Citation: Ministry of Health. 2014. Quality Standards for Diabetes Care Toolkit. Wellington: Ministry of Health.
Published in November 2014
by the Ministry of Health
PO Box 5013, Wellington 6145, New Zealand
ISBN 978 0 478 42873-5 (online)
This document is available at www.health.govt.nz
This work is licensed under the Creative Commons Attribution 4.0 International licence. In essence, you are free to: share ie, copy and redistribute the material in any medium or format; adapt ie, remix, transform and build upon the material. You must give appropriate credit, provide a link to the licence and indicate if changes were made.
Tui Hancock, Nurse Practitioner Whānau Ora, Central Primary Health Organisation
Kate Smallman, Diabetes Nurse Specialist, Diabetes Project Trust and East Tamaki General Practice
Shelley Mitchell, Diabetes Specialist Dietitian and Chair Diabetes Special Interest Group of Dietitians New Zealand
Dr Jeremy Krebs, Endocrinologist and Clinical Leader of Endocrinology and Diabetes at Capital and Coast District Health Board and President of the New Zealand Society for the Study of Diabetes
Dr Brandon Orr-Walker, Endocrinologist, Clinical Head of Endocrinology, Middlemore Hospital, South Auckland
Dr Helen Rodenburg, General Practitioner and Clinical Director CVD Diabetes Long Term Conditions Ministry of Health
Sam Kemp-Milham, Programme Manager CVD Diabetes Long Term Conditions, Ministry of Health.
The Quality Standards for Diabetes Care in New Zealand have drawn on the Quality Statements issued by the National Institute for Health and Care Excellence (NICE). Where relevant, the NICE statements and assessment criteria have been utilised to inform the content of the information contained in this toolkit.
For further information, please contact:
CVD Diabetes Long Term Conditions
Ministry of Health
Copyright: Ministry of Health 2014
This toolkit is subject to change as knowledge of diabetes care evolves and new information becomes available. Feedback is welcome on what could be added, changed or removed. This toolkit will be reviewed and updated by section 2016–2017.
Quality standards for diabetes care 6
Introduction to the toolkit 8
Rationale for the toolkit 8
Who is this toolkit for and how will it help you? 9
Toolkit structure 10
Underpinning frameworks 11
Integrated Performance and Incentive Framework 11
Implementation advice 12
Equality and diversity considerations applicable to all Standards 12
Specific relevance to Māori and Pacific people 12
Workforce implications 14
Basic care, self-management and education 18
Standard 1 20
Standard 2 32
Standard 3 42
Standard 4 54
Management of glycaemia and cardiovascular risk for people with diabetes 65
Figure 1: Steps to success in self-management education 26
Figure 2: Approach to management of hyperglycaemia 46
Quality standards for diabetes care
These standards should be considered when planning your local service delivery. They provide guidance for clinical quality service planning and implementation of equitable and comprehensive patient-centred care – scaled to local diabetes prevalence. They should be read alongside the NZ Guidelines Group (NZGG) and other guidelines which highlight specific clinical expectations. These standards are specific to people with diabetes – those identified with pre-diabetes should be managed in accordance with the specific advice provided by the Ministry of Health (2013a).
The Standards are arranged into five topic groupings:
Basic care, self-management and education
1. People with diabetes should receive high quality structured self-management education that is tailored to their individual and cultural needs. They and their families/whānau should be informed of, and provided with, support services and resources that are appropriate and locally available.
2. People with diabetes should receive personalised advice on nutrition and physical activity, together with smoking cessation advice and support if required.
3. People with diabetes should be offered, as a minimum, an annual assessment for the risk and presence of diabetes-related complications and for cardiovascular risk. They should participate in making their own care plans, and set agreed and documented goals/targets with their health care team.
4. People with diabetes should be assessed for the presence of psychological problems with expert help provided if required.
Management of glycaemia and cardiovascular risk for people with diabetes
1. People with diabetes should agree with their health care professionals to start, review and stop medication as appropriate to manage their cardiovascular risk, blood glucose and other health issues. They should have access to glucose monitoring devices appropriate to their needs.
2. People with diabetes should be offered blood pressure, blood lipid and anti-platelet therapy to lower cardiovascular risk when required in accordance with current recommendations.
3. When insulin is required it should be initiated by trained health care professionals within a structured programme that, whenever possible, includes education in dose titration for the person with diabetes.
4. People with diabetes who do not achieve their agreed targets should have access to appropriate (and timely) expert help.
Management of diabetes complications
1. All people with diabetes should have access to regular retinal photography or an eye examination, with subsequent specialist treatment if necessary.
2. All people with diabetes should have regular checks of renal function (eGFR) and albuminuria or proteinuria (ACR or PCR) with appropriate management and/or referral if abnormal.
3. People with diabetes should be assessed for the risk of foot ulceration and, if required, receive regular review. Those with active foot problems should be referred to and treated by a multidisciplinary foot care team within recommended timeframes.
4. People with diabetes with serious or progressive complications should have timely access to expert/specialist help.
While in hospital
1. People with diabetes admitted to hospital for any reason should be cared for by appropriately trained staff, and provided access to an expert diabetes team when necessary. They should be given the choice of self-monitoring and encouraged to manage their own insulin whenever clinically appropriate.
2. People with diabetes admitted as a result of uncontrolled diabetes or with diabetic ketoacidosis should receive educational support before discharge and follow-up arranged by their GP and/or a specialist diabetes team.
3. People with diabetes who have experienced severe hypoglycaemia requiring emergency department attendance or admission should be actively followed up and managed to reduce the risk of recurrence and readmission.
1. Young people with diabetes should have access to an experienced multidisciplinary team including developmental expertise, youth health, health psychology and dietetics.
2. All patients with type 1 diabetes should have access to an experienced multidisciplinary team, including expertise in insulin pumps and continuous glucose monitoring systems when required.
3. Vulnerable patients, including those in residential facilities and those with mental health or cognitive problems, should have access to all aspects of care, tailored to their individual needs.
4. Those with uncommon causes of diabetes (eg, cystic fibrosis, monogenic, post-pancreatectomy) should have access to specialist expertise with experience in these conditions.
5. Pregnant women with established diabetes and those developing gestational diabetes mellitus (GDM) should have access to prompt expert advice and management, with follow-up after pregnancy. Those with diabetes of child-bearing age should be advised of optimal planning of pregnancy including the benefits of pre-conception glycaemic control. Those not wishing for a pregnancy should be offered appropriate contraceptive advice as required.