1. Dr Jackie Sturt The Diabetes Manual 1:1 education Quality Assurance

2. Content of Presentation →What is the Diabetes Manual? →How was it developed? →How far have we “rolled out”? →What are the QA processes? In the RCT In the roll out programme →Next steps

3. The Diabetes Manual Intervention components →The Patient →The Nurse →Nurse Training →Workbook →Audiotapes x 2 (FAQ & Relaxation) →Telephone support

4. Heart Manual →6-week cardiac rehabilitation programme for secondary prevention of CHD →180 page workbook →FAQ tape for patient/partner →Relaxation tape →Telephone support from trained facilitator

5. Evidence for Diabetes Manual Heart Manual (Lewin et al 1992) →Fewer hospital admissions and GP visits at six and 12 months (Lewin et al, 1992; Linden, 1995) →Increased psychosocial adjustment to new health status (Lewin et al, 1992; Linden, 1995) →Reduced levels of anxiety and depression/psychological distress (Lewin et al, 1992; Linden, 1995) →Meets CHD NSF secondary prevention targets and was more popular than the group alternative and resulted in greater programme adherence (Dalal & Evans, 2003)

6. Diabetes Manual components →1:1 structured education →Delivered by PNs in PC →Self-efficacy theory →2-day nurse training →12 week patient workbook →Audiotapes x 2 (FAQ & Relaxation) →Telephone support x 3 →Meets national quality criteria for structured education in diabetes

7. Diabetes Manual Intervention components Self-efficacy theory 2-day nurse training Manual Audiotapes x 2 (FAQ & Relaxation) Telephone support 12 week programme Meets 4 national quality criteria for structured education →Mastery experiences →Vicarious experiences →Emotional arousal →Verbal persuasion by self or by others

8. Diabetes Manual Intervention components Self-efficacy theory 2-day nurse training Manual Audiotapes x 2 (FAQ & Relaxation) Telephone support 12 week programme Meets 4 national quality criteria for structured education →Self-efficacy theory →Diabetes Manual programme →Skill and confidence development eg. Telesupport/relaxation training for patients

9. Diabetes Manual Intervention components Self-efficacy theory 2-day nurse training Manual Audiotapes x 2 (FAQ & Relaxation) Telephone support 12 week programme Meets 4 national quality criteria for structured education

10. Diabetes Manual Intervention components Self-efficacy theory 2-day nurse training Manual Audiotapes x 2 (FAQ & Relaxation) Telephone support 12 week programme Meets 4 national quality criteria for structured education

11. Diabetes Manual Intervention components Self-efficacy theory 2-day nurse training Manual Audiotapes x 2 (FAQ & Relaxation) Telephone support 12 week programme Meets 4 national quality criteria for structured education

12. Diabetes Manual Intervention components Self-efficacy theory 2-day nurse training Manual Audiotapes x 2 (FAQ & Relaxation) Telephone support 12 week programme Meets 4 national quality criteria for structured education

13. Diabetes Manual Intervention components Self-efficacy theory 2-day nurse training Manual Audiotapes x 2 (FAQ & Relaxation) Telephone support 12 week programme Meets 4 national quality criteria for structured education →written curriculum →trained educators →quality assured →audited

14. How far is it rolled out? →Early days – papers in 2008 →Need to raise awareness amongst commissioners in addition to clinicians →Two courses piloted – curriculum/ learning needs → Piloting QA processes currently- no data yet!

15. QA in the RCT →Audio-recording 1 in 6 tele-consultations →Transcriptions of audio-recordings →Assessment of consultation by two scorers using Anderson’s +2 to -2 scale

16. +2 for statements occurring when the nurse responds to the patient’s feelings or the patient’s goals. E.G. Asking open questions about progress +1 for statements helping patients explore cognitive and behavioural dimensions E.G. Exploration of barriers “Do you have any particular ideas about why you wake up feeling so tired?” 0 for neutral statements (medical/technical) E.G Questions about medication -1 for statements where the nurse solves problems for the patient E.G. Interruptions from nurse -2 for statements that are judgemental about the patient E.G imply the patient is in the right or wrong

17. QA in the RCT →Audio-recording 1 in 6 tele-consultations →Assessment of consultation by two scorers using Anderson’s +2 to -2 scale Challenging for nurses within research study Not feasible in a pragmatic context Complex to get strong inter-rater reliability But…we believed in the Anderson approach

18. QA in the roll out →Re-visited Anderson’s guidance about +2 to -2 being a reflective tool →Developed a self and peer- assessment QA process →Developed a tool from the curruiculum

19. Diabetes Manual Quality Assurance Assessment Statements and Measures Assessment statement Assessment Measure Fully metPartially metNot at all metComments The DMF is adequately prepared to deliver the intervention 3 measures 1) DMF has attended 2-day preparation and has attended an update session within the last 18 months DM introductory consultation is consistent with the taught and practised skills 4 measures 2) DMF asks 3 open questions concerning the patients preparedness/ expectations Telephone consultation is consistent with the taught and practiced skills 6 measures 1) DMF uses self-efficacy theory to promote patient learning on minimum of 2 occassions

20. QA Summary →6 statements incorporating 19 measures →Ranging from environment, availability of resources to +2 to -2 statements and use of theory →Emphasis on self and peer reflection

21. QA data management →Internal QA is required, in the first 12 months, to be undertaken by facilitators on every 5th delivery of the programme (every 5th introductory consultation and every 5th telephone support call). →External QA by another DMF or a clinical colleague should take place every 30th delivery or six monthly, depending on which comes first. Arrangements for external QA will be triggered by re-ordering of the Diabetes Manual or 9 months post course →Re-ordering conditional on submission of QA data

22. Our QA Conclusions →Our QA journey →Still developing →Important to have QA processes that fit the programme philosophy →Assuring quality is tricky, assuring a willingness to “get better at it” is easier with the right messages during the training.