Ensuring corporate quality assurance

Commissioners should ensure that the services they commission represent value for money and offer the best possible outcomes for patients. Commissioners need to set clear specifications for monitoring and assuring quality in the service contract.

Commissioners should ensure that they consider both the clinical and economic viability of the service, and any related services, and take into account patients' and carers views and those of other stakeholders when making commissioning decisions.

A patient education programme for people with type 2 diabetes needs to:

• be evidence-based, written and have a structured curriculum with supporting materials
• be effective and efficient
• be patient-centred, responsive to the needs of patients and carers, and provide equitable access, ensuring that patients are treated with dignity and respect, are fully informed about their care and are able to make decisions about their care in partnership with healthcare professionals
• provide treatment and care based on best practice, as defined in NICE clinical guideline CG66 on type 2 diabetes (update)
• deliver the required capacity
• be integrated with other elements and services for people with type 2 diabetes
• be delivered by trained and competent staff
• define agreed criteria for referral, local protocols and the care pathway for people with type 2 diabetes
• monitor the number of patients offered a patient education programme in diabetes, and the number who have received and declined patient education
• audit service availability to ensure adequate provision in all groups, including those less well-reached by existing services
• audit patient outcomes following education to provide an evidence base for suture service commissioning
• be quality assured
• demonstrate how it meets requirements under equalities legislation
• demonstrate value for money
• meet all of this for each model of delivery.

Local quality assurance

Any mechanisms for quality assurance at a local level are likely to refer to the following.

• Patient and clinical outcomes: improved patient knowledge and the skills and confidence to self-manage, achieved as a result of the programme; changes, or levels of achievement, in surrogate biomedical disease markers such as weight, activity levels, blood pressure, cholesterol, haemoglobin A1c, smoking, incidence of the complications of type 2 diabetes, associated hospital admissions and healthcare service use, including uptake of monitoring and screening (for example retinal and foot screening); psychosocial changes in quality of life; levels of depression; proportions of people with goals and proportions meeting goals agreed in management plans; achievement of individual learning objectives set on the patient education programme; and concordance with medication and treatments.
• Quality assurance, of both the programme itself and the educators delivering it, using review by trained, competent, independent assessors acceptable to the commissioner, who assess it against key criteria (including environment, structure, process, content, use of materials, whether the programme has actually been delivered, and evaluation and outcome information) to ensure sustained consistency.
• Service and performance targets, including estimated activity levels and access by different patient groups, waiting times (ensuring that patients and carers do not experience unnecessary delays), complaints procedures, year-on-year improvement in reaching the people needing access, referral data, reasons why a service is declined or not offered, programme completion rates and levels of non-attendance.
• Clinical governance arrangements, including incident reporting.
• Clinical quality criteria: appropriateness of referral, consenting procedures, clinical protocols.
• Audit arrangements: frequency of reporting, reporting route and format, and dissemination mechanisms; arrangements should include auditing the proportion of eligible people with type 2 diabetes who are provided with education, and looking at various outcomes before and after the programme. For further information see audit support (clinical) and audit support (organisational) for NICE clinical guideline CG66 on type 2 diabetes (update).
• Demonstration that the curriculum is in place, is evidence-based, meets the published requirements and is based on a proven approach.
• Staff competencies: demonstration of individual and team baseline requirements, monitoring and performance, especially in educational skills and the continuing professional development of the educators in this role.
• Health, safety and security: infection control, waste management, confidentiality procedures, legislative requirements.
• Equipment: selection, testing and calibration, especially for point-of-care equipment.
• Accreditation requirements: for some or all elements of the service, the premises and staff.
• Patient satisfaction: patient and carer perspective and perception of service provision, complaints.
• Information requirements, including both patient-specific information (NHS number, referring GP) and service‑specific information (waiting times, workload trends, number of complaints).
• The process for reviewing the service with stakeholders, including decisions on changes necessary to improve or to decommission the service.
• Achieving targets associated with equalities legislation.

Further information

General informationon quality and corporate assurance can be obtained from the following sources:

• The National Patient Safety Agency (NPSA) oversees the implementation of a system to report and learn from adverse events and near misses occurring in the NHS. The publication ‘Seven steps to patient safety' provides an overview of patient safety and gives updates on the tools that the NPSA is developing to support patient safety across the health service.
• NHS Alliance online resources. NHS Alliance is the representational organisation of primary care and primary care trusts, and provides them with an opportunity to network and exchange best practice. The alliance supports its members with an open-access helpline, in-house and joint publications and briefings, internal newsletters and a website.
• The DH commissioning framework provides guidance on the commissioning process in the context of the NHS reform agenda.
• NHS Institute for Innovation and Improvement support for commissioners, includes Commissioning for Health Improvement products to accelerate the achievement of world class commissioning; The Productive Leader programme to enable leadership teams to reduce waste and variation in personal work processes, and Better care, better value indicators to help inform planning, to inform views on the scale of potential efficiency savings in different aspects of care, and to generate ideas on how to achieve these savings.
• 10 Steps to your SES: a guide to developing a single equality scheme. This guidance has been developed to assist NHS organisations that have a duty, as public authorities, to comply with the race, disability and gender public sector duties, and in anticipation of new duties in relation to age, religion and belief, and sexual orientation.

Specific information on quality and corporate assurance for a patient education programme for people with type 2 diabetes can be obtained from the following sources:

• Better metrics is a pragmatic project that provides clinically relevant measures of performance to support the development of measurable local targets and indicators for local quality improvement projects. See metrics for diabetes (notably 4.03 patient experience and engagement, 4.09 patient education and empowerment, 4.10 staff education and 4.12 annual review/care planning)
• The Quality and outcomes framework (QOF) was designed to deliver substantial financial rewards for high-quality care. The framework sets out a range of national standards based on the best available research evidence.
• Skills for health works with employers and other stakeholders to ensure that those working in the sector are equipped with the right skills to support the development and delivery of healthcare services. See details of the diabetes, learning and development, and patient education competence frameworks.
• NICE public health guidance of relevance to this topic includes: PH1 on interventions for smoking cessation; PH2 on increasing physical activity; PH6 on behaviour change; PH8 on encouraging physical activity; PH10 on smoking cessation services and CG43 on obesity. The audit criteria detailed for each of these may be useful to include in quality assuring these aspects of the structured education.
• The Department of Health and Diabetes UK Patient Education Working Group report sets out the requirements for developing a high-quality patient education programme.
• How to assess structured diabetes education: an improvement toolkit for commissioners and local diabetes communities is a resource to help local service providers to assess and improve their programmes and to enable diabetes educators to reflect on their current practice and enhance their skills.
• The Diabetes commissioning toolkit describes how to carry out a health needs assessment for a local diabetes population and provides a generic specification for diabetes care, signposting recognised quality markers and suggesting key outcomes for the service.
• Diabetes UK provides a range of resources, education and share examples of current practice.
• DESMOND is a collaborative group working together to improve opportunities for learning and support for people newly diagnosed with diabetes and the healthcare professionals involved with them.
• The X-PERT programme also provides a structured approach to patient education in diabetes aimed at people with established diabetes.
• The Warwick Diabetes Manual is aimed at people with a new diagnosis of type 2 diabetes, to improve their self-management. It can be delivered by healthcare professionals from primary or secondary care who are experienced in diabetes management.
• The Diabetes Education Network provides resources to help diabetes teams across the UK provide high quality self-management education for their patients.