Where required team members are not onsite, baseline requirements may be fulfilled through formal referral networks or shared-care arrangements.

The service has a clinical team that meets the NADC-defined baseline requirements for its service level. The structure of the diabetes service, including team roles, responsibilities and reporting lines, is clearly defined and documented to support safe, coordinated and accountable care.

Baseline clinical requirements by service.

• Primary: A general practitioner with expertise in diabetes and access to a Credentialled Diabetes Educator (CDE) via referral, or a clinic led by a CDE or Nurse Practitioner (NP) working in close collaboration with general practitioners, endocrinologists and allied health professionals
• Secondary: An onsite medical practitioner, CDE and dietitian, with visiting endocrinology support.
• Tertiary: Onsite endocrinologist, CDEs, dietitians, pharmacists, podiatrists and other allied health and medical specialists as required.
• Centre of Excellence: Meets all tertiary requirements and includes additional medical and allied health professionals integrated within an interdisciplinary diabetes care team.

• Organisational chart specific to the diabetes service, showing team composition and reporting lines
• Workforce or clinic staffing profile (including FTE or sessional arrangements where relevant)
• Clinic rosters or service schedules demonstrating role coverage
• Formal referral, shared-care or service agreements (particularly for Primary services or where roles are not onsite)

Clinical leadership roles are identified within the service and contribute to oversight of clinical governance, safety, and quality improvement

• Leadership meeting minutes
• Reports
• Staff Development plans

The service has a workforce development strategy that supports clinical capability, supervision, and ensures staff credentialing requirements are met

• Registration certificates (e.g. AHPRA)
• Training logs
• Professional development records

The multidisciplinary team have formal training in diabetes technologies and therapeutics including a planned schedule of regular updates across all available devices

• Training certificates,
• Technology training logs

The service demonstrates ongoing professional development of its team through journal clubs, seminars, and leadership training

• Journal club agendas
• Seminar attendance lists
• Leadership training certificates

The service provides comprehensive staff education, including training programs, student placements, and mentorship

• Training program outlines
• Placement agreements
• Mentorship records

The service demonstrates a succession plan based on staffing reviews, including mentorship and projected service demand

• Succession plan document
• Staffing profile report
• Mentorship agreements

The service implements programs to prevent staff burnout and promote wellbeing

• Staff wellbeing program descriptions
• Staff survey results
• Lists of support resources

The service ensures continuity of care through documented processes and standardised templates for referrals and discharge summaries

• Handover protocols
• Case conference records
• Meeting agendas
• Referral templates

The service fosters staff collaboration and growth through regular shared clinical lessons, case discussions and presentations

• Meeting minutes
• Staff presentation slides
• Meeting schedules,
• Case conference agendas
• Action plans

The service establishes and sustains formal partnerships with non-diabetes-specific organisations, such as PHNs, community services, and general practices, to co-design innovative initiatives that enhance diabetes care and address population health needs

• MOUs with community agencies
• Joint project reports
• Integrated digital health platforms
• Meeting minutes from joint initiatives

• Membership records
• Collaboration agreements
• Joint project reports
• Steering committee minutes

The service leads regional or shared-care partnerships to extend diabetes expertise and resources to smaller or rural/remote services. For example, this may include joint outreach clinics, telehealth

• Regional collaboration agreements
• Shared-care protocols
• Records of joint clinics or telehealth programs

The service engages in local data collection, quality improvement, and/or clinical research activities to improve diabetes care and contribute to the evidence base such as the Australian Diabetes Clinical Quality Registry (ADCQR) and the Australian Diabetes Foot Registry (ADFR) Activities are informed by reflective practice, internal review, and collaboration with academic or peer organisations

• Quality improvement plans
• Innovation projects
• Outcome evaluations
• Staff training in QI methods

The service integrates research findings and evidence-based practice into clinical care through guideline updates and staff education

• Clinical guideline versions
• Training sessions on new evidence
• evidence-informed pathway changes

The service participates in research relevant to diabetes care either as a lead site, contributor, or through ethics-approved involvement

• Research protocols
• Ethics approvals
• Publication lists
• Site agreement documents

The service contributes to national or international diabetes policy, guideline development, or model-of-care translation

• Publication authorship
• Advisory board roles
• Position statement contributions
• Consultation records

The service leads or coordinates multi-site research, translational trials, or innovations in diabetes technologies, models of care, or therapeutics

• Grant submissions
• Trial protocols
• Ethics review outcomes
• Project outcome summaries
• Journal publications
• User testing reports

The service uses both local population data and service user demographics to define its target population, guide planning, and tailor services to meet identified needs and reduce inequity

• Service profile documentation
• Local health data analysis
• Population needs assessments
• Appointment scheduling systems
• Triage policy

The service actively works to improve access and reduce barriers for priority populations, including people from culturally and linguistically diverse backgrounds, people experiencing socioeconomic disadvantage, Aboriginal and Torres Strait Islander peoples, people in rural or remote locations, and people with disability

• Access improvement plans
• Translation services
• Outreach programs
• Aboriginal health liaison roles
• Disability access audits

The service collaborates with Primary Health Networks, Aboriginal Community Controlled Health Organisations, and key partners to ensure culturally safe, integrated care and effective navigation support for people with diabetes across the health system

• Partnership MOUs
• Joint care pathways
• Co-designed models
• Navigation referral data

The service offers a variety of flexible care delivery options to meet individual needs, including inperson, telehealth, group education, and homebased services where possible

• Appointment schedules
• Telehealth logs
• Group session timetables
• Home visit records

The service documents and maintains structured referral pathways and shared-care agreements to enable coordinated and person-centred care across primary, secondary, and tertiary settings

• Clinic timetables
• Appointment availability data
• Shared care arrangements

The service ensures timely, structured communication with referring providers and external care partners to support continuity of care

• Referral agreements
• Care pathways
• Shared case conferences

The service supports navigation and transition across care settings, including between inpatient and outpatient, primary and tertiary, and paediatric to adult care

• Transition protocols
• Handover documentation
• Liaison notes

The service implements systems to minimise nonattendance and support re-engagement, particularly for people from vulnerable or marginalised groups

• Did-not-attend (DNA) logs
• Re-engagement protocols
• Follow-up call records
• SMS reminders

The service fosters a respectful, culturally safe, and inclusive environment that supports person-led care. Service delivery reflects principles of personcentred and trauma-aware care, particularly for individuals who may have experienced stigma or negative healthcare encounters

• Cultural safety training reports
• Inclusive care protocols
• Feedback reports

The service actively engages people with diabetes in the design, evaluation and improvement of care and services. Feedback and lived experience are used to inform program development and service planning.

Tertiary and Centre of Excellence services demonstrate structured, routine mechanisms for incorporating lived experience input into strategic and clinical priorities.

• Care plans
• Feedback surveys
• Documented person-centred goals

The service uses shared decision-making tools and approaches to support informed choices about diabetes care and therapies

• Decision aids
• Documented treatment options discussed
• Consent records

The service systematically collects and applies person-reported experience and outcome measures (PREMs and PROMs) to evaluate and improve the quality and responsiveness of care and can demonstrate what changes have been made using this data

• PROM/PREM summaries
• Actions taken in response to findings
• Dashboards or audit reports
• Minutes of meetings

The service supports care partners and families of people with diabetes, including in care planning, education, and psychosocial support where appropriate

• Family education materials
• Care team notes
• Support group records

The service provides structured diabetes education that is evidence-based, personcentred, and tailored to individual learning needs and literacy levels

• Education program outlines
• attendance records
• feedback forms

The service offers education on contemporary diabetes technologies and therapies, including CGMs, insulin pumps and discusses emerging treatment models as appropriate

• Technology training schedules
• Patient education handouts
• Trainer accreditation records

The service supports self-management, including goal setting, behaviour change strategies, and regular review of progress

• Self-management plans
• Documented goal reviews
• Behavioural support notes

The service ensures access to credentialled diabetes educators and other qualified staff trained in education delivery

• Saff credential logs and audits
• Continuing education certificates

The service refers people with diabetes to peer support programs or facilitates peer-led initiatives as part of its education and empowerment strategy

• Referral records
• Partnerships with peer groups
• Promotion materials

The service delivers external training, mentoring, or workforce development programs to support capacity-building in diabetes care across other health organisations or jurisdictions, complementing regional partnerships

• Workshop materials
• Participant feedback
• Inter-agency mentoring records

The service provides comprehensive assessment and review processes for people with diabetes, including glycaemic management, cardiometabolic risk, kidney health, mental health, and screening for diabetes-related complications, in line with national clinical guidelines

• Clinical templates
• Care plans
• Health assessment reports

The service provides coordinated, person-centred care through an integrated multidisciplinary team. This includes ensuring timely access to relevant diabetes specialists and allied health professionals (e.g. dietitians, podiatrists, mental health practitioners) via on-site availability, formal referral pathways, or shared-care partnerships

• MDT meeting minutes
• Shared-care agreements
• Referral wait times
• Team composition documentation.

* If referral and communication protocols have already been cited under 2.2.2 they may be referenced again here

The service maintains up-to-date clinical protocols for diabetes pharmacotherapy and technology management, including safe initiation and titration of medications and diabetes related devices

• Clinical guidelines
• Protocol review logs
• Staff training attendance

The service supports person-centred titration and deprescribing, particularly in older adults or people with multimorbidity

• Medication review notes
• Deprescribing protocols
• Care plan adjustments

The service routinely screens for psychosocial concerns using validated tools, and has established referral pathways to mental health or support services where required

• Screening tools
• Staff training records
• Documented referral pathways
• Mental health integration models

The service has a structured, co-designed transition pathway for young people or adults with complex diabetes transitioning across services (e.g. paediatric to adult, primary to tertiary)

• Transition protocols
• Consumer co-design workshop records
• Longitudinal care maps

The service monitors key clinical indicators for safety and quality (e.g., HbA1c, hypoglycaemia, time in range, adverse events) and uses data to drive improvement

• Clinical audit reports
• Quality dashboards
• Meeting minutes discussing indicators

The service participates in quality improvement activities aligned with national diabetes goals or frameworks

• QI project reports
• Benchmarking data submissions
• Improvement plans

Incidents, critical events, and adverse outcomes are documented, escalated where appropriate, and reviewed through clinical governance processes to enable service improvement

• Incident reports
• risk registers
• action plans
• staff training follow-up

The service maintains timely, accurate, and secure clinical documentation to support communication, continuity of care, and safe follow-up of test results, referrals, and care decisions. Systems are in place for auditing, handover, and access

• Documentation audits Policies
• Communication logs
• Secure access protocols

The service uses digital health systems and databases that enable clinical documentation, safeguard privacy, and ensure data security in alignment with national data governance standards

• EMR screenshots
• My Health Record integration logs
• Data-sharing agreements

The service supports sustainable diabetes care by promoting use of reusable devices where appropriate, minimising single-use waste, and educating people with diabetes about proper disposal and environmentally conscious choices

• Examples of sustainable prescribing practices (e.g. reusable pens)
• Staff training resources
• Patient education materials referencing waste reduction

The service ensures regular cleaning, calibration, and maintenance of devices used in diabetes care. Protocols are in place for infection prevention in handling blood-contaminated items and sharps

• Device cleaning and calibration logs
• Infection control policies
• Staff induction materials
• Incident reporting protocols related to cross-contamination

The service co-designs and pilots system innovations to improve diabetes care delivery, which may include digital health solutions, integrated screening models, or technologyassisted care pathways

• Project plans
• Prototype testing logs
• Implementation case studies

The service leads or contributes to initiatives that promote equitable and ethical use of digital health tools in diabetes care. This includes ensuring accessibility for priority and underserved populations, and aligning digital solutions with person-centred principles, data privacy, and national digital health standards

• Reports or evaluations of digital inclusion projects
• Co-designed digital tools, education resources
• Accessibility audits
• Documentation for digital projects
• Outreach records
• Research publications

Staff are actively involved in reflective practice, regular service reviews, and collaborative development of programs and systems

• Staff feedback surveys
• Workshop summaries
• Minutes from quality or planning meetings
• Internal improvement project documentation
• Policies or protocols supporting reflective practice