National Standards for Diabetes Patient Education and American Diabetes Association Review Criteria

NEEDS ASSESSMENT—A successful program is the product of a flexible policy based on the needs of the community it is intended to serve. Because the diabetes caseload varies from one institution to another, each institution should assess its own needs and match its resources to the needs of its caseload. The needs assessment should be performed initially to guide the management of the program and to form the basis for program planning. It should be a continuing process that will allow the program to adapt to changing service requirements. In addition to the needs of the program, the needs of the individual patient should be assessed to provide the basis for the instructional program offered to each patient. The person with diabetes is recognized to be an equal partner in all aspects of the educational process.

FACILITY Standard 1. The facility shall assess its diabetes caseload to determine the allocation of personnel and resources to serve the instructional needs of the caseload.

Review criterion
1. The applicant annually determines the case mix of diabetes patients to be educated.
Standard 2. There shall be a reasonable match between caseload requirements and resources allocated.

Review criteria
2. For lectures, resources are provided to support the appropriate caseload.
3. Demonstration class size is limited to 16 people (including patient and family members) per instructor.
4. Return demonstration session is limited to 4 people per instructor.

PROGRAM
Standard 1. An individualized and documented ongoing assessment of needs shall be developed with the patient's participation. This shall include medical history, present health status, previous diabetes education, health services utilization, associated medical conditions or risk factors, diabetes knowledge, skills, attitudes, self-assessment, identification of support system, barriers to learning, and financial status.

Review criteria
5. On enrollment of each patient into the program, a needs assess-REPRINTED FROM DIABETES CARE 9:XXXV1-XL, 1986.
COPYRIGHT 1986 BY THE AMERICAN DIABETES ASSOCIATION. ment is conducted that includes the items specified above.
6. Each patient's needs assessment is a permanent part of his/her written education record or is included in the medical record.
Standard 2. The needs assessment shall be the basis for the education program delivered to each patient.

7.
A written individualized education plan based on the needs assessment is developed. The person with diabetes is a participant in this process, and the written plan is shared with him/her before instruction.
PLANNING-Planning is an essential component of a diabetes patient education program. The planning process should describe the program's goals and objectives, target audience, setting (inpatient, outpatient), patient-referral mechanisms, procedures, and evaluation methods. This process should be a cooperative effort involving people with diabetes and health professionals.

FACILITY
Standard. The facility shall have a written policy that affirms patient education as an integral component of quality diabetes care.

Review criterion
8. The applicant has a written statement concerning diabetes patient education that is consistent with the goals and intentions of the standards.

PROGRAM
Standard 1. The planning participants shall include health professionals involved in the care and education of people with diabetes and their families.

Review criterion
9. An advisory committee is formed to oversee the diabetes patient education program. Members of the committee must include at least one physician, nurse (or qualified diabetes health educator), dietitian, and consumer.
Standard 2. The planning process shall define, in the following order, program goals and objectives, target audience, patient access mechanisms, instructional methods, resource requirements, patient follow-up mechanisms, and evaluation.

Program goals and objectives:
The applicant provides goals and measurable objectives of the diabetes patient education program. These should be consistent with the goals and intentions of the standards.
11. Target audience: The applicant specifies the age range of the patients, the types of diabetes patients the program serves, or any unique characteristic of the patients (e.g., language barriers, learning disabilities).
12. Patient access mechanisms: The applicant defines how a patient gains access to the patient education program. Methods of access include health-care professional referral, health-care agency referral, or patient selfreferral.
13. Instructional methods: The applicant identifies the instructional format (i.e., one-to-one, classroom, group, self-instruction modules, etc., or any combination of these) for each of the curricular areas.
14. Resource requirements: The applicant identifies the space, staff-ing, budget, and instructional materials that are part of the patient education program.
15. Patient follow-up mechanisms: The applicant identifies its patient follow-up methods.
16. Evaluation: The applicant identifies the program evaluation mechanisms.

PROGRAM MANAGEMENT -
Effective management is required to implement a patient education program successfully. Various health-care professionals are involved in the total care of people with diabetes. Clear lines of authority and efficient systems for communication should be established among everyone involved in the program. The ultimate responsibility for all aspects of program management should rest with one person designated the program coordinator. In addition, an advisory committee should be established to assist the coordinator and other members of the program staff in setting policy and managing the program.

FACILITY
Standard 1. The facility shall designate a coordinator responsible for all aspects of the program.

Review criteria
17. It is desirable that the coordinator be a health-care professional who holds either a valid license or registration. In addition, certification or a health-related degree from an accredited educational institution is desirable.
18. The coordinator completes an education program (minimum 24 h) that includes instruction in the 15 content areas listed under the CONTENT/CURRICULUM program standard as well as in educational principles.
19. The coordinator annually completes a minimum of 6 h of continuing education in diabetes and educational principles.
19a. If the program coordinator is not a health-care professional, he/she must complete a basic 24-h education program (as above), maintain 6 annual continuing education hours (as above), and not function as a program instructor.
20. The coordinator is responsible for a. liaison between the advisory committee and facility administration b. planning and participating in orientation of diabetes patient education personnel c. providing and/or coordinating in-service education for diabetes patient education personnel d. participating in the preparation of the program budget e. evaluating program content and effectiveness f. coordinating program curriculum.
Standard 2. The organizational relationships, lines of authority, staffing, and operational policies shall be defined.

Review criteria
21. The placement of the diabetes patient program within the organizational structure of the institution is denned.
22. The line of authority of the program coordinator is denned.
23. The approval mechanisms for both policy and program changes within the facility are defined.

Standard.
A standing advisory committee with both medical and community/ consumer representation shall be established.

Review criteria
24. The advisory committee's responsibility is to recommend policy, review curriculum, and provide advice concerning the diabetes patient education program.
25. Advisory committee members attend at least 2 meetings a year.
COMMUNICATION/ COORDINATION-Several levels of communication are essential to the effective coordination of the program. Physician or nurse educator leadership and participation are necessary to ensure the integration of patient education into the treatment regimen. A physician should be identified to serve as liaison between the education program coordinator and the medical staff. In addition, the institution should maintain regular channels of communication with its staff and the community it serves to inform diabetes patients and their families about the availability of the program. All information on the patient's educational experience should be incorporated into the permanent medical or educational record.

FACILITY
Standard 1. The facility shall select a physician to serve as liaison between the program coordinator and the medical staff.

Review criterion
26. The physician's liaison activities includep a. attendance at advisory committee meetings b. communication of new developments and activities of the program to medical staff, administration, and the medical community c. communication of input from medical staff, administration, or the medical community to the program coordinator and advisory committee.
Standard 2. The facility shall regularly inform its staff and the diabetes patients (and potential diabetes patients) it serves of the availability of its diabetes patient education program.

Review criteria
27. The applicant informs its staff twice yearly of the availability of the program, its content, and the referral process.
28. Newly employed health-care professionals are informed of the institution's diabetes patient education program during orientation.
29. The applicant identifies a communication system that informs the target population of available patient education services. For inpatient programs, the target audience is all patients with diagnosed diabetes at the time of admission. For outpatient programs, the target audience is the general public, physicians, and referral agencies in the service area.

PROGRAM
Standard 1. All information about the patient's educational experience shall be incorporated into the patient's permanent medical or educational record maintained by the institution.

Review criteria
30. The program establishes a diabetes education record that documents the educational experience and becomes a part of the patient's permanent medical or educational record.
31. The documentation of the educational experience includes a. preprogram assessment b. patient education plan c. content, dates delivered, instructors identified d. postprogram assessment e. plan for follow-up.
Standard 2. The role of each education team member shall be clearly defined, and the intercommunication between each shall be documented in the patient's record.

Review criteria
32. Members of the diabetes patient education staff have written job descriptions that state their responsibilities for patient care and patient instruction.
33. Education team members use the patient's permanent record to communicate about the patient's diabetes education.
Standard 3. There shall be written evidence of coordination between different care settings.

Review criterion
34. On completion of the education program, and with the patient's permission, the patient's permanent medical or educational record is made available to other health-care settings. On request, a copy of the educational record is also given to the patient.

PATIENT ACCESS TO
TEACHING -It should be the policy of the institution to facilitate access to patient education for the target audience specified in the plan. This is promoted by a commitment to inform patients and staff routinely about the availability and benefits of patient self-care programs. Diabetes patient education should be regularly and conveniently accessible, and the instructional program should be able to respond to patient-initiated requests for information. The program permits referral by health-care professionals, health-care agencies, or individual patients. The instructional design encourages active patient participation.

FACILITY
Standard. The facility shall have a policy to inform patients routinely about the benefits and availability of patient education.

See criterion 29.
PROGRAM Standard 1. The program shall be regularly and conveniently available.

Review criteria
36. For health-care institutions, individualized education services at diagnosis or times of crisis are available.
37. Diabetes patient education programs are offered at least quarterly or as the caseload warrants.
Standard 2. The program shall be responsive to patient-initiated requests for information and/or participation in the program's activities.

Review criterion
38. A person is designated within the program to be responsible for receiving and answering patient-initiated requests during business hours.
CONTENT/CURRICULUM-The individual needs assessment provides the basis for the instructional program offered to each patient. The assessment should be documented and should include all relevant information regarding the patient's treatment, education, and support systems. Responsibility for vari-ous facets of the assessment can be divided among the instructional team members. Curriculum and instructional materials should be appropriate for the specified target audience, taking into consideration the type and duration of diabetes and the age and learning ability of the individual. Both curriculum and available community resources should be reviewed and updated periodically. The institution should provide the program with adequate space, personnel, budget, and materials.

FACILITY
Standard 1. The facility shall provide space, personnel, budget, and instructional materials adequate for the program.

Review criterion
39. Space, personnel, budget, and instructional materials are available in the institution to support each content item identified in the CONTENT/CURRICULUM program.

Standard 2.
The facility shall periodically assess the availability of community resources.

Review criterion
40. The applicant, at least once every 3 yr, assesses public, private, and nonprofit health agencies within the service area for their potential contribution toward improving diabetes education. This assessment includes the name, address, and telephone number of each identified resource.

Each program content area has
written and measurable behavioral objectives, a content outline, a designated instructional method, instructional materials, and a means of evaluating the achievement of objectives.
Standard 2. The applicant shall specify the mechanism by which the curriculum shall be reviewed, approved, and updated.

Review criterion
42. The curriculum is annually reviewed and approved by the advisory committee and modified accordingly.
INSTRUCTOR-Qualified personnel are essential to the success of a diabetes patient education program. Each institution should be responsible for identifying and evaluating its instructors. Instructors should be skilled professionals with recent experience and training in both diabetes and educational principles. The number of instructors should be proportional to the caseload requirements.

FACILITY
Standard 1. The facility shall identify appropriate instructional personnel and ascertain their competence.
43. Instructors are health-care professionals who hold either a valid license or registration. In addition, certification or a health-related degree from an accredited educational institution is desirable.
44. Primary instructional personnel must complete a diabetes education program (minimum of 24 h) that includes educational principles.
Standard 2. The number of personnel identified shall be suitable for the diabetic caseload within the institution.

Review criterion
45. Appropriate resources are provided to support the case mix. See criteria 2-4.
Standard 3. Instructors shall be allotted sufficient time to accomplish the educational objectives.

Review criterion
46. The number and type of instructors are appropriate to the case mix, with adequate time for teaching provided. The teaching process must include program planning, implementation and instruction, documentation of the patient educational experience, and participation in program development and evaluation.

Standard.
A comprehensive diabetes patient education program has instructors skilled in teaching the curriculum of the program.
48. Instructors annually complete a minimum of 6 h of continuing education in diabetes and educational principles.
FOLLOW-UP-Follow-up services are important because diabetes requires a lifetime of proper care. The facility should provide follow-up services that include periodic reassessment of the patient's knowledge and skills and offer supplementary educational services when warranted. Written communication between the program staff and the primary-care physician is essential for ongoing identification of the patient's needs. This is especially appropriate in regard to referral for early diagnosis and treatment of the complications of diabetes. Referral to community resources may also provide ongoing support for longterm psychosocial needs and behaviormodification skills. If a patient changes care settings, the institution should request the patient's permission to send his/her records to the new setting.

Standard.
The facility shall transmit the educational record to other appropriate health-care settings when a patient transfers his/her care responsibilities.

PROGRAM
Standard. The program shall provide follow-up services for patients who want to maintain continuity of education within the institution. These services shall include a. periodic reassessment of knowledge and skills b. timely reeducation based on reassessment c. communication with the primarycare provider about the need for professional and nonprofessional services.

50.
The applicant informs and encourages the patient to utilize education follow-up services.
51. Patients who return for follow-up receive knowledge and skill reassessment.
52. Follow-up services/education needs are communicated to the primary-care provider.
EVALUATION-The facility should review the educational program periodically to ascertain that it continues to meet the national standards. This review should be conducted by the advisory committee. The results of this review should be used in subsequent program planning and modification. An assessment of each patient's needs and progress should also be conducted at regular intervals.

Standard.
The applicant shall periodically review the performance of the instructional program and ascertain that it continues to meet national standards.

Review criterion
53. The advisory committee and appropriate institutional officials conduct and record a yearly internal review of the program.

PROGRAM
Standard 1. The program shall conduct and record an individualized assessment of each patient's original needs and progress at regular intervals.
Standard 2. The program shall be reviewed continually for both process and outcome, and the results of this evaluation shall be used in subsequent planning and program modification. DOCUMENTATION-Program planning and evaluation should be documented to provide the basis for future program development and modification. All information about the patient's educational experience should be documented in the patient's permanent medical or educational record, as should communication among treatment and education professionals.

FACILITY
Standard. All aspects of the evaluation program shall be recorded by the facility and reviewed periodically to ascer-tain that national standards are being maintained.

PROGRAM
Standard. All aspects of the educational program offered to each patient shall be recorded in that patient's permanent medical or educational record as maintained by the facility.