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Leadership Chapter (LD)

LD.1. Qualified program director effectively manages the diabetes center.

LD.1.1. The center director must be Endocrinologist and has the knowledge and experience and management qualification to provide administrative leadership and clinical guidance to the program.

LD.1.2. The center director has a written job description and his/her qualifications match the requirements in the job description.

LD.1.3. The diabetes center director guides the center in meeting the mission, goals, and objectives.

LD.1.4. The center identifies members of its leadership team.

LD.1.5. The diabetes center defines the accountability of its director.

LD.1.6. The diabetes center director identifies, in writing, the composition of the interdisciplinary team.


LD.2. The Diabetes center director ensures availability of qualified and competent staff for the delivery of reliable timely and safe care.

LD.2.1. The Diabetes center director ensure that the staff have education, qualification consistent with the center scope of service based on the level of care.

LD.2.2. The program director ensures the credentials of required staff to match patient needs. Refer to appendix (1) SNDC standards of services and quality measures in diabetes centers and unit. Table 1.

Specific requirement staffing in tertiary health care

• At least one Endocrinology  

• Health educator specialist /Health coach.

• Clinical dietician specialist / Health coach.

• Nurse

• Ophthalmology technician /Optometrists /Trained Nurse

• Lab technician / Trained Nurse.

• Podiatrist/orthopedics/ Vascular/ General surgery specialty 

• Qualified specialist + Lab technician

• Pharmacist.

• social worker specialist

• Coordinator.

• Accessible medical service (in-hospital referral): Neurology, Nephrology, Cardiology, Retina specialist, Dentist and psychiatry

• Insulin Pump service: Endocrinologist/ diabetologist, Diabetic educator specialist and Clinical dietician specialist.

LD.2.3. The program director assures DC staff have relevant and current licensure. competencies, experience, orientation, training, and education.


LD.3. The Diabetes center steering committee ensure the provision of reliable, timely and safe service.

LD.3.1. The diabetes center director forms and leads a steering committee.

LD.3.2 The steering committee meets periodically at least every 3 months.

LD.3.3. The steering committee integrates all organizational services involved in the management of diabetes patients.

LD.3.4. The steering committee ensures that protocols, clinical practice guidelines, standards are shared as part of diabetes centers network cooperated alliances.

LD.3.5.  The diabetes center steering committee receives, and resolves, patient and non-patient related ethical dilemmas, within identified timeframe.

LD.3.6. Discussions, decisions, and actions taken are documented in a formal meeting minute.

LD.3.7. Diabetes center director summarizes the ongoing discussions to the hospital director.

LD.4. The Diabetes center optimizes patients flow throughout the hospital from the time they arrive until they leave.

LD.4.1. The Diabetes center director works collaboratively with hospital leadership to develop a map addresses all parts of patient's journey. 

LD.4.2. The Diabetes center director selects representatives from relevant clinical services as liaison officers to facilitate diabetic patients' journey.

LD.4.3. The Diabetes center identifies and overcomes all obstacles, in the patients' journey. 

LD.4.4. The Diabetes center matches capacity in line with demand and responds dynamically to changes in demand.

LD.4.5. The Diabetes center director works collaboratively with hospital leadership to reduces waiting time, backlogs, avoidable admissions, length of stay, improves the net response time, as well as the patient planning process for transfer or discharge.

LD.5. The Diabetes center manages the supply chain in a cost-effective manner.

LD.5.1 The center works collaboratively with hospital leadership to effectively manage the supply chain, to achieve timelines and efficiency of inputs, warehousing, and distribution. 

LD.5.2. The center ensures optimal use of the supply within the program by handling over, under and misuses.

LD.6. The Diabetes center enhances social and community participation in DIABETES healthcare services.

LD. 6.1. The diabetes center considers the perspective of the community as partners in healthcare decision-making processes.

LD. 6.2. The diabetes center with relevant stakeholders ensure a range of services is available locally for people to choose from as possible as they can. 

LD.6.3. The diabetes center coordinates with the community key stakeholders to improve the public awareness of the diabetes risk factors and early symptoms of diabetes.

LD.6.4. The diabetes center evaluates and utilizes stakeholders' inputs to guide decision making and the provision of health services.



LD.7. The Diabetes center provides the community with information on its services and its accessibility.

LD.7.1. The diabetes center provides the community through different means with an appropriate format and understandable information on its scope of services and when and how to access.

LD.7.2. Patients and their families/caregivers and the general community have a user-friendly access to information about health and healthcare services using different communication means.


LD.8. The Diabetes center provides on going community education to improve the public awareness of the risk factors, early symptoms and complications of diabetes.

LD.8.1. The diabetes center provides the Primary Health Centers (PHCs) with the educational materials according to the best evidenced based practice.

LD.8.2. The diabetes center empowers the PHC's personnel with the right tools in education by training and couching them.

LD.8.3 The diabetes center involves other amenities like universities and education facilities in the area in the process of development and training the PCH's personnel 

LD.8.4 The diabetes center provides awareness and education to the people with diabetes in regards the burden and complications of the disease and how to reach better control 

LD.8.5 The diabetes center ensures the implementation of the education process provided to the public by measurable indicators.


LD.9. The Diabetes center develops an effective policy and procedure to guide the management of patients and families /service users' complaints, concerns, and suggestions.

LD.9.1. Diabetic Center must have a process for receiving complaints, concerns and suggestions and making them publicly available.

LD.9.2. The diabetes center assigns a specific unit or person responsible for receiving, recording and managing complaints, concerns, and suggestions.

LD.9.3. Patients /service users receive feedback about their complaints concerns and suggestions within a defined timeframe.

LD.10. The Diabetes center seeks feedback from patients and service users regarding the services provided.

LD.10.1 The diabetes center conducts direct patients/service users interviews at the provision point, focus group, ‎telephone calls and the appropriated social media.

LD10.2. The diabetes centers conduct patients/service user's satisfaction survey periodically to improve patient experience.

LD.10.3. The diabetes center evaluates the patient satisfaction report through departmental meetings to improve the patient journey and their experience.  


LD.11. The Diabetes center director obtains participation of qualified quality staff to support the quality of provided services. 

LD.11.1. The quality staff support implementation of relevant quality management and patient safety plan, including risk management program.

LD.11.2. The quality staff assist the diabetes centers in integrated data collection, aggregation, validation, analysis, and interpretation of data.

LD.11.3. The quality staff support the diabetes centers in performance improvement activities including projects.


LD.12. A multidisciplinary quality and risk management committee to oversees the quality of service.

LD.12.1. The center director assigns a quality and risk management committee with periodic meetings and annual reports to be submitted to the director of the center.

LD.12.2. The committee chairman is one of the center consultants knowledgeable in quality and risk management tools by education and training.

LD.12.3. The committee provides oversight, monitoring and assessment of key organizational processes, outcomes, and reports; makes recommendations concerning physician credentialing and educational activities; and recommends appropriate policies.

LD.12.4. The committee is responsible to monitor the implementation of the quality improvement plans.

LD.12.5. Discussions, and actions taken are documented in a meeting minute.

LD.12.6. The committee chairman report to the center 's director discussions, decisions and actions taken.

LD.13. The Diabetes center quality team designs and monitors the implementation of risk management program, in line with hospital risk management program.

LD.13.1. The diabetes center risk management program has a plan that details the following: 

Identify Risk, Quantify & Prioritize Risk, Investigate & Report Sentinel Events, Perform Compliance, Reporting and Capture & Learn from Near Misses & Good Catches  

LD.13.2. Reducing medical errors must be set as a goal and one of the main concerns of the strategic plan of the center.

LD.14. The Diabetes center manages safety incidents, adverse events and near misses that affect or may affect patients/service users, staff, and facility and in line with hospital policy and procedures.

LD.14.1. The diabetes center develops a policy that outlines the types of safety incidents, adverse events and near misses to be reported internally and externally to relevant regulatory authorities with the time frame and mechanism for reporting.

LD.14.2. The center utilizes a risk scoring matrix to categorize the severity of incidences.

LD.14.3. Incidents involving patients/service users are documented in the medical record.

LD.14.4. The diabetes center quick fixes the situation, mitigates consequences of safety incident as needed.

LD.14.5. The diabetes center performs an intensive root cause analysis for all severe adverse events and high potential near misses.

LD.14.6. Staff are aware of the incidents in their working areas and educated on the notification and reporting mechanism.

LD.14.7. The diabetes center follows the hospital plan for managing sentinel events.


LD.15. The Diabetes center prioritizes and selects a set of indicators that focus on the essential structures, processes and outcomes of the services provided.

LD.15.1. The diabetes center develops a set of indicators cover the essential structures, processes and outcomes of the services provided.

LD.15.2. Diabetes centers should comply with SNDC key performance indicator. 

(for more details Refer to appendix (1) SNDC standards of services and quality measures in diabetes centers and unit. table 2)

LD.15.3. The indicators' results are discussed with staff and reported monthly to hospital leadership along with action plans taken for improvement.


LD.16. The Diabetes center implements and monitors a comprehensive quality management and patient safety program in line with hospital quality and patient safety program.

LD.16.1. The diabetes center leaders develop quality management and patient safety program collaboratively and allocate responsibilities and resources.

LD.16.2. The diabetes center covers all services provided and focuses on essential safety requirements. 

LD.16.3. The diabetes center utilizes key performance indicators, surveys, safety incidence, complaints, and suggestions for prioritizing quality improvement projects.

LD.16.4. The diabetes center utilizes an evidence-based quality improvement methods and tools. 

LD.16.5. Quality and patient safety information is readily accessible in a timely manner to those responsible ‎for the delivery of the services and is utilized for making improvements and supporting the leaders' decision making.


LD.17. The DIABETES center provides secure tele-DIABETES services to other hospitals in its network to ensure integrated DIABETES care, whenever the need arises.

LD.17.1. Diabetes center have virtual clinics distributing among pediatric endocrinologist, adult endocrinologist, clinical dietitian, and educator.

LD.17.2. Every specialty should have at least 1 virtual clinic per month and 10-12 clinics per year.

LD.17.3. The diabetes center develops a process for secure storage of data and information.

LD.17.4. The diabetes center monitors information security, confidentiality and integrity and takes actions on the areas of improvement.


LD.18. The center has continuing education and training program for all categories of staff

LD.18.1. the center has scheduled educational and training program based on needs/ scope of service include but not limited to: patient safety, risk management and infection control.

LD.18.2. Center has clinical evidence-based practice educational plan.

LD.18.3. There is a policy and procedure contain a list of required competency assessment in each staff category.

LD.18.4. All staff are evaluated annually for required competencies.

LD.18.5. Participate in post-graduate training program.

LD.18.6. Participate in research proposal/ publication.


LD.19. The DIABETES center participates in a registry for its population and services provided.

LD.19.1. The diabetes center registers all cases especially the new cases.

LD.19.2. The diabetes centers maintain a registry for its population and services provided. 

LD.19.3. The register follows SNDC diabetes registry, electronic statistical system for diabetes centers 

LD.19.4. Ensure assigning a personal to fulfill the requirements​


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