providing a similar service (i.e. C.M.H.T. compares with C.M.H.T.)
Different directorates.
Different Trusts
Across Region
Nation-wide Specialist Services.

Phase 3: Conduct Peer Review

The purpose of the peer assessment is to identify areas for improvement in relation to the range and quality of psychosocial interventions available in practice, thus improving the quality of service provision available to service users and carers. Peer reviewers would normally be individuals with background expertise and knowledge in psychosocial approaches to care of individuals experiencing psychosis and will be designated as suitably competent for this role by their organisation

Peer assessors should be sensitive to the local history and context of the team. The peer review may take the form of a discussion in an interview format with an individual(s) or a whole team. The tone of the meeting should be collaborative and enquiry based with a focus on strengths as well as areas that require improvement. The interview would normally take the following format:

1. Consider for each standard which indicators they already practice from those listed. Once identified consider the evidence that supports positive practice in this area. Evidence should be collated in the three categories of:

Service user and carer narratives collated through audit, interviews or focus groups.
Structures and governance needed to deliver the process, e.g. policies, procedures, education and development, information, communication.
Care delivery of the process; e.g. case notes, care plans, interviews, and surveys/questionnaires.
Reflect on the standard of local evidence gathered and whether there are opportunities to

3. Reflect on the standard of local evidence gathered and whether there are opportunities to improve/refine the type of evidence. For example, there may be lots of anecdotal evidence about what your team does but this is not routinely gathered.

4. For each criterion also consider whether this is practiced routinely across the team or whether it is located in the practice of the minority of team members.

n.b.Guidance on the use of patient information to improve services is given in Confidentiality - NHS Code of Practice (Department of Health, 2003

Phase 4: Agree Ratings and Provide Feedback

The criteria contained within the standards are rated according to whether there is evidence that is happens, and whether it happens across the whole team. There is obviously an element of subjectivity involved in this process. Peer reviewers rate the bench mark guided by the justification of evidence in phase 3 and state why the score was chosen.

There will be an electronic version of TAPPPS available and this will have an automatically generated 'behind the scenes' software to aid data crunching. This enables the automatic and standardised analysis of return data to a standardised formula and the subsequent overall rating of A through to D for each standard.

Over time this will facilitate comparisons of team effectiveness, which when matched with other organisational variables (resource availability, case load size, access to training and supervision, leadership, client need) should provide useful information for best determining the best team composition and process to meet local service user needs.

In instances where the standards are being rated manually use the following formula to determine the overall rating for each one:-

For a rating of A - More than 80% of the criteria have been rated as B and above
For a rating of B - Between 60 - 80% of the criteria have been rated as B with some C's and not more than one D
For a rating of C - Between 40 - 60% of the criteria have been rated as B, with majority C's and some D's
For a rating of D - Less than 40% rated as B's with mostly C's and D's being rated

Feed back to the team should be constructive and developmental and should provide the team with an indication of its strengths in addition to areas that require development. All teams will differ in the level and robustness of their practice development. The approach being suggested is one that recognises current strengths within the team, yet also strives to raise standards in all areas through a collective process of individual, team and organisational development.

Phase 5: Develop Local Action Plans

Each team considers their own assessment profile and identifies factors where development effort will be focused. The team compiles an action plan to support improvements and agree a date for further peer review. This activity will be strengthened where it is linked into the care governance activity in the host organisation (i.e. Trust) to ensure organisational development and change.

The members with stronger profiles may wish to present and share their own practice. Those with less positive profiles use comments and examples of other teams to help them compile action plans to improve local practice

Phase 6: Implementation and Evaluation

Many approaches to change suggest that detailed and thorough plans are drawn up. Whilst recognising that for 'higher order' change this may be necessary, we are encouraging teams to identify small and achievable steps that will lead to positive outcomes for service users, carers and individual team members. Some of the changes may require outside facilitation (i.e. training or education) or there may be opportunities for additional input from within the organisation or from practice development networks.

A wide variety of change processes may be experimented with such as Action Research, Learning Sets or Plan Do Study Act (PDSA) cycles. What is similar to each of these approaches is that individuals and teams are able to learn from their approaches to change improvements and amend according to the experience of it, and outcomes from it.

Phase 7: Sharing Positive Practice

Wherever possible, attempts should be made to share positive practice and improvements. Dissemination may take a variety of forms such as:

In house presentations.
Newsletters
Publications
Conferences
Web site (e.g. www.nimhenorthwest.org.uk )
Royal Colleges
Local NIMHE NW DC networks

The action plans do not have to be named and identifiable. They may serve as local histories of a team's attempts to improve its own practice and in themselves illustrate strategies that worked and those that were least successful. They may form the basis of team level development plans and the action required to secure effective development activity across different levels.

Alternatively, the action plans may be a useful aide to securing additional resources for enhancing positive practice in psychosis, and for maintaining a focus on the need for optimism and hope that individual's with psychosis and their carers have a right to expect.

NIMHE NW DC supports several specialist practice networks (such as Crisis and Assertive Outreach) and there may be opportunities for teams within such networks to review each other across these networks. As the application of new evidence based approaches increases over time, the standards may be subject to modification in light of new evidence.

Click the links below to view the Standards and Documentation for TAPPPS