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Provision of Care (PC) Chapter

PC.1. The DIABETES services are accessible and obtainable in equity manner, to all patients whose medical needs can be met within the capability of the DIABETES program.

PC.1.1. The diabetes center informs patients about how to access care, treatment, and services.

PC.1.2. Timely access to and appropriateness of care and treatment are available to all patient out of any discrimination. 

PC.1.3. The diabetes center ensures that all relevant services for its targeted population are available.

PC.1.4. Acuity of the patient's condition determines the resources allocated to meet the patient's needs.

PC.2. The hospital's layout, structure and function facilitate the delivery of reliable, timely and safe care to patients.

PC.2.1. The hospital's layout optimizes flow of inpatients between all needed units.

PC.2.2. The laboratory tests and other required investigations are ease accessible and obtainable in identifiable time, whenever the need arises. 

PC.3. The Diabetes center uses clinical pathways and protocols to guide the process of providing effective emergency care to DIABETES patients through: 

PC.3.1. The diabetes center program implements a standardized emergency care protocol for diabetes patients

PC.3.2. The diabetes center monitors the implementation of the protocol

PC.3.3. Educate staff and spreading the materials to make sure staff following the standard of care in emergency management.

PC.4. The clinical laboratory is fully equipped for a spectrum of tested procedures and has qualified and competent staff to meet the patients' needs.

PC.4.1. The clinical laboratory department is available and accredited

PC.4.2. Qualified and competent staff perform and report the tests.

PC.5. Multidisciplinary team involved in the management of DIABETES patients, develops a policy and procedure for the assessment / reassessment of patients.

PC.5.1. The policy defines the scope, content of the assessment, frequency of the reassessment process to all diabetic patients.

PC.5.2. The team utilizes assessment sheet which contain at least diabetes classification, lab finding, social/family history, allergy, comorbidities, physical examination, diabetes education, foot exam and plan.

PC.5.3. The assessment sheet for pediatric includes national growth chart.

PC.5.4. The assessment identifies the patient discharge or referral planning based on the patient's needs.

PC.5.5. The assessment identifies the risk stratification of patients.

PC.6. The DIABETES team develops a comprehensive multidisciplinary plan of care, based on assessment findings, and directed by clinical practice guidelines

PC.6.1. The center's programs are collaboratively designed, implemented, and evaluated.

PC.6.2. The center's program develops a plan of care that is based on the patient's assessed needs 

PC.6.3. The center develops a standardized process originating in SNDC Saudi Diabetes Mellitus Clinical Practice Guidelines first addition 2021 to deliver or facilitate the delivery of clinical care.

PC.6.4 Patients' needs are reassessed when indicated and care plan is revised and modified accordingly.

PC.6.5. The most responsible physician ensures the relevance and integration of other healthcare givers' plans. 

PC.6.6. Care plan is documented for each patient.

PC.6.7. the center emphasizes PHCs to implement SNDC screening program.

PC.7. The center involves patients in making decisions about managing their disease or condition.

PC.7.1. The center involves patients in decisions about their care, treatment, and services. 

PC.7.2. The center assesses the patient's readiness, willingness, and ability to engage in self-management activities. 

PC.7.3. The center assesses the family and/or caregiver's readiness, willingness, and ability to provide or support self-management activities when needed.

PC.7.4. The center utilizes the assessment of the patient and family and/or caregiver to guide the development of a self-management plan. 

PC.7.5. Patients and practitioners mutually agree upon goals.

PC.8. The Diabetes centre addresses the patient's self-management plan and supports patients to pursue an independent healthy lifestyle.

PC.8.1. The center promotes lifestyle changes that support self-management activities.

PC.8.2. The center evaluates barriers to lifestyle changes. 

PC.8.3. The center engages family and community support structures in the patient's self-management plan, as directed by the patient. 

PC.8.4. The center assesses and documents the patient's response to recommended lifestyle changes. 

PC.8.5. The center refers the patient if needed to Psychology/psychiatry or adolescent medicine specialist depending on the age.

PC.8.6. The center refers the patients to diabetes educator and Clinical dietitian if needed

PC.8.7. The center prescribes glucose monitoring machine and equipment as needed

PC.9. Skilled multidisciplinary team guides the provision of comprehensive education services.

PC.9.1. The center education materials comply with recommended elements of care, treatment, and services, which are supported by literature, clinical practice guidelines and evidence-based practice.

PC.9.2. The center presents content in an understandable manner according to the patient's level of literacy.

PC.9.3. The center presents content in a manner that is culturally sensitive. 

PC.9.4. The center addresses the education needs of the patient regarding his or her disease or condition and care, treatment, and services.

PC.10. The Diabetes center conduct periodically, minimum every 3 months and as needed, mortality and morbidity meetings.

PC.10.1. The center has a mortality and morbidity committee assigned in diabetes center

PC.10.2. All mortality and morbidity cases are reviewed on ongoing basis to highlight avoidable cases.

PC.10.3. The center documents the interventions taken by the meeting minutes.

PC.10.4. Shared cases between departments are referred to the medical director to decide on presenting it to the hospital morbidity and mortality committee.

PC.11. Referral pathway guides patient referral process within the DIABETES network, based on the patient's health needs according to SNDC.

PC.11.1. The pathway highlights the patient's acceptance criteria.

PC.11.2. The pathway identifies the required essential information communicated and care needed during transfer.

PC.11.3. The pathway defines the operation times of the communication channels to facilitate immediate transfer.

PC.11.4. The pathway determines staff accountability on both ends of the transfer process.

PC.11.5. The pathway addresses the infection prevention and control measures to be followed. 

PC.11.6. The referral center has availability of access to care for new patient with one of the team within 2 to 4 weeks and follow up visit for follow up patient within 3 months.

PC.11.7. The referral center has availability visit with educator, clinical dietitian, and retina exam within 3 months from the first visit and encouraging to be seen by all in the first visit (ONE stop).

PC.12. The diabetes center initiates discharge planning and facilitates arrangements for subsequent care, treatment, and services to achieve mutually agreed upon patient goals

PC.12.1. Diabetes center team discusses and plans with the patient and family the care, treatment, and services that are needed to achieve the mutually agreed upon self-management plan and goals. 

PC.12.2. Diabetes center team member collaborates with patients to arrange a follow-up appointment within one month of discharge with the patient's primary care provider, endocrinologist, or diabetes educator. 

PC.12.3. In preparation for discharge, the program communicates the patient's needs and goals to other practitioners who will continue to support the patient in achieving the desired outcomes. 

PC.12.4 Patients and families could identify and discuss their post- discharge needs.

PC.12.5. All medications and support services necessary for a safe discharge should be organized and documented in the discharge summary.

PC.13. Diabetes center has specific requirement for the initial visit

PC.13.1. All DM referrals must be screened within 1 week of referral date.

PC.13.2. Patient who is accepted must do laboratory tests (CBC, LIPID, A1C, LFT, RENAL, ACR) one week before his appointment in the clinic.

PC.13.3. Diabetes center has acceptant criteria to accept patients with diabetes.

PC.13.4. Five parties (stations) is preferred to be done in one visit, if not possible it has to be completed within 2 weeks from 1st visit. The five parties include (Physician: covered by the assistant and consultant on call for DM, Diabetes educator, Retinal examination, Clinical dietitian and Foot examination.

PC.13.5. All patients with diabetes, at the end of first visit, receive the needed medication, medical supply and needed education.

PC.13.6. All patients with diabetes receive follow up appointment in 3 months or according to patient needs.

PC.14. Diabetes center has a policy for high risk patients with diabetes.

PC.14.1. DC has a policy to identify high risk patient including but not limited to the following: severe hyperglycemia, severe and/or frequent hypoglycemia, hypoglycemia unawareness and frequent DKA.

PC.14.2. High risk Patients have 2 to 3 visits per month.

PC.14.3. High risk patients are seen by three parties: Physician: covered by the consultant endocrinologist/diabetologist, Diabetes educator and Clinical dietitian.

PC.15. Diabetes Center has insulin pump services 

PC.15.1. Insulin pump service is supervised by endocrinology consultant.

PC.15.2. Diabetes center has eligibility criteria for insulin pump

PC.15.3. Pump clinic run by the following: Physician: Endocrinology/diabetology Consultant, Diabetes educator with special training on insulin pump and clinical dietitian

PC.16. the diabetes center has a process for management of children and adolescents with Type 1 Diabetes

PC.16.1 The MRP is pediatric endocrinologist.

PC.16.2. Individualized medical nutrition therapy is recommended for children and adolescents with type 1 diabetes as an essential component of the overall treatment plan. 

PC.16.3. Clinical dietitian is monitoring carbohydrate intake by carbohydrate counting.

PC.16.4. Diabetes center follow the international Physical Activity and Exercise recommendations.

PC.16.5. Psychosocial services are available for pediatric patients and their families.

PC.16.6. All type 1 patient with diabetes are screened for autoimmune disease. (Table 3)

PC.16.7. All type 1 patient with diabetes are screened for long-term complications. (Table 4)

PC.17. Diabetes center has diabetes in pregnancy service

PC.17.1. DC has specific Eligibility criteria: 

• Pregnant women followed by hospital or Obs/Gyn clinic within attachment area who has type 1 or 2 DM

• Pregnant women followed by hospital Obs/Gyn or clinic within the attachment area has GDM with poor control (FBS > 100 or 2hPPS > 120, or HbA1C >6.5)

PC.17.2. Diabetes Center provides institute with SNDC clinical practice guidelines to manage pregnant patients with diabetes throughout intrapartum management.

PC.17.3. Diabetes Center educate pregnant patients with diabetes to follow up with family physician after delivery.​

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