Personalised Care and Support Plan
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About this toolkit

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Getting to grips with the standard


Getting people on board

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Taking stock and planning

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Putting the standard into practice

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Shared resources and learning

Taking stock and planning

Before embarking on a change programme to implement the Diabetes Record Information Standard, organisations need to understand their starting point including readiness of the workforce, any current or planned systems and the local priorities for change.

This will help inform a route map where changes can be delivered in small, achievable steps, building confidence and momentum, and increasing chances of successful change. Progress can be measured against the priorities and goals agreed by local stakeholders.

small group of people in a workshop session

This section takes you step-by-step through assessing your readiness to change, taking stock of your current position and planning implementation of the Diabetes Record Information Standard. There are three phases consisting of:  

There are three phases:

  • Assess your readiness: The current state from clinical, technical and operational perspectives
  • Plan the changes
  • Agree how you will measure and evaluate the change programme

Assess your readiness

The following tools will help you at the beginning of your project to evaluate the readiness of your organisation:

Planning a stock take

Follow the steps below to start planning your stock take.

Schedule events and meetings to tell people about your standard implementation plans as part of digital transformation and encourage them to join in the project.

Check your understanding of the problem you might be trying to fix and consider how your sense of the situation is different from the view other stakeholders might have based on their different knowledge and experience, for example as point-of-care professionals.

Offer an opportunity to bring representatives from different stakeholder and professional groups together to find out what they might have in common, how they are different in their approaches, culture, and language, and how they can work towards a shared objective.

Remember that the implementation of the PRSB (Professional Record Standards Body) standard is a people-based cultural endeavour and cannot succeed without the hearts, minds and professional expertise of all your stakeholders.

Holding a stock take workshop

The table below illustrates how you might plan a stakeholder workshop to take stock of your local system’s readiness to adopt the Diabetes Information Record Standard. 

It outlines your potential participants, the purpose of the stock take and what materials/questions you may want to include in the sessions.

Systems and data flows

To understand how diabetes process and outcome information is currently recorded in each of the stakeholder organisations it is recommended that an information gathering exercise is undertaken.

The grid below can be used to capture how each stakeholder group currently captures and shares diabetes process and outcome information:

Process mapping

To help us understand each step in the capturing and sharing of diabetes information a process mapping exercise can be undertaken by your organisation. 

The ‘to be’ process maps should then be developed for each of the systems that will be implementing the Diabetes Record Information Standard and should take a whole service (patient pathway) design approach.

Download the process map


To baseline a project you will need to consider four elements; milestones, budget, schedule and scope.

  • Milestones: These are the key points in a project you expect to reach by a specific date or range within the project’s start and end dates.
  • Budget: Your budget is how much you plan to spend on the project.
  • Schedule: When planning any project, you and your team members need to know its duration. The schedule baseline is your project’s planned timeline.
  • Scope: Scope is the expected project outcome, any deliverables, and the problem they solve.
woman smiling at work colleague

Beyond these four elements, you may also want to include other project documents like the work breakdown structure (WBS), activity or task list, and more, to add detail to each of these steps.

Your organisation’s Project Management Office (PMO) will have project management templates to support you to baseline and deliver you project. However as the Diabetes Information Standard is best implemented in partnership across multiple organisations (e.g Integrated Care System) it may be that each organisation has its own project plan which feeds into an overarching programme plan.

Assessing current conformance to the standard

How your system supplier can conform to our standard

The PRSB team work closely with system suppliers and health and care providers to implement the standard and also provide robust and independent evidence of their implementation with the award of the PRSB Quality Mark. Systems which have undergone this process can be found on the Quality Partner section of our website.

Your can ask system suppliers to provide evidence of their level of compliance including whether they have been independently assessed and achieved the PRSB Quality Mark. Even if the supplier system is compliant, you will still need to check that your local implementation is compliant. For help and support with assessing compliance with standards, please get in touch with the PRSB help desk.

If a supplier system is unable to reach compliance, a procurement exercise may need to be undertaken.

System suppliers should provide evidence that they conform with the standard. More information can be found in the standards conformance process section.


If, as part of the stock take, a system procurement is identified the choice of system procurement route is a local decision and driven in part by the proposed option (for example an extension to an additional service or system vs. a completely new procurement).

There will be national and local procurement protocols that will need to be followed in relation to the PRSB standard implementation.

Understanding governance requirements

It is important to engage the local care system Information Governance team early in the project. They will confirm what activity must be done prior to any data sharing.

Regardless of the system being used for sharing information, Information Governance is a key requirement. If your area has a shared care record in place you may find an over-arching Information Sharing Agreement (ISA) has already been signed by the data sharing partner organisations.

Data Protection Impact Assessment

If the sharing of diabetes process and outcome information involves a new set of data about a person or significantly changes the way in which the data is processed, you will need to carry out Data Protection Impact Assessment (DPIA). The DPIA is a structured assessment of the potential impact on confidentiality, privacy, and data protection. The data items to be shared or processed are included. Your Information Governance team will have a DPIA template for you to complete.

Clinical safety and risk management

It is recommended that you make contact with your local care system clinical safety officer or clinical safety management team early in the project. They will be able to advise you on the clinical safety management process that is in place and advise on the development of the clinical safety management process and fulfilling DCB0160 (see below).

Organisations embarking on deployment of health IT systems are required to apply clinical risk management for the deployment, use, maintenance or decommissioning of Health IT Systems within the health and care environment NHS England standard DCB0160 expands on the DCB0129 clinical safety standard applied by the manufacturers of the health IT system.

Health organisations must establish a framework within which the clinical risks associated with the deployment and implementation of a new or modified health IT system are properly managed.

See NHS England’s Clinical risk management guidance

Building a roadmap

Taking all the baseline evidence and material gathered, develop your local roadmap for change. Focus on all aspects of change including staff readiness.

Work with key stakeholders to develop the plan to ensure commitment and buy-in. 

Here is an example roadmap that you may want to follow as a guide.

Checklist and questions to consider

The following checklist will help you determine whether you have the right leadership, governance and controls in place for a transformation programme to succeed. The set of questions that follows will help you gauge your readiness to take stock and plan your transformation programme.


Clear senior management ownership and leadership

Appropriate skills for the programme/project team

Clear roles and responsibilities

Effective financial control

Success criteria that clearly link objectives to outcomes, and clear links with the organisation’s key strategic priorities

Effective risk management

Sound commercial knowledge of the supplier marketplace, linked to the requirement and management of the supplier over the contract term

Involvement of key stakeholders throughout the programme/project

Breaking development and implementation into manageable steps

Effective project team integration between clients, the supplier team and the supply chain


What are the ‘fixed’ points – e.g. system upgrades, procurements etc.?

What activities must take place to achieve change? Awareness raising, training, information governance agreements, clinical safety assessments, system changes, testing etc.

What have stakeholders identified as the biggest priorities for them and when could those changes be delivered?

What are the dependencies? What must happen before other changes can be achieved?

Which changes could be achieved relatively quickly and achieve tangible benefits for staff and patients?

What are the opportunities for piloting the new system (or parts of the new system) on a small scale and who needs to be involved?

Should organisations join the process in a phased way? What is the preferred phasing for organisations joining in?

What needs to happen to ensure smooth running of existing systems during the transition?

What needs to happen to ensure smooth running of existing systems during the transition?

Desired outcomes and measuring

The review of the systems and data flows across the organisations, may provide an opportunity to review the current diabetes key performance indicators (KPIs). The KPIs should be used to develop a baseline measurement to be used to evidence improvement upon implementing the standard. However, current KPIs may not be agreed across the whole system and may require further work to reach a common set of indicators.

measuring outcomes images

There will already be nationally reported metrics which will be monitored and are noted in the business case as a driver for change and these could be used as the basis for KPIs.

For diabetes there is a family of audits conducted under the National Diabetes Audit Programme for England and Wales (National Diabetes Audit Programme – NHS Digital). The audit measures the effectiveness of diabetes healthcare against NICE Clinical Guidelines and NICE Quality Standards.

Example measures below are taken from the Core National Diabetes Audit but there are other measures from the suite of diabetes audits that could also be used:



Measures (SNOMED CT)

NICE recommends that people with type 1 diabetes should have HbA1c checks every 3 to 6 months (or more often if the person’s blood glucose control is suspected to be changing rapidly)

Improvement in percentage of people diagnosed with T1 diabetes that have a record of having two or more HbA1c tests within a year.

371981000000106 |Haemoglobin A1c measurement – International Federation of Clinical Chemistry and Laboratory Medicine standardised (procedure)|

43396009 |Hemoglobin A1c measurement (procedure)|

1107481000000106 |Substance concentration of haemoglobin A1c in blood (observable entity)|

NICE recommends that people with type 1 diabetes should be offered structured education 6 to 12 months after diagnosis.

Improvement in percentage of people diagnosed with T1 diabetes that have a record of being offered structured education, by year of diagnosis

1103691000000102 |Diabetes structured education programme offered (situation)|

306591000000103 |Diabetes structured education programme declined (situation)|

<< 415270003 |Referral to diabetes structured education program (procedure)|


Improvement in percentage of people diagnosed with T1 diabetes that have a recorded structured education programme attendance, by year of diagnosis

<< 413597006 |Attended diabetes structured education program (finding)|

NICE recommends that smoking should be assessed annually as it is cardiovascular risk factor. They also recommended that adults with type 1 diabetes who smoke should be given advice on smoking cessation and use of smoking cessation services.

 Improvement in percentage of people with T1 diabetes that have their smoking status checked annually

^ 999000891000000102 |Smoking simple reference set (foundation metadata concept)|

NICE recommends that blood pressure should be measured at least annually as it is cardiovascular risk factor.

 Improvement in percentage of people with T1 diabetes that have their blood pressure measured annually

<< 46973005 |Blood pressure taking (procedure)|

< 392570002 |Blood pressure finding (finding)| MINUS (129899009 |Blood pressure alteration (finding)| AND 55973006 |Decreased pulmonary arterial wedge pressure (finding)| AND << 392571003 |Finding of arterial pulse pressure (finding)| AND 24184005 |Finding of increased blood pressure (finding)| AND 301141002 |Finding of pulmonary arterial pressure (finding)| AND << 366161004 |Finding of venous pressure (finding)| AND 9027003 |Normal pulmonary arterial wedge pressure (finding)|)

<< 18352002 |Abnormal systolic arterial pressure (finding)|

49844009 |Abnormal diastolic arterial pressure (finding)|

< 24184005 |Finding of increased blood pressure (finding)| MINUS (12377007 |Increased central venous pressure (finding)| AND 30261008 |Increased pulmonary arterial wedge pressure (finding)| AND 80436007 |Increased venous wedge pressure (finding)|)

< 163020007 |On examination – blood pressure reading (finding)| MINUS << 274283008 |On examination – jugular venous pulse (finding)|

<< 163023009 |On examination – blood pressure reading low (disorder)|

271870002 |Low blood pressure reading (disorder)|

<< 75367002 |Blood pressure (observable entity)| MINUS (<<37087001 |Arterial wedge pressure (observable entity)| AND << 165077006 |Intracardiac pressure (observable entity)| AND <<386533006 |Invasive blood pressure (observable entity)| AND <<1036531000000108 |Non-invasive central blood pressure (observable entity)| AND << 386536003 |Systemic blood pressure (observable entity)| AND <<252076005 |Venous pressure (observable entity)| AND 276764003 |Wedge pressure – a wave (observable entity)| AND 276766001 |Wedge pressure – v wave (observable entity)| AND 276765002 |Wedge pressure – x trough (observable entity)| AND 276767005 |Wedge pressure – y trough (observable entity)|)

NICE recommends that serum cholesterol (blood test for cardiovascular risk) is tested at least annually.

Improvement in percentage of people with T1 diabetes that have their serum cholesterol tested annually

166836002 |Serum cholesterol studies (procedure)|

<< 271244005 |Measurement of serum lipid level (procedure)| MINUS (313768006 |Serum apolipoprotein A-I measurement (procedure)| AND 313769003 |Serum apolipoprotein A-II measurement (procedure)| AND 313770002 |Serum apolipoprotein B measurement (procedure)| AND <<412989000 |Serum long chain fatty acid measurement (procedure)| AND 391341007 |Serum phytanic acid level (procedure)| AND << 269868008 |Serum sodium valproate measurement (procedure)|)

<<77068002 |Cholesterol measurement (procedure)|

<< 365793008 |Finding of cholesterol level (finding)|

NICE recommends that serum creatinine (blood test for kidney function) is tested at least annually.

Improvement in percentage of people with T1 diabetes that have their serum creatinine tested annually

<< 54610007 |Kidney panel (procedure)|

<< 113075003 |Creatinine measurement, serum (procedure)|

<< 1107001000000108 |Substance concentration of creatinine in serum (observable entity)|

<< 365757006 |Finding of serum creatinine level (finding)|

NICE recommends that Body Mass Index (measurement for cardiovascular risk) is measured at least annually.

Improvement in percentage of people with T1 diabetes that have their BMI measured annually

698094009 |Measurement of body mass index (procedure)|

<< 60621009 |Body mass index (observable entity)|

<< 301331008 |Finding of body mass index (finding)|

NICE recommends that Urine Albumin/Creatinine Ratio (urine test for risk of kidney disease) is tested at least annually.

Improvement in percentage of people with T1 diabetes that have their Urine Albumin/Creatinine Ratio tested annually

271075006 |Urine albumin/creatinine ratio measurement (procedure)|

<< 1023491000000104 |Urine albumin:creatinine ratio (observable entity)|

NICE recommends that foot risk surveillance (examination for foot ulcer risk) is carried out at least annually

Improvement in percentage of people with T1 diabetes that have their foot risk checked annually

<< 870681000000109 |In-house diabetic foot screening (procedure)|

394683006 |Diabetic foot risk assessment (procedure)|

367011000000100 |Diabetic foot screen (regime/therapy)|

401191002 |Diabetic foot examination (regime/therapy)|

407672007 |Seen in diabetic foot clinic (finding)|

<< 164480009 |On examination – foot (finding)| MINUS (<<416178005 |On examination – abnormal foot color (finding)| AND 164481008 |On examination – equinovarus (finding)| AND << 416854003 |On examination – foot color normal (finding)| AND 416854003 |On examination – foot color normal (finding)| AND 164486003 |On examination – in turning feet (finding)| AND 414891006 |On examination – left dorsalis pedis pulse normal (finding)| AND 308104009 |On examination – Left foot deformity (finding)| AND 414895002 |On examination – left healed foot ulcer (finding)| AND 414907000 |On examination – right dorsalis pedis pulse normal (finding)| AND 308103003 |On examination – Right foot deformity (finding)| AND 414911006 |On examination – right healed foot ulcer (finding)| AND 1033261000000109 |On examination foot callus present (finding)|)

NICE recommends that digital retinal screening (photographic eye test for early detection of eye disease) is carried out at least annually

Improvement in percentage of people with T1 diabetes that have their eyes tested annually

134395001 |Diabetic retinopathy screening (procedure)|

775841000000109 |Diabetic retinopathy detected by national screening programme (disorder)|

<< 4855003 |Retinopathy due to diabetes mellitus (disorder)|

201141000000103 |No diabetic retinopathy (situation)|

<< 721103006 |Diabetic retinopathy of eye not detected (situation)|

<<373031000000105 |Diabetic retinopathy screening administrative status (finding)|

NICE recommends that people with type 1 diabetes should aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long-term vascular complications.

Improvement in percentage of people with T1 diabetes that have an HbA1c level of 48 mmol/mol (6.5%) or lower

1107481000000106 |Substance concentration of haemoglobin A1c in blood (observable entity)|

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PRSB Standards Explained

Why we need standards to record our health and care information in a consistent way so that it can be made available whenever it is needed.

Making change happen

Transformation programmes need clear goals, the right leadership and engaged staff and stakeholders. Get started by reading our information on transformational change.

PRSB Support Available

If you have a question for PRSB, please contact our support team. We have an expert team who can help you find the answer, or direct you to the right place.