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as charged with reviewing the current DSME standards for their appropriateness, relevance, and scientific basis. The Standards were then reviewed and revised based on the available evidence and expert consensus. The committee convened on 31 March 2006 and 9 September 2006, and the Standards were approved 25 March 2007. DEFINITION AND OBJECTIVES Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life. GUIDING PRINCIPLES Before the review of the individual Standards, the Task Force identified overriding principles based on existing evidence that would be used to guide the review and revision of the DSME Standards. These are: Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term (1–7). DSME has evolved from primarily didactic presentations to more theoretically based empowerment models (3,8).

GUIDING PRINCIPLES Before the review of the individual Standards, the Task Force identified overriding principles based on existing evidence that would be used to guide the review and revision of the DSME Standards. These are: Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term (1–7). DSME has evolved from primarily didactic presentations to more theoretically based empowerment models (3,8). There is no one “best” education program or approach; however, programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes (9–11). Additional studies show that culturally and age-appropriate programs improve outcomes (12–16) and that group education is effective (4,6,7,17,18). Ongoing support is critical to sustain progress made by participants during the DSME program (3,13,19,20). Behavioral goal-setting is an effective strategy to support self-management behaviors (21). STANDARDS Structure Standard 1. The DSME entity will have documentation of its organizational structure, mission statement, and goals and will recognize and support quality DSME as an integral component of diabetes care.

e explored, the coordinator plays a pivotal role in ensuring accountability and continuity of the educational process (23,60–62). The individual serving as the coordinator will be most effective if there is familiarity with the lifelong process of managing a chronic disease (e.g., diabetes) and with program management. Process Standard 5. DSME will be provided by one or more instructors. The instructors will have recent educational and experiential preparation in education and diabetes management or will be a certified diabetes educator. The instructor(s) will obtain regular continuing education in the field of diabetes management and education. At least one of the instructors will be a registered nurse, dietitian, or pharmacist. A mechanism must be in place to ensure that the participant's needs are met if those needs are outside the instructors' scope of practice and expertise.

n regular continuing education in the field of diabetes management and education. At least one of the instructors will be a registered nurse, dietitian, or pharmacist. A mechanism must be in place to ensure that the participant's needs are met if those needs are outside the instructors' scope of practice and expertise. Diabetes education has traditionally been provided by nurses and dietitians. Nurses have been utilized most often as instructors in the delivery of formal DSME (2,3,5,63–67). With the emergence of medical nutrition therapy (66–70), registered dietitians became an integral part of the diabetes education team. In more recent years, the role of the diabetes educator has expanded to other disciplines, particularly pharmacists (73–79). Reviews comparing the effectiveness of different disciplines for education report mixed results (3,5,6). Generally, the literature favors current practice that utilizes the registered nurse, registered dietitian, and the registered pharmacist as the key primary instructors for diabetes education and members of the multidisciplinary team responsible for designing the curriculum and assisting in the delivery of DSME (1–7,77). In addition to registered nurses, registered dietitians, and pharmacists, a number of studies reflect the ever-changing and evolving health care environment and include other health professionals (e.g., a physician, behaviorist, exercise physiologist, ophthalmologist, optometrist, podiatrist) (48,80–84) and, more recently, lay health and community workers (85–91) and peers (92) to provide information, behavioral support, and links with the health care system as part of DSME.

nted in behavioral terms and thereby exemplify the importance of action-oriented, behavioral goals and objectives (13,21,55,121–123,128,129). Creative, patient-centered experience-based delivery methods are effective for supporting informed decision-making and behavior change and go beyond the acquisition of knowledge. Standard 7. An individual assessment and education plan will be developed collaboratively by the participant and instructor(s) to direct the selection of appropriate educational interventions and self-management support strategies. This assessment and education plan and the intervention and outcomes will be documented in the education record. Multiple studies indicate the importance of individualizing education based on the assessment (1,56,68,131–135). The assessment includes information about the individual's relevant medical history, age, cultural influences, health beliefs and attitudes, diabetes knowledge, self-management skills and behaviors, readiness to learn, health literacy level, physical limitations, family support, and financial status (10–17,19,131,136–138). The majority of these studies support the importance of attitudes and health beliefs in diabetes care outcomes (1,68,134,135,138,139). In addition, functional health literacy (FHL) level can affect patients' self-management, communication with clinicians, and diabetes outcomes (140,141). Simple tools exist for measuring FHL as part of an overall assessment process (142–144).

Multiple studies indicate the importance of individualizing education based on the assessment (1,56,68,131–135). The assessment includes information about the individual's relevant medical history, age, cultural influences, health beliefs and attitudes, diabetes knowledge, self-management skills and behaviors, readiness to learn, health literacy level, physical limitations, family support, and financial status (10–17,19,131,136–138). The majority of these studies support the importance of attitudes and health beliefs in diabetes care outcomes (1,68,134,135,138,139). In addition, functional health literacy (FHL) level can affect patients' self-management, communication with clinicians, and diabetes outcomes (140,141). Simple tools exist for measuring FHL as part of an overall assessment process (142–144). Many people with diabetes experience problems due to medication costs, and asking patients about their ability to afford treatment is important (144). Comorbid chronic illness (e.g., depression and chronic pain) as well as more general psychosocial problems can pose significant barriers to diabetes self-management (104,146–151); considering these issues in the assessment may lead to more effective planning (149–151). Periodic reassessment determines attainment of the educational objectives or the need for additional and creative interventions and future reassessment (7,97,100,152). A variety of assessment modalities, including telephone follow-up and other information technologies (e.g., Web-based, automated phone calls), may augment face-to-face assessments (97,99).

he selected goals. For some areas, the indicators, measures, and timeframes may be based on guidelines from professional organizations or government agencies. In addition to assessing progress toward personal behavioral goals, a plan needs to be in place to communicate personal goals and progress to other team members. The AADE Outcome Standards for Diabetes Education specify self-management behavior as the key outcome (112,160). Knowledge is an outcome to the degree that it is actionable (i.e., knowledge that can be translated into self-management behavior). In turn, effective self-management is one (but not the only) contributor to longer-term, higher-order outcomes such as clinical status (e.g., control of glycemia, blood pressure, and cholesterol), health status (e.g., avoidance of complications), and subjective quality of life. Thus, patient self-management behaviors are at the core of the outcomes evaluation. Standard 10. The DSME entity will measure the effectiveness of the education process and determine opportunities for improvement using a written continuous quality improvement plan that describes and documents a systematic review of the entities' process and outcome data.

The AADE Outcome Standards for Diabetes Education specify self-management behavior as the key outcome (112,160). Knowledge is an outcome to the degree that it is actionable (i.e., knowledge that can be translated into self-management behavior). In turn, effective self-management is one (but not the only) contributor to longer-term, higher-order outcomes such as clinical status (e.g., control of glycemia, blood pressure, and cholesterol), health status (e.g., avoidance of complications), and subjective quality of life. Thus, patient self-management behaviors are at the core of the outcomes evaluation. Standard 10. The DSME entity will measure the effectiveness of the education process and determine opportunities for improvement using a written continuous quality improvement plan that describes and documents a systematic review of the entities' process and outcome data. Diabetes education must be responsive to advances in knowledge, treatment strategies, educational strategies, psychosocial interventions, and the changing health care environment. Continuous quality improvement (CQI) is an iterative, planned process (161) that leads to improvement in the delivery of patient education (162). The CQI plan should define quality based on and consistent with the organization's mission, vision, and strategic plan and include identifying and prioritizing improvement opportunities (163). Once improvement projects are identified and selected, the plan should incorporate timelines and important milestones including data collection, analysis, and presentation of results (163). Outcome measures indicate the result of a process (i.e., whether changes are actually leading to improvement), while process measures provide information about what caused those results (163–164). Process measures are often targeted to those processes that typically impact the most important outcomes. Measuring both process and outcomes helps to ensure that change is successful without causing additional problems in the system (164).

process measures provide information about what caused those results (163–164). Process measures are often targeted to those processes that typically impact the most important outcomes. Measuring both process and outcomes helps to ensure that change is successful without causing additional problems in the system (164). The previous version of the “National Standards for Diabetes Self-Management Education” was originally published in Diabetes Care 23:682–689, 2000. This version received final approval in March 2007. Acknowledgments Work on this article was supported in part by grant nos. NIH5P60 DK20572 and 1 R18 0K062323 from the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health. The Task Force gratefully acknowledges the assistance and support of Paulina Duker, MPH, APRN-BC, CDE, and Nathanial Clark, MD, CDE, of the American Diabetes Association; Lori Porter, MBA, RD, CAE, of the American Association of Diabetes Educators; and Karmeen Kulkarni, MS, RD, BC-ADM, Past President, Health Care and Education of the American Diabetes Association; Malinda Peeples, MS, RN, CDE, Past President of the American Association of Diabetes Educators; and Carole' Mensing, RN, MA, CDE, for their insights and helpful suggestions.

ation of Diabetes Educators; and Karmeen Kulkarni, MS, RD, BC-ADM, Past President, Health Care and Education of the American Diabetes Association; Malinda Peeples, MS, RN, CDE, Past President of the American Association of Diabetes Educators; and Carole' Mensing, RN, MA, CDE, for their insights and helpful suggestions. We also gratefully acknowledge the work of the previous Task Force for the National Standards for DSME: Carole' Mensing, RN, MA, CDE; Jackie Boucher, MS, RD, LD, CDE; Marjorie Cypress, MS, C-ANP, CDE; Katie Weinger, EdD, RN; Kathryn Mulcahy, MSN, RN, CDE; Patricia Barta, RN, MPH, CDE; Gwen Hosey, MS, ARNP, CDE; Wendy Kopher, RN, C, CDE, HTP; Andrea Lasichak, MS, RD, CDE; Betty Lamb, RN, MSN; Mavourneen Mangan, RN, MS, ANP, C, CDE; Jan Norman, RD, CDE; Jon Tanja, BS, MS, RPH; Linda Yauk, MS, RD, LD, CDE; Kimberlydawn Wisdom, MD, MS; and Cynthia Adams, PhD

as charged with reviewing the current DSME standards for their appropriateness, relevance, and scientific basis. The Standards were then reviewed and revised based on the available evidence and expert consensus. The committee convened on 31 March 2006 and 9 September 2006, and the Standards were approved 25 March 2007. DEFINITION AND OBJECTIVES Diabetes self-management education (DSME) is the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life. GUIDING PRINCIPLES Before the review of the individual Standards, the Task Force identified overriding principles based on existing evidence that would be used to guide the review and revision of the DSME Standards. These are:Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term (1–7). DSME has evolved from primarily didactic presentations to more theoretically based empowerment models (3,8).

GUIDING PRINCIPLES Before the review of the individual Standards, the Task Force identified overriding principles based on existing evidence that would be used to guide the review and revision of the DSME Standards. These are:Diabetes education is effective for improving clinical outcomes and quality of life, at least in the short-term (1–7). DSME has evolved from primarily didactic presentations to more theoretically based empowerment models (3,8). There is no one “best” education program or approach; however, programs incorporating behavioral and psychosocial strategies demonstrate improved outcomes (9–11). Additional studies show that culturally and age-appropriate programs improve outcomes (12–16) and that group education is effective (4,6,7,17,18). Ongoing support is critical to sustain progress made by participants during the DSME program (3,13,19,20). Behavioral goal-setting is an effective strategy to support self-management behaviors (21). STANDARDS Structure Standard 1. The DSME entity will have documentation of its organizational structure, mission statement, and goals and will recognize and support quality DSME as an integral component of diabetes care.

betes community (98). An additional credential that indicates specialized training beyond basic preparation is board certification in advanced Diabetes Management (BC-ADM) offered by the American Nurses Credentialing Center (ANCC), which is available for master's prepared nurses, dietitians, and pharmacists (48,84,99). DSME has been shown to be most effective when delivered by a multidisciplinary team with a comprehensive plan of care (7,31,52,100–102). Within the multidisciplinary team, team members work interdependently, consult with one another, and have shared objectives (7,103,104). The team should have a collective combination of expertise in the clinical care of diabetes, medical nutrition therapy, educational methodologies, teaching strategies, and the psychosocial and behavioral aspects of diabetes self-management. A referral mechanism should be in place to ensure that the individual with diabetes receives education from those with appropriate training and credentials. It is essential in this collaborative and integrated team approach that individuals with diabetes are viewed as leaders of their team and assume an active role in designing their educational experience (7,20,31,100–102,104). Standard 6. A written curriculum reflecting current evidence and practice guidelines, with criteria for evaluating outcomes, will serve as the framework for the DSME entity. Assessed needs of the individual with pre-diabetes and diabetes will determine which of the content areas listed below are to be provided:Describing the diabetes disease process and treatment options

vidence and practice guidelines, with criteria for evaluating outcomes, will serve as the framework for the DSME entity. Assessed needs of the individual with pre-diabetes and diabetes will determine which of the content areas listed below are to be provided:Describing the diabetes disease process and treatment options Incorporating nutritional management into lifestyle Incorporating physical activity into lifestyle Using medication(s) safely and for maximum therapeutic effectiveness Monitoring blood glucose and other parameters and interpreting and using the results for self-management decision making Preventing, detecting, and treating acute complications Preventing detecting, and treating chronic complications Developing personal strategies to address psychosocial issues and concerns Developing personal strategies to promote health and behavior change