© IDF (Europe) 1998

1 Framework of diabetes care
2 The diabetes consultation
3 Organization of clinical monitoring
4 Monitoring quality of care

TYPE 1 DIABETES - 1 - DELIVERY OF CARE

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1 FRAMEWORK OF DIABETES CARE

1.1 A framework for quality diabetes care

Ensure provision of the following :

• A diabetes team ( professionals ) with up-to-date skills

doctors
educators ( diabetes nurse specialists )
nutritionists ( dieticians )
podiatrists ( chiropodists )

• Structure

easy access for people with diabetes
protocols for diabetes care
facilities for education ( Patient education )
information for people with diabetes
structured records
recall system for Annual Review / eye surveillance
database / software for quality monitoring and development
continuing education for professional staff

• Process

service for regular review
service for Annual Review
education service ( Patient education )
foot care service ( Foot damage )
emergency advice line
joint obstetric / medical pregnancy and pre-pregnancy service
adolescent service
access to related professionals ( heart, renal, eye, vascular specialists )

• Feedback from people with diabetes on service performance

• Regular review of service performance ( Quality monitoring )

( Top of 'Delivery of care' )

TYPE 1 DIABETES - 1 - DELIVERY OF CARE

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TYPE 1 DIABETES - 2 - DIABETES CONSULTATION

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2 THE DIABETES CONSULTATION

2.1 Consultation infrastructure

Make available for consultations the following :

necessary members of the diabetes team
adequate time and adequate space
records and information for the individual with diabetes
means of communication to other health professionals involved in the individual's care

2.2 Consultation process

Include the following in any diabetes consultation :

• Welcome

1. Friendly greeting of the individual and early establishment of rapport

• Problems review

2. Understanding of any recent events disturbing the person's life-style
3. Enquiry after general well-being and identification of new difficulties
4. Review of self-monitored results, and discussion of their meaning
5. Review of dietary behaviours and physical activity
6. Review of diabetes education, skills, and foot care
7. Review of insulin therapy and experience of hypoglycaemia
8. Review of other medical conditions and therapy affecting diabetes
9. Management of arterial risk factors identified at Annual Review
10. Management of complications and other problems identified at Annual Review

• Analysis and planning

11. Summary of, and agreement on, main points covered in consultation
12. Agreement on targets for future months
13. Agreement on, and explanation of, changes in therapy
14. Agreement on interval to next consultation

• Recording

15. Completion of a structured record / patient-held record of the consultation

2.3 Annual Review

Include additionally, at Annual Review, surveillance of the following:

1. Symptoms of ischaemic heart disease, peripheral vascular disease, neuropathy, impotence
2. Feet including footwear, deformity or poor skin condition, ischaemia, ulceration, absent pulses, sensory impairment ( Foot problems )
3. Visual acuity
4. Retinopathy by ophthalmoscopy / retinal photography ( Eye damage )
5. Kidney damage by albumin excretion and serum creatinine ( Kidney damage )
6. Hypertension ( Arterial Risk Factors ) and smoking ( Smoking )
7. Dyslipidaemia ( Arterial Risk Factors )
8. Injection sites
9. Attendance at podiatry / ophthalmology / other if indicated

See Clinical Monitoring protocol below

( Top of 'Diabetes consultation' )

TYPE 1 DIABETES - 2 - DIABETES CONSULTATION

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TYPE 1 DIABETES - 3 - CLINICAL MONITORING

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3 ORGANIZATION OF CLINICAL MONITORING

3.1 Schedule for clinical monitoring at different types of visit

Review topics	Initial review	Regular	Annual
	/ referral	review	Review
Long-term and/or recent diabetes history
Social history / lifestyle review
Diabetes understanding / self-management
Self-monitoring skills / results
Complications history and/or symptoms
Smoking
Other medical history / systems review
Family history diabetes / arterial disease
Drug history / current drugs
Weight / body mass index
General examination
Foot examination / injection sites
Eye / vision examination
Blood pressure
Glycated haemoglobin
Lipid profile*
Urine protein
Urine albumin excretion**
Serum creatinine
*, 3-yearly if normal at previous initial review / Annual Review
**, not required if proteinuria

( Top of 'Clinical Monitoring' )

TYPE 1 DIABETES - 3 - CLINICAL MONITORING

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TYPE 1 DIABETES - 4 - QUALITY MONITORING

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4 MONITORING QUALITY OF CARE

4.1 Protocol for quality development and monitoring of performance

Aggregate	:	the data gathered at Annual Review onto a computerized database
Choose	:	indicators ( see below ) to reflect outcome as well as process of care
Analyse	:	data in line with published recommendations
Compare	:	performance with pre-determined standards or other providers of diabetes care
Review	:	performance at regular meetings of your diabetes team
Discuss	:	the performance of education programmes

4.2 Indicators for quality development and monitoring

	Measure	Calculate
Intermediate outcomes
	HbA1c	Percent >7.5 %Hb
	Albumin excretion	Percent abnormal albumin excretion
	Eye damage	Percent with retinal damage
True	outcomes
	Amputation above ankle	Incidence
	Myocardial infarction	Incidence
	Stroke	Incidence
	Foot ulceration	Incidence
Risk factor control
	Hypertension	Percent >=135/85 mmHg
	Smoking	Percent people still smoking
Process of care
	Eyes screened	Percent people examined in year
	Education performed	Percent people seeing nurse educator in year
	Feet examined	Percent people examined in year
These are examples; many other indicators are possible

( Top of 'Quality Monitoring' )

TYPE 1 DIABETES - 4 - QUALITY MONITORING

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