DAFNE © F03.004, Version 13 – 16 December 2014

DAFNE Audit Auditor Questionnaire

Centre: «Centre» Lead Educator: «Lead_Educator» Date of QA audit visit: «Audit_Date» Auditor: «Auditor» Period covered by audit: From «Period_from» to «Period_to» Auditor Notes You will need to have access to the DAFNE Professional Development files for each DAFNE Educator in order to complete this form. These files must be made available to you. This questionnaire must be completed in ink

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List of Educators and Doctors

Educator

Discipline Completed

training Goal

setting PR

training No of Int PR

No of Ext PR

5x1 training

Pump training

«Educator_1» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_2» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_3» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_4» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_5» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_6» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_7» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_8» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_9» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_10» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_11» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_12» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_13» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_14» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy «Educator_15» dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy

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Doctor Discipline Completed training Category Sessions

dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy

DAP Advisors Discipline Completed DAP training Category

dd/mm/yyyy dd/mm/yyyy

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Section A: Maintaining Educator status A1. All Personal Development files for all Educators

(a) For all Educators listed in the table overleaf Auditor to: • record whether PD file has been provided • compare Audit Form A with Evidence in PD file (i.e. Core Skills and Session

Learning Outcome forms) • check mandatory sessions 4, 6 and 22 are being delivered • check correct curriculum is being used

Note 1: New resources were launched at the 2014 DAFNE Collaborative meeting. All DAFNE services must have implemented the use of all new resources by 18 August 2014 and this should be reflected on each educators Audit Form A and in their PD file

Note 2: Where a centre has more than 6 Educators, up to 8 files should be viewed (2 Educators observed plus up to 6 Educators, including Category 3 Doctor Educators, files randomly selected).

(b) For a random selection of files (2 Educators observed during audit plus 2 Educators

files randomly selected and reviewed by the Auditor) check Session Learning Outcome forms are available, and dated appropriately, for those sessions observed.

.

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Session and curriculum comparison for all Educators (including Dr Educators)

Auditor to complete for all Educators listed Auditor to complete for random selection

Educator Name

PDP File provided

for Auditor

Educator delivers Session

Evidence available in PDP file to support

information provided on

Audit Form A?

Correct version of curriculum? If No answered for provision of PDP Files,

evidence to support information provided on Audit Form A or

Version of Curriculum provide reason here

Session Learning Outcome forms

available, and dated appropriately, for those sessions

observed

Standard T02.002,

V11, Jun 2014

Pump T12.001,

V2, Oct 2012

5 week T13.014,

V3, Jun 2014

Yes No 4 6 22 Yes No Yes No Yes No Yes No «Educator_1»

«Educator_2»

«Educator_3»

«Educator_4»

«Educator_5»

«Educator_6»

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Session and curriculum comparison for all Educators (including Dr Educators) continued…

Auditor to complete for all Educators listed Auditor to complete for random selection

Educator Name

PDP File provided

for Auditor

Educator delivers Session

Evidence available in PDP file to support

information provided on

Audit Form A?

Correct version of curriculum? If No answered for provision of PDP Files,

evidence to support information provided on Audit Form A or

Version of Curriculum provide reason here

Session Learning Outcome forms

available, and dated appropriately, for those sessions

observed

Standard T02.002,

V11, Jun 2014

Pump T12.001,

V2, Oct 2012

5 week T13.014,

V3, Jun 2014

Yes No 4 6 22 Yes No Yes No Yes No Yes No «Educator_7»

«Educator_8»

«Educator_9»

«Educator_10»

«Educator_11»

«Educator_12»

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Session and curriculum comparison for all Educators (including Dr Educators) continued…

Auditor to complete for all Educators listed Auditor to complete for random selection

Educator Name

PDP File provided

for Auditor

Educator delivers Session

Evidence available in PDP file to support

information provided on

Audit Form A?

Correct version of curriculum? If No answered for provision of PDP Files,

evidence to support information provided on Audit Form A or

Version of Curriculum provide reason here

Session Learning Outcome forms

available, and dated appropriately, for those sessions

observed

Standard T02.002,

V11, Jun 2014

Pump T12.001,

V2, Oct 2012

5 week T13.014,

V3, Jun 2014

Yes No 4 6 22 Yes No Yes No Yes No Yes No «Educator_13»

«Educator_14»

«Educator_15»

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A2. If any Educator is not delivering the mandatory sessions 4.0, 6.0 and 22.0, summarise discussion with Lead Educator the plan for when they will start to deliver the sessions.

Educator name Summary of discussion with Lead Educator

A3. What measures are in place to ensure that all DAFNE Educators maintain their status

by delivering a patient course every 26 weeks?

Auditor Note: This information should be obtained from discussions with the Lead DAFNE Educator. Comments:

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A4. Documentation present for alternative format course delivery Documentation present in Section 6 of PD files for 2 Educators being observed and Educators whose PD files randomly selected by the Auditor (minimum of 2 files) 5 week curriculum

Note: Central DAFNE to complete Note: Auditor to complete using date format: dd/mm/yyyy Educator Name Date 5 week

training workshop attended

Date of last 5 week course delivery

Date Core Skills form completed

Date Learning outcomes

completed for additional session

Date Reflective Tool completed in PD file

(first course following training only)

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

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Pump curriculum Note: Central DAFNE to complete Note: Auditor to complete using date format: dd/mm/yyyy

Educator Name Date workshop attended

Date of last pump course delivery

Date Core Skills form completed

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

dd/mm/yyyy

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A5. What is the centre policy for the reintroduction to the delivery of the DAFNE patient course following an extended break? Please provide details.

Auditor Note: This information should be obtained from discussions with the Lead DAFNE Educator. Comments:

A6. What systems are in place to ensure that all DAFNE Educators achieve development

objectives outlined in their PDPs and that new development objectives are set?

Auditor Note: This information should be obtained from discussions with the Lead DAFNE Educator. Comments:

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Section B: Evidence of Ongoing Internal QA within a 3 year period B1. Evidence that individual educators are being observed by their local colleagues.

Audit Form A – Internal QA A copy of completed Audit Form A (F03.026) for each Educator listed below will be provided by Central DAFNE. These forms can be located in the plastic wallet provided at the back of the Auditor file. «Educator_1» «Educator_2» «Educator_3» «Educator_4» «Educator_5» «Educator_6» «Educator_7» «Educator_8» «Educator_9» «Educator_10» «Educator_11» «Educator_12» «Educator_13» «Educator_14» «Educator_15»

To complete questions B2 to B5 you will need access to:

• Professional Development files for each Educator listed in B1 as you will need to reference Section 5 of the DAFNE Professional Development files for each DAFNE Educator in order to complete Section B.

• Completed Audit Form A (F03.026) for each Educator listed in B1 (provided via Central DAFNE).

You need to sort the Professional Development files into those for Educators which have been internally observed (information on Audit Form A) and those that have not. In order to complete questions B2 – B5, you must then randomly select 2 Professional Development files for Educators that have been internally observed. If possible do not select the files of the 2 Educators that are delivering the patient course, as the DAFNE Professional Development files for these two educators will be looked at in more detail later in Section C.

Auditor Note: You will need to reference Section 5 of the DAFNE Professional Development files for each DAFNE Educator in order to complete Section B.

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B2. Does the information provided on Audit Form A (F03.026) reflect the Session Learning Outcome forms completed for internal review, located in Section 5 of the Educator’s Professional Development file? Educator 1 Name:

Completed Session Learning Outcome forms available for all sessions on Audit form A

recorded as having been internally reviewed? Yes No Partial

If you have recorded No or Partial, record the differences below

If applicable, summarise discussion with the Lead Educator of the above differences.

Educator 2 Name: Completed Session Learning Outcome forms available for all sessions on Audit form A

recorded as having been internally reviewed? Yes No Partial

If you have recorded No or Partial, record the differences below

If applicable, summarise discussion with the Lead Educator of the above differences.

Auditor Note: Please ensure the Audit Form A (F03.026) for each Educator is replaced in the plastic wallet at the back of the Auditor file.

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B3. Have all Session Learning Outcome forms (located in Section 5 of the Educator’s Professional Development file) been completed and correctly evidenced during internal review?

Educator 1 Name: Session Learning Outcome form completed during Yes No Partial internal review? Session Learning Outcome form adequately Yes No Partial evidenced? Approximate % of learning outcomes completed correctly: If you have recorded No or Partial, list Sessions concerned (if all Session Learning forms just write “All”) and reason / evidence below to substantiate your decision

Session No. Session Title Reason / Evidence

If applicable, summarise discussion with the Lead Educator of the above reasons.

Auditor Note: Please ensure the Internal QA and Session Learning Outcome forms have been completed during the current audit period and not prior to the commencement of the audit period.

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Educator 2 Name:

Session Learning Outcome form completed during Yes No Partial internal QA? Session Learning Outcome form adequately Yes No Partial evidenced? Approximate % of learning outcomes completed correctly: If you have recorded No or Partial, list Sessions concerned (if all Session Learning forms just write “All”) and reason / evidence below to substantiate your decision

Session No. Session Title Reason / Evidence

If applicable, summarise discussion with the Lead Educator of the above reasons.

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B4. Have Core Skills forms (located in Section 5 of Educator’s Professional Development file) been completed and correctly evidenced during internal review?

Educator 1 Name: Version number listed on completed Core Skills form Date Core Skills form completed Core Skills forms completed? Yes If yes complete sections a) and b) below. No If No complete section c) below a) How many of the 27 items on the Core Skills form have been correctly evidenced? b) DAFNE Philosophy evident from pages 4 and 5 of the Core Skills form completed

during internal QA? Yes No Partial Evidence to support your decision. If No or Partial, complete section c) also. c) Summarise discussion with the Lead Educator.

Auditor Note: Please ensure the Internal QA and Core Skills forms have been completed during the current audit period and not prior to the commencement of the audit period.

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Educator 2 Name: Version number listed on completed Core Skills form Date Core Skills form completed Core Skills forms completed? Yes If yes complete sections a) and b) below. No If No complete section c) below a) How many of the 27 items on the Core Skills form have been correctly evidenced? b) DAFNE Philosophy evident from pages 4 and 5 of the Core Skills form completed

during internal QA? Yes No Partial Evidence to support your decision. If No or Partial, complete section c) also. c) Summarise discussion with the Lead Educator.

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B5. Have PDPs (located in Section 6 of Audit Form A) been completed and updated with new development objectives as indicated by Audit Form A?

Educator 1 Name: PDP(s) Completed? PDP Updated?

Yes Yes No No Partial Partial If you have recorded No or Partial for the completion and/or updating of PDPs, please summarise discussion with the Lead Educator regarding plan for the completion of PDPs and the need to identify new development objectives during internal observation.

Educator 2 Name: PDP(s) Completed? PDP Updated?

Yes Yes No No Partial Partial

If you have recorded No or Partial for the completion and/or updating of PDPs, please summarise discussion with the Lead Educator regarding plan for the completion of PDPs and the need to identify new development objectives during internal observation.

Auditor Note: Please ensure the PDPs have been completed and updated during the current audit period and not prior to the commencement of the audit period.

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Section C: Validating the internal peer review: observing sessions of a patient course being delivered.

The timetable(s) and corresponding completed Audit Form F, provided by the centre to Central DAFNE, will be placed in the labelled plastic wallet in the Auditor file prior to the visit. You must check all timetables provided and record your findings in C1 and C2 below. C1. Do all timetables provided include all DAFNE sessions?

Course delivery format

Format delivered at centre

Timetable provided

Timetable includes all DAFNE sessions

Standard MDI Yes No Yes No Yes No

5 week Yes No Yes No Yes No

Pump Yes No Yes No Yes No

If no, record reasons why sessions are omitted below

Record the timetable ID (from Audit Form F) and details of sessions omitted for all timetables which have sessions omitted. Information to be obtained from Lead DAFNE Educator

Timetable ID (from Audit

Form F)

Number of Session omitted

Name of Session omitted

Reason

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C2. Does the timetabling of sessions follow a logical order for all timetables detailed in Audit Form F?

Course delivery format Sessions flow in a logical order Standard MDI Yes No

5 week Yes No

Pump Yes No

If no, record reasons why sessions are omitted below

Record the timetable ID (from Audit Form F) and details of sessions which do not follow a logical order for all timetables.

Timetable ID (from Audit

Form F)

Course Format (i.e. Standard, 5 week or Pump

Flow in logical

order (Y/N)

If no, please list reason(s) why

Refer to Example 1 overleaf as a guide to session flow for Standard DAFNE and Pump and Example 2 for 5 week curriculum. .

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Guide to session flow for Standard DAFNE and Pump curriculum

Session Title Day / Time of Day

1 Introduction and Organisation 1st session Day 1 2 What is Diabetes Day 1

3 Nutrition 1 – CHO & CPs Day 1 Nutrition 1 – Glycaemic Index Any time

4 Lunchtime CP Estimation & Dose Adjustment Daily: Mon – Fri lunchtime 5 Control / Targets By end of day 3

6 Individual Dose Adjustment / Action Plans - pm Mon – Thu: end of the day Individual Dose Adjustment / Action Plans - am Tue – Fri: start of the day

7 Insulin – Regimen By end of day 3 Insulin – Injection Technique By end of day 3

8 Insulin Pump Anytime (Standard DAFNE) By end of day 3 (Pump)

9 Nutrition 2 – CP Practise By end of day 3 Nutrition 2 – Snacks By end of day 3

10 Hypoglycaemia – minor hypos By end of day 3 Hypoglycaemia – severe hypos / glucagon By end of day 3

11

Nutrition 3 – Labels By end of day 3 Nutrition 3 – Recipes Anytime Nutrition 3 – Sweeteners Anytime Nutrition 3 – Difficult Foods By end of day 3

12a 13a Principles of Dose Adjustment – Step-wise Approach By end of day 3

12 Insulin Dose Adjustment - Reduction By end of day 3 13 Insulin Dose Adjustment - Escalation By end of day 3 14 Corrections By end of day 3

15

Nutrition 4 – Eating Out Anytime Nutrition 4 – Alcohol Anytime Nutrition 4 – Healthy Eating / Weight Management Anytime

16 Illness / Sick Day Rules After day 3 17 Physical Activity / Exercise Anytime 18 Theory of Goal Setting / Action Planning Anytime 19 Annual Review / Complications After day 3

20

Social Aspects – Pregnancy Anytime Social Aspects – Driving Anytime Social Aspects – Travel Anytime Social Aspects – Employment / Benefits Anytime

21 Action Planning Day 5 Quiz / Evaluation / Follow-up / DUG & dafneonline Final session Day 5

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Guide to session flow for 5 week curriculum Session Title Day / Time of Day

1 Introduction and Organisation Beginning of Week 1 2 What is Diabetes Beginning of Week 1

3 Nutrition 1 – CHO & CPs Week 1 Nutrition 1 – Glycaemic Index Week 1

4 Lunchtime CP Estimation & Dose Adjustment Weekly at lunchtime

5

Meters Week 1 BG Targets Week 2 Monitoring & Control Week 3 DKA & Ketone Testing Week 4 DCCT Anytime (Week 5 workbook)

5x1 Taster and Action Planning End of day, Weeks 1 – 4 6 Individual Dose Adjustment / Action Plans Beginning of Weeks 2 – 5

7 Insulin – Regimen Beginning of Week 2 Insulin – Injection Technique Week 1

8 Insulin Pump Anytime from Week 2

9 Nutrition 2 – CP Practise Week 1 Nutrition 2 – Snacks Week 2

10 Hypoglycaemia – treatment (ref GI) Week 1 Hypoglycaemia – minor hypos Week 3 Hypoglycaemia – severe hypos / glucagon Week 3

11

Nutrition 3 – Labels Week 1 Nutrition 3 – Recipes Anytime (Week 4 workbook) Nutrition 3 – Sweeteners Anytime (Week 4 workbook) Nutrition 3 – Difficult Foods Week 1

12a 13a Principles of Dose Adjustment – Step-wise Approach Week 2

12 Insulin Dose Adjustment – Reduction Week 2 13 Insulin Dose Adjustment – Escalation Week 2 14 Corrections Week 2

15

Nutrition 4 – Eating Out Anytime (Week 3 workbook) Nutrition 4 – Alcohol Anytime (Week 3 workbook) Nutrition 4 – Healthy Eating / Weight Management Anytime (Week 4 workbook)

16 Illness / Sick Day Rules Week 4 17 Physical Activity / Exercise Week 3 18 Theory of Goal Setting / Action Planning Anytime (Week 4 workbook) 19 Annual Review / Complications Week 5

20

Social Aspects – Pregnancy Anytime (Week 5 workbook) Social Aspects – Driving Anytime (Week 5 workbook) Social Aspects – Travel Anytime (Week 5 workbook) Social Aspects – Employment / Benefits Anytime (Week 5 workbook)

21 Action Planning (5x1) Weeks 1 – 5 Quiz End of Week 4 Evaluation / Follow-up / DUG & dafneonline End of Week 5

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Two sessions of the patient course, to include dose adjustment, must be observed being delivered by each Educator. You must complete Core Skills forms (F03.005) and relevant Session Learning Outcome forms (F03.006) for each of the Educators, these forms can be found at the back of this folder. The Core Skills forms that you complete must be compared with the Core Skills forms completed as part of internal QA of these two Educators (reference Section 5 of the DAFNE Professional Development files for both Educators). Evidence of philosophy observed must be provided in the Evidence to support decision text boxes below. Failure to do so could impact on the centre’s overall audit score. C3. Was the DAFNE philosophy evident during Auditor observation?

Name of Educator 1: Was philosophy evident during auditor observation? Yes No Partial Evidence to support decision (must be completed):

Name of Educator 2: Was philosophy evident during auditor observation? Yes No Partial Evidence to support decision (must be completed):

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C4. Was the DAFNE philosophy evident from pages 4 and 5 of the Core Skills form completed during internal observation?

Name of Educator 1:

Was philosophy evident during internal observation? Yes No Partial Evidence to support decision (must be completed): Name of Educator 2: Was philosophy evident during internal observation? Yes No Partial Evidence to support decision (must be completed):

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C5. Core Skills forms: Is there common agreement between the comments made during internal observation and the comments you recorded for the 2 Educators observed delivering sessions during the audit?

Educator 1 Name:

Core Skills forms completed during internal QA? Yes No Version number listed on Core Skills form completed during internal QA? Date recorded on Core Skills form completed during internal QA? Agree with Auditors assessment? Yes No Partial How many of the 27 items on the Core Skills form completed during internal observation have been correctly evidenced?

Evidence from Core Skills forms in PD file to support decision and summary of discussion with the Lead Educator of the above differences if applicable.

Auditor Note: Please ensure the Internal QA and Core Skills forms have been completed during the current audit period and not prior to the commencement of the audit period.

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Educator 2 Name:

Core Skills forms completed during internal QA? Yes No Version number listed on Core Skills form completed during internal QA? Date recorded on Core Skills form completed during internal QA? Agree with Auditors assessment? Yes No Partial How many of the 27 items on the Core Skills form completed during internal observation have been correctly evidenced?

Evidence from Core Skills forms in PD file to support decision and summary of discussion with the Lead Educator of the above differences if applicable.

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C6. Have all Session Learning Outcomes forms (located in Section 5 of the Professional Development file) been completed and is there agreement between Session Learning Outcome forms completed during internal observation and those that you have completed for the 2 Educators observed during audit?

Educator 1 Name observed:

Session Learning Outcome form completed during Yes No current audit period? Session Learning Outcome form completed during Yes No Partial internal QA? Session Learning Outcome form adequately Yes No Partial evidenced? Approx % of Essential Learning Outcomes evidenced: % Agree with Auditors assessment? Yes No Partial Evidence to support decision

Auditor Note: Please ensure Session Learning Outcomes forms have been completed during internal QA, during the current audit period and not prior to the commencement of the audit period.

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Educator 2 Name observed:

Session Learning Outcome form completed during Yes No current audit period? Session Learning Outcome form completed during Yes No Partial internal QA? Session Learning Outcome form adequately Yes No Partial evidenced? Approx % of Essential Learning Outcomes evidenced: % Agree with Auditors assessment? Yes No Partial Evidence to support decision

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Section D: Background Insulin Adjustment pre-course Evidence that course participants have:

• Attended a pre-course assessment or participated in pre-course assessment by telephone

• All pre-course assessments have been conducted by a DAFNE Educator, DAFNE Advisor or DAFNE Doctor

• All course participants have been given recommendations in accordance with DAFNE guidelines

To complete question D1 you will need access to:

• Baseline data collection form for each course participant for the course being delivered during the audit visit only

D1. Number of course participants

D2. Number already on twice daily BI before the pre-course assessment

Isophane Levemir Lantus Total:

D3. Number of course participants with written evidence provided

to show that participant has attended a pre-course assessment or participated in pre-course assessment by telephone

D4. Number of course participants who had pre-course assessment conducted by a DAFNE Educator, DAFNE Advisor or DAFNE Doctor

D5. Number of course participants with written evidence of advice given pre-course to

change to:

a) Twice daily BI

b) Reduce the dose

If advice not given pre-course, provide reasons below:

Auditor Note: In order to complete Section D you will need to reference the section of the Baseline data collection form entitled Background Insulin Adjustment pre-course for each course participant (for the course being delivered during the audit visit only).

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D6. For those who changed regimen for the course, what were they changed to / from? (Please enter the number who changed to / from in each relevant box below)

Changed to Isophane bd: From: Isophane od Levemir od Lantus od

Changed to Levemir bd:

From: Isophane od Levemir od Lantus od Changed to Lantus bd:

From: Isophane od Levemir od Lantus od

D7. Number of participants who had their BI dose reduced following the pre-course assessment

D8. Changes and / or reductions made in line with DEP guidelines (see Appendix I)?

All Some None Please comment:

D9. Number of participants who changed to twice daily BI during the course:

Changed to Isophane bd: From: Isophane od Levemir od Lantus od

Changed to Levemir bd:

From: Isophane od Levemir od Lantus od Changed to Lantus bd:

From: Isophane od Levemir od Lantus od

D10. Were changes made during the course a result of (tick all that apply):

Educator advice Negotiation Peer (group) pressure Patient choice

Comments:

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Section E: Declaration The information reported in this form and the evidence made available to the Auditor are an accurate, reflection of the current internal QA practices at «Centre» and ensure the quality of our DAFNE service is maintained. Lead DAFNE Educator «Lead_Educator» ............................................................ ..................................................... ........................................................ Please print name Signature Date Auditor «Auditor» ............................................................ ..................................................... ........................................................ Please print name Signature Date

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Appendix I

DAFNE Educator Programme (DEP) and DAFNE Doctor Programme (DDP)

The DAFNE Insulin Regimen The regimen used in the original DAFNE trial in 2000 was based on the Dusseldorf model of twice daily isophane (NPH): in the morning and at bedtime, plus soluble or analogue quick-acting insulin matched to carbohydrate portions (CPs). Subsequently, analogue background insulins have been introduced and are more commonly used for multiple dose injection (MDI) therapy in clinical practice, injected either once or twice daily. Audit findings presented at the Collaborative meeting in June 2013 show that a statistically significant reduction in HbA1c 12 months after DAFNE occurs only in patients taking background insulin twice daily. Analysis of groups taking different types of background insulin (NPH, detemir or glargine) showed no difference in HbA1c outcome between types, but consistently showed statistically significant reductions in HbA1c only in patients taking twice daily background insulin. There may be reasons to consider analogue use, such as patient preference for a once daily regimen, or problematic overnight hypoglycaemia, but in the absence of such indications the DAFNE Collaborative continues to recommend twice daily NPH insulin as the default regimen for DAFNE. In addition, many people tend to be over-insulinised prior to DAFNE due to a different approach to the titration of their insulin doses and frequently eat to avoid hypoglycaemia, so they often require extreme reductions in their overall insulin doses at the start of the DAFNE course. v3 Oct 2013

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Appendix I Guidelines for Insulin Adjustments for Start of the DAFNE Course

DAFNE Starting Regimen Standard Resistant and/or high HbA1c

(>1u/kg/day) Sensitive or Honeymooning

(<30u/day) BI QA BI QA BI QA

Cur

rent

regi

men

MDI (may be currently using BI either once or twice a day)

12u in the morning (on rising) and 12u at bedtime (on retiring)

1u : 1CP (1:1 ratios)

14u-16u in the morning (on rising) and 14u-16u at bedtime (on retiring)

1u : 1CP (1:1 ratios) may consider 1½ :1 or 2:1

6u-8u in the morning (on rising) and 6u-8u at bedtime (on retiring)

1u : 1CP (1:1 ratios) may consider ½ :1

Starting from Sunday bed-time (or the evening prior to week 2 of 5x1)

Suggest a dose of QA for the 1st morning based on 1:1 ratio

Twice daily pre-mix

12u in the morning (on rising) and 12u at bedtime (on retiring)

1u : 1CP (1:1 ratios)

14u-16u in the morning (on rising) and 14u-16u at bedtime (on retiring)

1u : 1CP (1:1 ratios) may consider 1½ :1 or 2:1

6u-8u in the morning (on rising) and 6u-8u at bedtime (on retiring)

1u : 1CP (1:1 ratios) may consider ½ :1

Continue usual pre-mixed insulin up to and including Sunday evening and commence DAFNE regimen on

Monday morning (or week 2 of 5x1) Suggest a dose of QA for the 1st morning based on 1:1 ratio

For the minority of participants who may (continue to) use once daily analogue BI Reduce dose of BI to 24u (adapt according to sensitivity, i.e. 12u – 32u daily). Consider the washout period of longer-acting analogues and plan to reduce 2-3 days prior to the course. v3 Oct 2013