NURS FPX 9040 Assessment 1 Manuscript with Abstract

Abstract

There is a significant gap in glycemic control in the outpatient primary care setting with most of the non-deal control coming from lack of follow up, poor patient education and poor medication management in adults with type 2 diabetes. There was a higher percentage of patients with HbA1c level >9% at the project site (42%) as compared to the national average of 22% of U.S. adults with diabetes (Adjei et al., 2025; APRN, personal communication, November 2025). The PICOT question used to guide the research was: For the diabetes nurse caring for diabetes adults (P), what is the difference between the effect of using the ADA diabetes follow-up protocol (I) and the current practice (C) on glycemic control (O) in 8 weeks (T)? The quality improvement project involved a structured follow-up protocol in an outpatient primary care setting, and was designed to be ADA compliant, for 8 weeks. The interdisciplinary implementation team was all health care providers and nurse professionals who received education and training through structured learning sessions on diabetes management and use of EHRs. In bi-weekly follow-up visits, adult patients with type 2 diabetes were involved. Evaluation was performed on HbA1c results, frequency of visits, and adherence checking utilizing functionality in the EHR. A mean change in HbA1C was 1.52 percentage points (9.95% to 8.22%) that exceeded the success criterion of 0.5%. Follow-up was good with 89.2% attendance of follow-up visits. The HbA1c goal of <7% was not reached by 10% of the people within 8 weeks. Such use of this structured protocol to follow ADA standards was determined to benefit glycemic control and thus it is said to prove the PICOT hypothesis. Research suggests that protocol-based care with the nurse has a positive effect on diabetes care. There may be a need for longer intervention time for optimal target achievement, however. The project contributes to more sustainable adoption of more harmonised follow-up procedures to enhance the management of chronic diseases in primary care.

Keywords: Diabetes Management, HbA1c Reduction, Nurse-Led Intervention, Outpatient Primary Care, Quality Improvement, Follow-Up Protocol.

Table of Contents

Improving Glycemic Control in Adult Patients with Type 2 Diabetes Through Implementation of a Structured ADA Diabetes Follow-Up Protocol in an Outpatient Primary Care Setting. 5

Practice Problem.. 5

Project Site. 8

Project Population. 10

Evidenced-Based Interventions. 12

Role of the Project Lead. 16

Roles of Other Team Members. 17

Literature Synthesis. 18

Analysis of Evidence. 20

Theme 1: ADA Guideline Adherence and Clinical Practice Standards. 22

Theme 2: Nurse-Led Interventions and Staff Competency Development 24

Theme 3: Diabetes Self-Management Education and Support Interventions. 26

Theme 4: Technology-Enhanced Diabetes Care and Remote Follow-Up Protocols. 28

Synthesis of Findings. 30

Implementation Plan for the Intervention. 31

Conceptual Model 33

Data Collection and Analysis. 35

Ethical Considerations. 37

Project Results. 39

Project Outcomes. 40

Recommendations. 43

Summary. 44

Appendix A.. 58

Demographic Characteristics and Baseline HbA1c (N = 20) 58

Appendix B.. 60

HbA1c Outcomes Across Measurement Time Points (N = 20) 60

Appendix C.. 62

Follow-Up Adherence and Visit Completion Data (N = 20) 62

Appendix D.. 64

Nursing Staff Competency Assessment Results (N = 8) 64

Appendix E.. 65

Self-Management Behavior Checklist — Week 8 (N = 20) 65

Appendix F. 67

Summary Statistics: Project Implementation Outcomes. 67

Improving Glycemic Control in Adult Patients with Type 2 Diabetes Through Implementation of a Structured ADA Diabetes Follow-Up Protocol in an Outpatient Primary Care Setting

Lack of standardised and protocol-led pathways for follow-up is an important practice gap occurring across outpatient primary care practice settings. It has the potential for missed opportunities for education, non-standardised medication review, and preventable complications amongst adult patients with type 2 diabetes mellitus. Only 36% of the adults in the project site had hemoglobin A1c levels < 7%, and 42% with hemoglobin A1c levels > 9%, far below the target level in the U.S., seen at the national level, where 38% of U.S. adults with diabetes have hemoglobin A1c levels < 7% (Adjei et al., 2025; APRN, personal communication, November 2025). Despite the known clinical practice guidelines of the American Diabetes Association, gaps in implementation persist in areas of follow-up, staff competency, and structured patient education in all levels of diabetes care provided by nurses in primary care settings. PICOT question: In the care of the adult patient with diabetes (P), does the use of the ADA diabetes follow-up protocol (I) improve glycemic control (O) over 8 weeks (T) over the care of the adult patient with diabetes using the current practice (C)? A structured follow-up process with a system of successive steps in treatment, staff competence development, and patient education on self-management will lead to clinically important glycemic results and to evidence-based practice in the outpatient primary care environment for chronic disease management.

Practice Problem

Chronic disease management programs (CDM) for outpatient primary care should be systematic, evidence-based, and effective in bridging the gap between diabetic control in adults with type 2 diabetes and the desired health system outcomes. From the site-level data of the outpatient primary care clinic, 42% of all the adult patients had out-of-range HbA1c levels>9%, and 36% had levels <7% (APRN, personal communications, November 2025). The national performance data for the adult population with diabetes is also poor – nearly a quarter (22%) of the adult diabetes population with a history of diabetes is not well controlled and nearly half (45%) of all adult diabetes patients worldwide have never met an HbA1C below 7% (Adjei et al., 2025; Dinavari et al., 2023) – which is far below the healthy benchmarks of health systems. An HbA1c level of above 9% is indicative of the poor metabolic control of 1 in 4 adults in the United States and Europe (Gomes et al., 2022). Among adults with diabetes who visit an outpatient clinic, low glycemic control is mostly attributable to behavioral and demographic risk factors; the need for early identification of those with a higher risk of low glycemic control and use of structured clinical intervention to achieve glycemic control is highlighted (Karmakar et al., 2025). The quantitative information collected on this site gives it an objective measure by which to enhance the quality of the site in use for a specific intervention at the practicum site.

A thorough assessment of existing workflow and process flows, staffing patterns,s and care coordination efforts in the clinical setting is needed to determine the causal factors associated with poor glycemic control fully. Challenges with scheduling EHR, lack of structured follow-up, and inconsistent delivery of education were noted as typical issues affecting delivery of core processes identified during the chart review and documentation review at the project site (APRN, personal communication, November 2025). A lack of a follow-up plan that was protocolised meant there was no consistent arrangement for follow-up, inconsistent use of reminders on the EHR, and no multidisciplinary coordination, which impacted timely adjustments to the medications and delivery of tailored education for patients most likely to develop complications (APRN, personal communication, November 2025). There were also systemic issues with setting up visits and tracking patients via APRN that were identified during follow-up visit completion rates and via the EHR documentation audit (APRN, personal communication, November 2025). Improved access to education through the use of a monthly, general educational session was provided in the past; some of these sessions supported by telehealth did not have clear evaluation tools which meant that patients didn’t always understand the content and there was a lack of consistency in the delivery of education (Dailah, 2024). Therefore, the need for a follow-up pathway that has been protocolized was determined as the most modifiable determinant that came out of the comprehensive needs assessment of the identified practice gap.

When the ‘all stakeholders’ approach is applied to chronic disease management, a lot of attention will have to be given to which of these stakeholders will be impacted by ‘what’ and what responses will need to be made in a timely and systematic manner to support them to improve quality. However, poorly controlled diabetes has been associated with higher morbidity and mortality rates, higher health services utilization, and higher burden of long-term diabetes complications such as heart disease, neuropathy, and preventable hospitalizations; all of which impact key stakeholders of the continued glycemic disparities, namely nursing staff, diabetic adults, and leaders. Results revealed that the use of timely and effective evidence-based interventions was not clinically justifiable: for structured nurse-led interventions, the effects of structured nurse-led interventions on HbA1C were shown to be approximately 0.4–0.9 percentage points across all outpatient primary care settings, reflecting strong evidence for the impact of structured nurse-led interventions (Sun et al., 2025). With regard to glycemic control, there is a national report of sub-optimal glycemic control which needs to be addressed immediately with a standardized method at the project site, particularly with vulnerable and low-income patients (Centers for Disease Control and Prevention, 2024). To address this identified practice gap, not only was this a clinical need, but it was also an organizational strategic priority in keeping with the mission of the site to give accessible, evidence-informed primary care.

Project Site

The foundation of implementing structured chronic disease management interventions is diverse outpatient primary care clinics in urban areas. One such example was the outpatient primary care clinic in New York City that was the project site. The clinic population is wide-ranging and includes adults from diverse cultural and socio-economic backgrounds. Around 60% of the clinic’s patients suffer from long-term diseases like diabetes and hypertension (APRN, personal communication, November 2025). The clinic’s infrastructure consists of 6 examination rooms, 2 private rooms for counselling, Telehealth workstations with the option of Virtual Business and Patient Remote Monitoring. There are six health care professionals (nurse practitioners, medical assistants, a care coordinator, and a health educator), and office staff with care-coordinating responsibilities and work-related demands related to patient care. The clinic’s vision is to help people be healthy by offering primary care and preventive health services that are accessible to the community and based on evidence. Thus, the clinic is an appropriate setting to develop a quality improvement project related to diabetes.

Learning about the specific context of the practice site will allow the reader to appreciate the timing and appropriateness of a quality improvement project to address a practice issue. The clinic is mainly for health education and for follow-up and chronic disease management. Opportunity to expand diabetes follow-up process with an established process (APRN, personal communication, November 2025), health education, continuity of care, and management of chronic conditions without any significant organizational changes needed. The clinic implemented electronic health records, facilitating improved patient data management, appointments,s and monitoring of outcomes. There was already an established standardised protocol for helping to educate patients and offering medication reinforcement; therefore, the protocol would be added to current protocols and would not place a strain on staff. There was a gap in practice, and the leadership agreed that the project was important as it had potential clinical and financial implications. Leadership knew that glycemic stabilization would help propel this organization’s performance metrics for quality and would allow it to meet value-based care and patient satisfaction requirements. The project closely followed the strategic priorities of the organization and provided an ideal setting for the quality improvement intervention at the practicum site.

The team working in the practicum site engaged in careful study of the process for diabetes management prior to the project to gain an understanding of how the current process has contributed to poorer glycemic control outcomes in the practicum site. The most frequently mentioned aspects of diabetes care and education by the nursing staff were frequent visits of the providers and the absence of a structured and/or standardized follow-up process for both types of diabetes care. There was no standard follow-up process, and translation of diabetes education and communication about self-management measures between nurses and patients was inconsistent. The process issues that mattered most were: ad hoc scheduling and rescheduling, untimely use of EHR reminders, lack of multispecialty coordination, and lack of proper review of patient follow-up data to lead to timely medication changes and targeted patient education for patients at greatest risk. The glycemic outcomes and adherence to recommended self-management behaviors of patients have been shown to be poorer in unstructured diabetes care processes in outpatient care settings consistently (Heise et al., 2022). In addition, benchmarking and routine use of a follow-up protocol and incorporating it into EHRs have been found to decrease missed visits, delays in timely interventions, and quality gaps in diabetes management (Wang et al., 2025). An evidence-based needs assessment (baseline data extraction, staff interviews, chart auditing, and EHR auditing data) identified a need for an intervention to address poor diabetes follow-up at the clinic. The process failures point to the need for implementing a diabetes follow-up programme based on a protocol at the practicum site.

Project Population

Knowing who the target population is and defining it is fundamental for interventions for quality improvement to be effective and for the expectation of real, measurable results. The project population was identified as a subset of nursing staff who provide care for patients with type 2 diabetes in the outpatient primary care clinic only, as that’s where the intervention was to be used to boost nursing staff competency levels for implementing the standardized ADA diabetes follow-up protocol (APRN, personal communication, November 2025). There were also differences in the approaches to diabetes management and patient education among the various types of nursing staff within the project due to their different education, clinical training, and professional experiences. A minimum of 8-10 nursing staff members were needed to gain meaningful progress on competency levels and follow up on the registered diabetes protocol. The targeting of the intervention to address identified competencies, the development of that intervention, and its implementation all took into account whole-staff competency mapping that occurred in the initial design of the quality improvement intervention.

The example mentioned characteristics of the nursing staff as the basis for preparation towards the implementation of a standardized diabetes follow-up intervention. Most project nurses were either registered nurses (RN) or nurse practitioners (NP) in the state who are licensed and directly care for adults with type 2 diabetes as part of a nurse-led multidisciplinary team that includes education, self-management support, port, and chronic disease follow-up as a core component (APRN, personal communication, November 2025). Prior to the intervention, the nursing staff showed a wide range of confidence, knowledge, and level of practice of established diabetes management protocols (pre-intervention competency level 59%), and it was evident that an integrated structured diabetes education program was needed. The multidisciplinary nursing team included three nurse practitioners, two medical assistants, one care coordinator, and one health educator, and took part in the structured competency development program. The common characteristics of the professional staff members provided a good starting point for developing a quality improvement program for the follow-up protocol intervention for the ADA.

The inclusion/exclusion criteria for the nursing staff in the project resulted in a population focus, where any improvement of the population in terms of glycemic outcomes would be included in the project if the care provided by the staff member involved in the project. The inclusion criteria for the project focused on nursing staff who provide care to adults who have a type 2 diabetes diagnosis; engaging in patient education regarding diabetes, providing medication management for diabetes, and/or providing diabetes-related follow-up as part of normal, routine clinical functions at the clinic (APRN, personal communication, November 2025). All nursing staff at the site have to engage in all of the above roles and have to be actively working in the project site during the entire eight weeks of the implementation period, and actively working in clinical provider roles directly related to the follow-up protocol goals of the ADA. The project excluded the following nursing staff: Nursing staff who were employed in administrative positions (not engaged in direct patient care), Nursing staff in support positions (not engaged in providing direct patient care), Nursing staff who held temporary and/or short-term employment positions (not providing adequate direct patient care). The project’s inclusion criteria, as well as the exclusion criteria for the project, greatly enhanced the internal validity of the project and allowed for the results of the structured intervention to accurately reflect the impact of the structured intervention on the nursing population included in the project.

Evidenced-Based Interventions

Effective quality improvement efforts need to build on more than one intervention component in order to gain greater and more sustained glucose improvements than single-component interventions do. Literature validated the need for a blend of strategies to ensure fidelity and outcomes, and that the strategies need to be scalable, culturally appropriate, EHR-integrated, and iteratively measured. During an 8-week implementation period, the project implemented the recommended diabetes follow-up protocol from the ADA more consistently, which was able to support diabetes care processes. Healthcare providers received diabetes-specific education sessions on diabetes pathophysiology, effective utilization of EHR tools for monitoring outcomes, and also to enhance patient engagement and adherence (Fracso et al., 2022). To encourage and support the practical implementation of evidence-based diabetes management concepts in the real world, the educational programme involved simulation sessions, case scenario sessions, and peer mentoring sessions. Teaching observations, a performance checklist, and knowledge tests were used to assess pupil competency to ensure that they can use validated patient education resources and consistently follow a standard process for follow-up procedures with confidence. Staff education was key to the sustainability of the initiative, and was important for staff to share ownership, standardize clinical practice, and encourage a culture of continuous improvement (Dailah, 2024). Regular refresher, peer discussion, and feedback circuits were added to help explore barriers and assess the impact of training and sharing best practices among the nursing participants. The HbA1c parameters were selected as there were known quasi-experimental outpatient clinical sites that demonstrated substantial decreases in HbA1c (Kerari et al., 2024). The health literacy and resource differences proved to be important. They will impact the applicability of the ADA guidance. Still, the design used for the intervention was iterative and somewhat similar to the design of the structured 8-week intervention that was developed by ADA (American Diabetes Association, 2024). The transfer of ADA standards into the system of the clinic processes laid the groundwork for achieving measurable results in glycemic control during the entire implementation.

A multidisciplinary team-based care was implemented, with the aim of sharing the clinical responsibilities in a fair manner amongst the clinicians, care coordinators, and the health educator. The rationale of interprofessional role distribution in clinical implementation was also evident in the consistent reduction in hospitalizations and improvement in adherence to population-level diabetes care in team-based models (ElSayed et al., 2022). In addition to the clinical team, competency-oriented team trainings were provided, resulting in improved coordination and fidelity to implementation of all roles in the clinic in delivering the interventions (Samardzic et al., 2020). It was consistently found that interventions at the system (whole approach) level with multiple providers resulted in higher levels of change versus single provider education interventions (ElSayed et al., 2022; Samardzic et al., 2020). However, the amount of resources needed and staffing shortages also meant that there could only be a limited scope for scalability in smaller clinics without undergoing strategic reallocation of resources. Structural aspects of the intervention design that enabled the consistent and equitable delivery of the intervention across the project site, therefore, included multidisciplinary team-based care.

Patient-centered self-managing programs were identified as an important intervention to improve the self-efficacy and glycemic control outcomes for all patients enrolled. Asmat et al. (2024) conducted a multicenter randomized study that showed that intensive patient-centered teaching led to a significant reduction in HbA1c and better measures of self-care. Fracso et al. (2022) conducted a phenomenological study that described the empowerment mechanisms of peer support and setting individual goals for vulnerable subjects. Two systematic reviews reported significant effect sizes but also reported differences in the way programs are delivered and how measurement is done across the studies in the review (Asmat et al., 2024; Fracso et al., 2022; Huang et al., 2024). Fidelity monitoring and tailored curricula were added to the program as it was delivered on-site to a broad spectrum of patients to ensure that the program would be most effective with the various patient populations. Patient-centred self-management education was an important process where nurse-led visits resulted in improved glycemic control and behaviour change.

To support improving accessibility and adherence, telehealth follow-up and automated electronic health record (EHR) alerts to remind people were put into practice. Ezeamii’s (2024) analysis revealed that the areas that needed to be improved in the national telemedicine implementation were the use of telemedicine in appointment attendance and remote monitoring aspects. However, there were some moderating factors to the effectiveness of telehealth that were unevenly distributed by socioeconomic status, such as disparities in digital access and in health literacy. Glycemic outcomes after the use of telehealth in relation to a structured follow-up program in the short-term are equivalent to in-person visits (Ezeamii, 2024; ElSayed et al., 2022). Coordination of follow-ups, reminder of missed appointments, and the ability to roll up HbA1c results from the project site were implemented through the HbA1c tracking system of the EHR. The results in general suggest that the web-based tools increased the accuracy of documentation on outcomes of children and young people and facilitated monitoring of outcomes by provider teams. Comparative findings showed that the protocolized visits were more effective with the addition of EHR prompts than passive reminders (Okemah et al., 2023; ElSayed et al., 2022). To ensure high quality and usefulness of the data during the intervention period, training investments, reorganisation of workflow, and periodic audits were required. Monitoring at scale and tightly integrating the monitoring with the measurement-based, outcome goals of the project was an important element of EHR integration.

The education interventions were conducted culturally appropriately, to transcend language barriers and culturally-specific self-management beliefs identified by those who signed up for the program. Wadi et al. (2021) identified better outcomes of HbA1c where interventions included culturally appropriate food management techniques and family engagement techniques. Goetz and Schork (2020) discussed the personalized medicine concepts as a way to enhance the relevance of personalized medicine and health care in both rural and urban settings. Education that was culturally-targeted was more effective in facilitating more long-term behavior changes in education with a variety of populations compared to generic education. Training on the use of diabetes education protocols and to reinforce teaching skills was given through simulation training to staff. Using web-based faculty training modules, Okemah et al. (2023) have demonstrated increases in knowledge as well as improvement of patient education performance. In the comparative studies, it was shown that the practical skill that was retained during the didactic sessions was less compared to the simulated practical sessions with hands-on experiences (Bisbey et al., 2021; Dailah, 2024). Hence, the project dealt with the use of the simulation, demonstrated to the observers, and the competency checklist to secure sustainable competence of staff when implementing the project. The follow-up visits incorporated patient-centered behavioral goal setting and motivational interviewing techniques to support patient-centered behavior change and help patients sustain behavior change within their lifestyle. The culturally responsive education and behavioral strategies in the structured follow-up protocol ensured relevance, equity, and consistency of intervention delivery in relation to the diverse self-management needs of patients enrolled in the protocol.

Peer mentoring and group support sessions were included as a way of utilising and enhancing social reinforcement and common experience in maintaining interest in self-management. Qualitative findings from Fracso et al. (2022) indicated that, as a result of regular and structured group interactions, confidence, self-efficacy, and problem-solving skills were improved. Comparative studies demonstrated higher rates of knowledge change with individual interventions, and group interventions demonstrated more behavior change and peer accountability. Biweekly data reviews and adaptations were embedded throughout the project to keep the fidelity and accelerate learning (Lin et al., 2022). However, many factors, such as the price of the device, patient safety of the data, and patient receptivity to the device, have limited the use of the device in smaller practices. The targeted rollout and integration of the system into the EHR systems helped to ensure the system was most valuable for engaged patients and reduced system implementation resource demands during implementation. Peer mentoring, group support, and step-by-step review of data were strategically and cohesively used to make sure the intervention was responsive, socially reinforced, and patient engagement with the intervention was maintained through full 8-week implementation.

Role of the Project Lead

For quality improvement projects, there will be a need for systematic and logical designs, as well as scholarly, decisive leadership at every step of the process that links the clinical knowledge/experience component, the interprofessional teamwork component, and systems thinking. The DNP student took on the leadership role in designing a standard ADA diabetes follow-up protocol, creating educational materials to help facilitate the implementation, setting up EHR dashboards to support the protocol, and ensuring that all logistical aspects were taken care of during the eight-week implementation period (APRN, personal communication, November 2025). The project lead completed a baseline needs assessment, which included obtaining HbA1c results from EHRs for patients enrolled in the project, staff competency scores, and follow-up completion rates to provide clear baseline measures for use as benchmarks. It was essential to regularly engage the project lead with each of the organizational stakeholders and interprofessional team members, as well as with the academic mentors, during the completion of the project to stay true to the implementation process and the scholarly rigor of the project. To ensure that the workflow changes that occurred during each implementation cycle were based on data and transparent, the plan-do-study-act (PDSA) framework was implemented. The site preceptor and the DNP faculty mentor met regularly with the student, and continued communication took place with the clinic leadership (APRN, personal communication, November 2025) via structured meetings, virtual sessions, and written progress reports, with ongoing completion of implementation tasks and/or adaptations. Throughout the project, ethical considerations were addressed, and a great deal of care was taken to ensure that everyone involved in the project knew they were participating in the project and that they were de-identifying all data they provided for HIPAA compliance. The scholars’ rigorous project led to clinical resources and collaborative leadership through the entire implementation process, demonstrating the crucial role that the APRN can play in sustainable quality improvement in the nursing profession.

Other Team Members’ Roles

Effectiveness of QI programs in outpatient primary care requires designated team roles and shared responsibility among team members, as well as more coordinated care in the provision of services by all components of an intervention. The preceptor from the clinical site was the clinical supervisor and APRN, directly supervised implementation of the protocol, and was the main liaison with the organization’s leadership throughout the entire eight weeks of the clinical project (APRN, personal communication, November 2025). Nurse practitioners completed clinical assessments and asked the patient about their experiences during each biweekly visit to provide education and counseling, and to assist the patient in achieving target goals recommended by the ADA. In general, the association between role clarity within a quality improvement team and shared accountability and fidelity to delivery of evidence-based intervention (Hempel et al., 2022) is clear. The care coordinator was not involved in setting up telehealth arrangements, reminder setups in the EHR, or in attendance to keep the follow-up rates up to benchmarks. The health educator translated and/or adapted patient education materials into the target language and/or health literacy level for a group of patients enrolled in the program who have varying language and health literacy needs. Each team member understood and was made aware of the evidence-based goals of the project and their role to play throughout the project’s implementation, ensuring consistency, accountability, and alignment.

Each member of a quality improvement team needs to have a unique and complementary role to play in implementing the project in order to ensure implementation fidelity and scholarly rigor throughout the entire project. Medical assistants collected patient information, including vital signs, created educational resources, facilitated communication with patients, and recorded clinical information gathered from every other week visit to the EHR. All nurses attended all education sessions, and standardized components of follow-up protocol prescribed by ADA (Patient Visit Fidelity Checklist) were completed during the patient visits by each nurse. Interprofessional working and formal communication between professions are seen as vital to the continuous success of quality improvement work in primary care (Dellafiore et al., 2025). When everyone in the team is responsible for the same, shared responsibility increases compliance with the protocol of implementation and helps to identify any obstacles to implementation promptly (Grant et al., 2024). During the entire implementation process, the DNP Faculty Mentor was available to the DNP Student for academic consultation, reviewing the reports kept by the DNP Student. To maintain communication, transparency, and collaborative efforts between the project team and the interdisciplinary team members, they met with the stakeholders every other week.

Literature Synthesis

A comprehensive and systematic search begins with finding good-quality evidence that is relevant to the PICOT question at hand and needs to be addressed by the quality improvement project. PICOT: Once formed, the PICOT question is: What is the effect of an ADA diabetes follow-up protocol (I) versus current practice (C) on glycemic control (O) for patients with diabetes (P) over 8 weeks (T)? This issue was dealt with extensively by conducting several searches in various databases, including PubMed/MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Web of Science, Scopus, and ProQuest Dissertations and Theses. In the databases, relevant peer-reviewed research literature, clinical practice guidelines, and doctoral projects related to nurse-led diabetes management, and the implementation of the ADA guidelines in an outpatient primary care setting were identified. MeSH terms used were: diabetes mellitus, type 2 diabetes, nurse-led, self-management education, glycemic control, HbA1c, clinical practice guideline and follow-up protocol and combinations of the Boolean operators were used as follows: (“type 2 diabetes” OR “diabetes mellitus”) AND (“nurse-led” OR “nursing intervention”) AND (“ADA guidelines” OR “clinical practice guideline” OR “follow-up protocol”) AND (“glycemic control” OR “HbA1c”). A good search strategy must be well designed and applied, and the evidence retrieved representative, reproducible, and directly relevant to the clinical problem being investigated.

The initial searches of the databases resulted in 362 records being returned from the databases searched. After removing 54 redundant articles, 308 different articles were screened for title and abstract and upon this screening, some of them were excluded based on inclusion and exclusion criteria. Peer-reviewed English papers from January 2021 to February 2026, which included adult populations, nurse-led interventions or structured follow-up interventions, and quantifiable glycemic outcomes (HbA1c), were included. The following were excluded: pediatric patients, inpatient-only acute care interventions, non-clinical commentary/editorials, and studies lacking a measurable HbA1c/glycemic control. A subsequent systematic search of manual reference lists from systematic reviews, clinical position statements, and publications from the American Diabetes Association Standards of Care publications yielded a total of 11 more resources for searching. Out of the outpatient literature, professional standards published by the diabetes associations, government literature, and doctoral dissertations that compared nurse-led models of diabetes care in outpatient settings were searched. Clear and logical screening criteria add to the credibility and academic rigour of the evidence synthesis.

A full-text appraisal was conducted, and 20 sources were selected for synthesis and development of the evidence table following another in-depth assessment of the relevance of the sources to the PICOT focus, methodological rigour, and measurable glycemic outcomes. Each study included in the final analysis was assessed for methodological quality and clinical applicability by systematically using the strength of recommendation taxonomy (SORT) framework; this is a method developed by Duke University (2023). This outcome-focused approach emphasised HbA1c reduction, preventing complications, and avoiding hospitalisation, which were all patient-oriented outcomes. Seven studies met SORT criterion A (high-quality RCTs, systematic review, and/or meta-analysis). Ten studies were rated as level B; that is, they were well-designed comparative effectiveness studies, quasi-experimental studies, or cohort investigations. Three studies were given Level C classifications, with clinical practice guidelines, quality improvement projects, and narrative reviews. The level of evidence supporting diabetes follow-up interventions is consistent with the dominance of moderate-to-high level evidence supporting structured diabetes follow-up by nurses in a variety of outpatient settings, in line with the ADA clinical practice standard.

Analysis of Evidence

The review of the 20 studies selected revealed that there was an overall convergence and consistency in the evidence that nurse-driven interventions for the implementation of diabetes follow-up studies compliant with the ADA guidelines are effective in improving glycemic control, self-efficacy, and self-management behaviors among adults with type 2 diabetes. Investigations’ effect sizes varied from small to very large. With the nurse-led interventions, HbA1c was reduced by 0.25% to 1.69% compared with the comparators (usual care) (Asmat et al., 2024; Chen et al., 2025; Koo et al., 2024), which represents statistically significant metabolic changes. The pooled standardized mean differences (SMD) for structured diabetes self-management education and support (DSMES) were -0.468 (95% confidence interval [CI]: -0.658 to -0.279). These mean differences varied between -0.59 (95% C: -0.85 to -0.34) for clinical populations across a variety of delivery settings (Yimer et al., 2025; Chen et al., 2025). The technology-enriched delivery modalities (telehealth consultation, structured telephone coaching, and peer-supported instant messaging) were found to be clinically equal to a face-to-face follow-up. This was a great improvement in the modalities where patients can access, participate, and comply with the self-monitoring procedures. Findings from different types of studies and across different geographic settings help to establish the applicability of nurse-led interventions to support diabetes follow-up.

There was limited information in the literature on follow-up frequency protocols and no longitudinal outcome data (more than 12 months) available across the literature retained. There were also a number of challenges that were identified in the regular application of ADA guidelines, including providers’ lack of knowledge, breakdown of the workflows, and lack of institutional accountability mechanisms. Themes that developed from the analytic synthesis were: adherence to the ADA guidelines and standards of clinical practice; nurse-led interventions and competency development of staff; diabetes self-management education and support interventions, and technology-based diabetes care and remote follow-up. Themes highlight various elements of the evidence base, but they all collectively strengthen the argument for tackling this issue of clinically meaningful and organizationally sustainable improvement in glycemic control in a multi-faceted manner. Results from the evidence gaps identified also further support the scholarly value and relevance of conducting a structured and protocol-driven quality improvement initiative in an outpatient primary care setting. Honing in on one or a handful of key study findings, a thematic organization can permit a systematic review of how various, but related, components of an intervention work together to accommodate the complexity of outpatient diabetes care.

Theme 1 – ADA Guideline Adherence & Clinical Practice Standards

Clinical practice guidelines need to be followed to provide effective glycemic control in the outpatient primary care setting, whereas in the outpatient primary care setting, care delivery is often inconsistent and fragmented, resulting in a more organized and reliable care delivery system. In this study, elevated adherence with a high compliance score (89.8%) was highly associated with a significantly higher proportion of adults attaining target HbA1c levels, while low adherence was highly associated with poor metabolic outcomes among the study population. Likewise, Tiwari and Aw (2024) determined that additional issues that influence providers’ regular adherence with guidelines—such as provider lack of knowledge and inefficiencies in workflow—also contribute to the gap. These results suggest that there are factors at both the system and provider levels that pose challenges to successfully implementing the ADA guidelines, while protocol-driven nursing interventions fit well. A systematic approach to integrating sufficient follow-up into the nursing workflow can enhance the measurement and application of published follow-up guidelines to help achieve patient outcomes.

Adopting ADA-compliant practices for nursing care will translate the recommendations that were based on evidence into clinically relevant glycemic burden reductions. Abukhalil et al. (2024) showed that for patients in a patient-centered medical home (PCMH) with ADA-guided follow-up pathways, there was a reduction in HbA1c (0.74%) (p < .01) and an increase in the percentage of guideline-concordant antihyperglycemic medication prescriptions. Similarly, with a better effect size, the HbA1c levels reduced by 1.02% at 12 weeks with structured follow-up visits to adhere to the ADA guidelines, along with medication review by a nurse (p < .001) (Chen et al., 2025). These studies indicate that structured nurse-led follow-up intervention is more likely to result in clinically relevant and consistent glycemia reduction when compared to unstructured intervention in a primary care outpatient setting.

Systems of reinforcement, accountability, and continuous monitoring, in addition to guidelines, are necessary for achieving the best glycemic control. Structured reinforcement interventions, which are more likely to yield consistent results, are more effective than interventions that do not include reinforcement, even though interventions that do include reinforcement tend to be more effective but are more likely to yield heterogeneous results (Sun et al., 2025). Moreover, ElSayed et al. (2022) demonstrated that just 23% of the adult population achieved simultaneous target attainment of HbA1c, blood pressure, and lipids, which emphasized that diabetes management is multifaceted and that achieving adherence with one or two components of the trinity does not reveal this complexity. However, Tiwari and Aw (2024) observed that despite the updates in the guidance, there were still significant knowledge gaps at the provider level, while data revealed that even if providers have access to it, this does not ensure appropriate use of the guidance in practice. Likewise, Abukhalil et al. (2024) reported that despite the anticipation for comprehensive care, the uptake of preventive screening and pharmacotherapy care is low. For efficient and sustainable glycemic improvements, therefore, the standards of ADA should form part of a nurse-led and accountable system of structured education, continuous monitoring, and follow-up to diabetes care, thus offering a more holistic and effective approach to diabetes. 

Theme 2: Nurse-led interventions and staff competency development.

Nurse-led care is an evidence-based, quality-driven initiative that enables patients to stay involved with their care and assist them in organizing their care with other health care providers. The models emphasize ongoing interaction and patient-centeredness, rather than the more traditional physician-centered models. The study’s findings indicate that nurse-led education programs for diabetes can improve knowledge, self-management, psychological factors, and the HbA1C level in patients with diabetes, provided they are continued, engaging, and encourage the patients. This is compared with models that have shorter follow-up periods and do not get such continuous improvement. Subsequently, Jiang and colleagues conducted a study that revealed significant results (p< .001) after 6 months in terms of knowledge about diabetes, anxiety, depression, and self-care activities among patients receiving follow-up from a nurse than the patients receiving routine care (2024). In contrast, multifaceted educational programs to enhance the nursing skills demonstrated to improve HbA1c, blood pressure, and lipid parameters uniformly when the role of the nurses is well-defined, and systematic education programs are carried out (Aldahmashi et al., 2024). Nurse-led interventions under these circumstances, where the nurse is empowered and held accountable, show consistent and multidimensional benefits to patient outcomes, particularly when compared to less structured care settings.

The provision of a mechanistic link between staff competency development and the provision of patient-centred diabetes care in the outpatient setting is well organised. Aldahmashi et al. (2024) found that targeted education significantly improved the confidence of the nurses in implementing the ADA protocols, and therefore ensured adherence to the glycemic monitoring guidelines and provision of good patient education in comparison to low education resources settings. More recently, Abukhalil et al. (2024) illustrated the systemic benefits of competency integration, with a mean HbA1c reduction of 0.74% seen with follow-up in the team-based primary care setting based on the ADA protocol, along with beneficial effects in the areas of prescribing concordance and care coordination. Just as with the delivery of fragmented care, the outcomes include the need for coordinated delivery of care based on skills. Dailah (2024) found that there are gaps in knowledge, although diabetes is in increasing demand for diabetes specialist care, only approximately 22% of hospitals have diabetes inpatient specialist nurses. This is supported by the results of a study conducted by Jiang et al. (2024), which showed that nurse-led care plus multiple engagement strategies and structured education led to significantly greater outcomes than nurse-led care (control group) + additional support for physical activity. The data indicate a more consistent and powerful impact of investing in nurses’ development rather than singular interventions on glycemic outcomes.

Interprofessional working and explicit roles for nurses, beyond the primary care system, further enhance the effectiveness of nurse-led diabetes management interventions. Collaborative care includes multidimensional care management, which is not possible for individual care or multidisciplinary care. Anguish and depression scores were lower and glycemic control was better in nurse-led programs with structured educational and multimodal engagement strategies than in less integrated programs that address clinical measures only, as shown by Jiang et al. (2024). Aldahmashi et al. (2024) identified four essential aspects of the nurse’s role that all positively contributed to guideline adherence and improved patient safety, including education, collaborative practice, program design, and documentation review. Consistent with this, Abukhalil et al. (2024) reported that post-visit follow-up using a systematic checklist in patient-centered medical home (PCMH) clinics led by a nurse was more extensive than in the non-PCMH clinics, for example, better prescribing practices and better care coordination. In addition, nurses, as the health care workers who have the most frequent and closest contact with patients, are in the best position to provide more education and motivation than many other health care workers, according to Dailah (2024). Overall, interventions delivered in diabetes management by nurses in an interprofessional team with a clear interprofessional working model yield improved results – and are more likely to be sustainable – than when delivered to individuals in a single-discipline team.

Theme 3: Diabetes Self-Management Education and Support Interventions

Structured, DSMES (diabetes self-management education and support) programs are best suited to follow-up by nurses to implement clinic recommendations into long-term physiological and behavioral changes. DSMES provides a systematic and patient-centred method for behaviour change that is not done in an unstructured or routine manner. Patients with a patient-centered self-management intervention in a multi-center randomized controlled trial by Asmat et al. (2024) had a mean decrease in HbA1c of 0.25% (p = .03), and a significant increase in self-efficacy and self-care behaviors, which may not be achieved with routine care. Another finding that was confirmed by the mediation analysis was that behavioral changes were the most significant factors in obtaining glycemic outcomes. This was supported by a systematic review and meta-analysis of 19 trials that examined the impact of DSMES on HbA1c levels, which showed that DSMES indeed led to a significant decrease in HbA1c compared to structured DSMES programs, which generally had more beneficial glycemic outcomes than routine care (Yimer et al., 2025). In general, patient education programmes that incorporate personal counselling and reinforcement are more effective and more measurable than traditional patient education programmes.

The duration, intensity, and coordination of the programs of DSMES are among the most significant factors that must be taken into account for sustained patient outcomes. A one-time or short-term education intervention is not as effective as a long-term intervention. Fracso et al (2024) did a systematic review and meta-analysis of 34 studies, with a total of 7603 participants, and found that interventions of 6–12-month duration were significantly superior in terms of improved quality of life, sustained reduction in depressive symptoms, and self-efficacy. Similarly, but more powerfully, Fracso et al. (2022) provided qualitative evidence that over time, participation in a Chronic Disease Self-management Program led to changes in patients’ motivation, sense of belonging, commitment to their own personal improvement, and generally not the outcomes of a short-term intervention. The results were extended by Chen et al. (2025), who found that the combination of the two interventions (bi-weekly telephone coaching + nurse-led follow-up) was more effective at enhancing self-efficacy and increasing frequency of blood glucose monitoring than was nurse-led follow-up alone, and it was more effective at activating behavioral pathways to physiological benefit. Therefore, the programs under DSMES that involve patients for longer durations and provide support through structured reinforcement and continuity of care are more effective in delivering long-term outcomes as compared to short and fragmented interventions.

Culturally responsive and contextually-based content further helps in being effective in the implementation of DSMES programs. Programs that are culturally adapted will produce more equitable and impactful results, rather than generic, “one-size-fits-all” programs. Effectiveness varied widely between studies, and effectiveness could be attributed to cultural adaptation, teacher training, and fit with patient health literacy, with programs tailored to specific populations having more positive outcomes (Yimer et al. 2025). Sun et al. (2025) stated that culturally-unadapted modules perform poorly, while those with culturally specific content, such as community health beliefs, medication-taking times, and dietary preferences, work well. As Asmat et al. (2024) said, culturally adapted nurses’ interventions provide lasting improvements, explaining a significant proportion of the variance of outcomes, through self-efficacy. Culturally responsive content combined with structured reinforcement and extended follow-up is found to be more effective and equitable in glycemic control when compared to non-tailored interventions in a variety of populations. 

Theme 4: Technology-enhanced diabetes care and remote follow-up protocols.

The application of technologies in channels for delivering services creates more opportunities for convenient and scalable nurse-led diabetes follow-up care. Technology-based models can impact much more than traditional face-to-face models while maintaining clinical effectiveness. A systematic review and longitudinal meta-analysis of 13 studies, involving 2,294 patients, noted a mean reduction in HbA1c of -0.59 (95% CI -0.85 to -0.34, p < .00001) with nurse-led telephone intervention and even larger reduction of -1.23 (p < .001) with optimized protocols (16 contacts, 20–25 minutes). The findings contrast with those of other, less structured (or frequent) contact models, suggesting a need for recurring and formalised contacts. In a 24-month cohort study, Koo et al. (2024) also showed the beneficial effect of the remote self-care program in the HbA1C level using telephoning and smartphone technology, with HbA1C levels ranging from 7.33% to 7.62%. From the long-term perspective, technology-supported, nurse-led follow-up demonstrates long-term and consistent patient engagement and clinically relevant glycemic control versus traditional follow-up.

Longitudinal studies also support that technology-supported nurse-led models are short and long-term effective. The models have a long-lasting impact, compared to shorter programmes based on trials, which have a short-term impact. Ezeamii (2024) concluded that nurse-led telemedicine was an effective intervention in the management of chronic diseases that provided better disease outcomes than face-to-face visits and enhanced access and patient satisfaction with nurses despite geographic and Transportation barriers. Kamal et al. (2023) showed that interprofessional engagement for 12 months significantly reduced glycemia, weight, and waist circumference; however, qualitative results suggested that if there is a greater awareness in the patients, they require more time to make a lasting change in behaviors. Sun et al. (2025) emphasized the value of using digital solutions such as automated reminders, virtual consultations, and message structuring to enhance engagement and accessibility, particularly over traditional methods of healthcare delivery. Technology-based care, therefore, can provide a more flexible and scalable way of achieving sustained glycemic control when combined with a structured protocol than standard follow-up.

While results are always positive when using technology in follow-up models, there are challenges in providing equal access and effectiveness that must be addressed. There are good opportunities for implementation, but in reality, there are issues around Digital literacy, access to devices, and socio-economic differences. This restriction could lead to loss of the advantages of telemedicine, particularly to the marginalised groups, while those with more exposure and technological proficiency enjoy more advantages with the Telemedicine service Ezeamii (2024) observed. Graue et al. (2023) recognized that this can be too short a time period to see changes in behavior because of empowerment-based interventions, but that longer, more adaptive engagement models show changes. High heterogeneity was found between studies (I² = 87%), which may be related to the differences in protocol designs, patient characteristics, and outcome measures; this may make it difficult to compare the effectiveness of these studies. Sun et al. (2025) also warned that a one-size-fits-all digital intervention strategy may not be equally effective in providing benefits to various populations as a context-specific intervention, considering patient-specific needs and engagement. Finally, a technology-based diabetes care model, if it is to be equitable and effective, must address inequities in access to care as much as possible, harmonize protocols, if any, and provide high-level nursing care to match that of poorly-integrated and/or poorly-segmented models.

Synthesis of Findings

In reviewing evidence within each of the categories, a thorough conclusion was made: Structured nurse-administered diabetes follow-up interventions for outpatient primary care can be based on clinically actionable evidence. A consistent overall positive direction (improvement) in HbA1c outcomes in persons with diabetes was seen in all of the twenty studies that met the inclusion criteria, irrespective of the type of delivery model, geography, or type of study design assessed. The impacts covered a broad range of effect sizes, from very small (short-term-only effects from RCTs with reductions in HbA1c of 0.25%) to clinically significant (large structured longitudinal diabetes programs with effective effects of > 1.5% reduction in HbA1c) (Asmat et al., 2024; Koo et al., 2024). A single bundle of interventions (ADA adherence, nurse-led competency, patient-centered education, and technology-enhanced follow-up) will provide better and more sustainable HbA1C results than each intervention (ElSayed et al., 2022; Sun et al., 2025). Therefore, a comprehensive, multi-faceted approach to outpatient diabetes management is needed to achieve clinically significant and sustainable glycemic results in the outpatient setting.

Along with evidence synthesis that established the relevance for the proposed quality improvement project, review of the existing literature led to the identification that there were plenty of existing gaps that still require quality improvement in the area. In the early stages, evidence synthesis methodology moved from guideline following to doing a meta-analysis of evidence, without any longitudinal literature studies greater than 12 months in duration, limited standardization of the frequency of follow-up and/or data acquisition, limited cost-effectiveness analysis, and limited consideration for culture-specific needs for access to models for technology-enhanced service delivery. Thus, there is a need for several implementation studies of contextually relevant interventions, which should have been methodologically evaluated by rigorous and thorough examination, to examine further the outcomes in various outpatient care settings (American Diabetes Association, 2024). Evidence gap closure will add to the literature and assist in achieving practical goals in the realm of nurse-led sustainable chronic disease management.

Implementation Plan for the Intervention

A coherent, systematic, and sequential plan needs to be developed and carefully carried out to achieve fidelity, replicability, and uniformity across all project phases when implementing a structured quality improvement intervention. The time for implementation included an 8-week process, which included weeks 1 and 2, where baseline HbA1c, patient follow-up completion, and nursing staff competency scores (based on competency checklists) were obtained in the EHR system and used as measurable benchmarks for pre-implementation. It is common in the quality improvement process that the same data is used at the baseline assessment to measure the effectiveness of the intervention and identify the presence of a clinical change that is important over time (Lighterness et al., 2024). A pre-intervention benchmark is a critical piece for the project team to understand what needs to be improved, what they can reasonably hope to accomplish, and how they can measure progress toward the goals of the organization (Willmington et al., 2022). In weeks three and four, nursing participants focused on structured staff education, which included instructional sessions on Diabetes Pathophysiology, ADA Guidelines for Diabetes Management, Principles of Medication Reconciliation, and Documentation into EHRs using simulation and case-based learning as well as peer mentoring workshops. In the end, all nurses who participated in the nursing education sessions filled out both their competency checklists and their knowledge questionnaires prior to and following the nursing education session to determine that each nursing staff member was at a competency level of 80% or more to implement the patient-facing portion of the intervention. Sequential delivery of the instruction and training ensured accountability, consistency, and quantifiable fidelity over the 8 weeks of the implementation.

Iterative changes were needed over the subsequent weeks to ensure fidelity of implementation and were done using the PDSA approach for iterative changes in the process of implementing the plan through structured interprofessional collaboration processes. Structured biweekly patient follow-up visits were made available during Weeks 5 and 6; continuous patient Telehealth visits were offered to patients who had challenges accessing Transportation; and mid-point competency assessments of the nursing care delivery with adaptive changes of educational delivery strategies were provided as needed due to lack of protocol compliance or patient engagement. There is extensive evidence that real-time performance monitoring throughout a QI process can assist in identifying QI barriers early in the process and can help to correct QI performance in response (Lighterness et al., 2024). With respect to the management of chronic disease, especially diabetes, or to primary care, often there is a system of structured collaboration and communication that would facilitate quality improvement (Sze et al., 2025). Process and outcome data from the EHR-based tracking systems used were proactively managed and monitored during weeks 7 and 8 to schedule revisits, to identify overdue patient visits, to centralize HbA1c data, and to give performance dashboards that allowed real-time monitoring at the practicum site of process indicators and outcomes. A structured checklist review was used to confirm fidelity of the processes, and an extensive outcome analysis process was used to ensure that all baseline and post-intervention patient-related outcome data (glycemic, competency, and behavioral domains) were comprehensively analyzed during week eight. This was an intervention planned based on the structure, iteration, and 8-week time frame; it involved evidence-based practice and was able to deliver clinical improvements in the area of glycemic control for the practicum site.

Conceptual Model

Quality improvement frameworks provide the necessary elements to start, test, and improve evidence-based practices with systems and cycles of learning/adjustments. The PDSA model was selected to guide the project from its long history of success with chronic disease management (BARR & Brannan, 2024). The PDSA is a method for learning/refining “in a process way” based on the theory of quality improvement developed by W.E. Deming. It is about learning/refining in the context of complex systems. With chronic diseases, repeated cycles of evaluation using QI frameworks are proven to be effective (Endalamaw et al., 2024). During the ‘plan’ phase, the team decided that the main focus for adult patients would be poor glycemic control, outcome targets were identified, and a staff competency/structured ADA diabetes follow-up protocol was created. The ‘do’ phase involved simulation-based staff training, patient follow-up visits every 2 weeks (including telehealth), and activation of the EHR dashboards throughout the intervention. The evidence-based, iterative nature of PDSA led to decisions about implementation being made based on measurable evidence. It will directly help lead to a more sustainable level of glycemic control through the standardisation of the nurse-led protocols.

The PDSA phases helped with the evaluative and adaptive aspects of the PDSA model to keep the intervention’s fidelity/quality and improve learning throughout the implementation period of 8 weeks. Barriers being encountered and adaptive strategies for improving them were identified by collecting formative data weekly during the ‘study’ phase, which included the following: trends in HbA1C level, staff competency score, follow-up visit completion rate, and documentation error rate in the EHR system. One advantage of the PDSA model is that it can be constantly repeated to allow adaptation to the barriers that may emerge during implementation and provide an opportunity to leverage the data collected to modify the original PDSA plan (Abuzied et al., 2023). PDSA cycles have been used in the context of a structured diabetes management program (DMP) with success, showing a mean HbA1c reduction of 0.5%-1.0% if systematic testing of workflows has been done and continuously improved, congruent with the current project (Konnyu, 2023). In the ‘act’ phase, efforts to embed systematic change in the workflow scheduling processes to enhance the delivery of adult education content and the outreach process to patients with lower engagement in the telehealth environment will be undertaken, which, after implementation, will be integrated into the routine clinic workflow. The flexibility, measurable processes, and looped feedback of the PDSA process remain the obvious project quality improvement model, and the ideal model for effective and repeatable implementation and maintenance of improved outpatient glycemic management.

Data Collection and Analysis

The choice of design, as well as the careful data collection procedures, are important to facilitate evidence-based, clinically meaningful, and interpretable data for quality improvement activities. The project design was a pre-post evaluation with all 20 adult Type 2 diabetes (T2DM) patients and 8 nursing staff members at the facility completing a questionnaire both before and after the project. The pre-post design used in this study is one of the most common and accepted in the quality improvement context to evaluate the effectiveness of a structured intervention in a real-world setting, and is pragmatic and feasible to compare results of the same group of participants over specific time frames (Klaic et al., 2022). Pre-test and post-test studies of chronic disease management in the outpatient setting have had acceptable sensitivity to detect clinically meaningful changes in patient outcomes on a regular basis (Lee et al., 2022). Baseline measures of the facility’s EHR system were conducted to include measures on HbA1C, nursing competency testing, and attendance to follow-up. The project was approved by the Institutional Review Board prior to the project, and concerns related to HIPAA regarding confidentiality of participants and coding the names for use in data collection and analysis were addressed. Outcome evidence was obtained through the application of proven quality improvement research methodology and upon a sound, comparable, and clinically interpretable pre-post design and standardized baseline data extraction for the project.

Crucial to credible and dependable evidence of clinical and non-clinical operations quality improvement is valid and consistent instruments of record and measures/metrics. The main outcome variable was the mean HbA1C at baseline and week 8, and was measured with a point-of-care laboratory test incorporated into the clinics’ EHR system. A decrease from baseline to <0.5 percentage point, or greater, was considered a clinically significant HbA1C reduction (Tiwari & Aw, 2024). It is recommended that measurement instruments have a high content validity and measurement reliability both prior to and following the project, for outcomes to be a valid measure for determining the efficacy of a structured intervention. Validated and reliable outcome measures were essential to the quality improvement entity’s evidence base for clinical decision making, changing protocols, and planning for sustainability (Gabriela et al., 2025). Secondary outcome measures were: Diabetes management competency test scores (pre- and post-training) of the nursing staff on a validated instrument. Follow-up visits rate number of follow-up visits completed (as shown in scheduling audit logs in the electronic health record (EHR) system) X 100. Structured behaviour checklists to estimate insulin adherence and blood glucose checking frequency, and patient involvement in diabetes self-management. Prior to the use of any measurement instruments, an expert panel was consulted to assess the content validity of the instruments, as well as guidelines for using the same data collection procedures at each of the measurement time points throughout the 8-week project, so that the outcomes collected would be reliable and valid. A full set of primary and secondary outcome measures in the areas of glycemic, competency, and behavior will provide a full picture of the intervention.

Ethical Considerations

For the quality improvement projects, ethical principles need to be carefully considered to not only protect participants and maintain confidentiality of data, but also to ensure institutional compliance at each step of the way (i.e., during planning, implementing, and evaluating). Implementation included an IRB evaluation of the project, and the project was determined not to be “human subjects research. Therefore, the IRB decided that the project would not be a full IRB-reviewed project, as the research was to improve practice and not to assess generalizable knowledge (APRN personal communication, November 2025). Health care institutional quality improvement projects that are directed at ongoing institutional practices are frequently not classified as human subjects research, and those that use evidence-based practices and/or clinical data collected before the project may not be classified as human subjects research. Just checking institutional review requirements and federal ethics guidelines is not enough to fulfill the ethical responsibilities of conducting a nurse-led quality improvement project.

In addition, ethical compliance entails that all data collection methods and procedures, as well as the recruitment/consent process and outcome reporting process, have been reviewed and approved by the IRB. All CITI certification requirements must be completed before the project leader’s ability to conduct quality research that meets ethical standards of practice in the clinical environment (APRN, personal communication, November 2025). The IRB determination, along with all required CITI certifications, acted as the ethical framework upon which all data collection, analysis, and reporting activities were based during the implementation of the project (8 weeks). The project’s moral practices of implementation were helpful to build trust among the participants, integrity in institutions, and scholarly integrity at each stage of the implementation and outcome data collection.

One of the most important ethical responsibilities in each of the stages of implementing a project is to conduct a quality improvement project ethically, which includes preserving the confidentiality of the patient information and providing for the storage of all the project documents and information. The unique coded identifiers were used to replace all patient identifiers in patient data collected during the course of the QI project prior to any document creation, data extraction, analysis, or reporting activities, so that individual patients can no longer be identified by the documents created, the results of the data analysis, or the dissemination of materials produced in the 8-week implementation phase of the project. Under the HIPAA requirements, all individually identifiable health information (IIHI) that is used in a health care quality improvement project needs to be de-identified, secure, and accessible only to authorized personnel and staff. De-identification of IIHI in quality improvement projects is an important ethical protection for the individual’s right to privacy and for adherence to federal guidelines for protecting confidential information (Lulamba et al., 2025). To ensure the safety of all electronic and competency assessment data, all data were stored on password-protected and encrypted electronic devices (project lead, site preceptor, or designated project personnel can access the electronic data), and all hard copy data were stored in locked cabinets that are only accessible to the clinic (APRN, personal communication, November 2025) for the 8 weeks of implementation. Weekly checks were made to confirm adherence to the entire de-identification procedure; the deviations from adherence to the procedures, as noted on the weekly checks, were immediately corrected to ensure the integrity of the data and adherence to institution requirements for data de-identification. The highest possible standards of ethics were applied, and data security and de-identification procedures were adhered to with confirmation that there was credible evidence of sustainable quality-improving management of diabetes in the outpatient setting.

Project Results

The clinical significance and organizing impact of the quality improvement intervention (QI) should be presented, organized, and evidence-based to all stakeholders when presenting results of the project. The primary outcome results showed an 8-week mean difference in HbA1c of 1.52 percentage points (a mean value of 8.22% compared with a mean of 9.95% and a threshold value of 0.5 percentage points for a successful intervention prior to the QI intervention). 89.2% of the scheduled follow-up visits were attended after 8 weeks of applying the QI intervention to the program, indicating that patients were using the structured system for follow-up visits within the ADA diabetes program.

In addition, patients and nursing staff having finished the bi-weekly follow-up visit schedule confirm the feasibility of the current operations to accommodate the bi-weekly visit schedule. There was significant improvement in glycemic measures, though only 10% of the patients in the study achieved all the glycemic targets at the end of the 8-week practicum. Undoubtedly, other factors would have helped patients reach those targets, and a longer timeframe of intervention. Overall, the primary outcome findings agree with the project site nurse-led follow-up protocol for T2DM adult patients with glycemic control following a standardized, ADA-compliant approach, which resulted in clinically and dimensionally meaningful clinical changes. The secondary outcome results also resonate with the overall and multi-faceted impact of the structured intervention in the 8-week structured intervention on the three domains of nursing staff competency, patient self-management engagement, and nursing staff delivery fidelity. At the end of the structured training, the nursing staff competency scores went up dramatically from a mean pre-training score of 59.0% to a mean post-training score of 85.4%, with seven of the eight nursing staff achieving the minimum competency score of 80% needed for independent protocol delivery (APRN, personal communication, November 2025).

At 8 weeks, self-management engagement scores were 7.4 on 10 (70% of patients were taking 100% of the prescribed treatment, and 65% of patients were routinely monitoring their blood glucose every day during the structured 8-week intervention period). Potential barriers to implementing a comprehensive diabetes follow-up program identified in the study include Transportation, since only 67% of the visits made to the clinic were scheduled, adding to a suboptimal glycemic trajectory of some patients enrolled in the study and highlighting the need for an integrated telehealth approach, as an equitable alternative to the structured diabetes follow-up. The secondary outcome results indicated overall a consistent and uniform change across scientific domains (clinical, operations, and behavioral), suggesting that the diabetes follow-up protocol was organized and compliant with the ADA and that it provided a dimensional and meaningful change at the project site. The results of the project are presented in the appendix.

Project Outcomes

An assessment of progress toward the objectives of the project will give us data on the value of the programme as a whole as an evidence-based intervention and as part of clinical practice. The main goal of the project (HbA1c decrease) was successfully achieved: HbA1c decreased by 1.52 percentage points (from baseline), and there was a broad margin of success for the necessary HbA1c decrease (of 0.5 percentage points). The 8-week use of the structured diabetes follow-up protocol (ADA) was clinically significant, with steady and clinically significant decreases from baseline in glycemic measures after the first 8 weeks of use. The QI project’s results showed a similarly impressive decrease in HbA1c when compared to previous studies involving patients of similar type in nurse-led (protocol driven) diabetes follow up care, which ranged from 0.25% to 1.69% in similarly structured outpatient primary care organizations (Asmat et al., 2024; Koo et al., 2024) and greater than the literature in diabetes QI suggests is achievable (Asmat et al., 2024; Koo et al., 2024). The results of the nurse-driven self-management education revealed that the majority of the items in patients’ self-care behavior were improved, as well as the scores of nurse competency when a nurse-driven self-management education was delivered in a protocol-driven, structured nurse follow-up process (Dailah, 2024). While a T-test difference in the number of patients who achieve an HbA1C value < 7% was not demonstrated in the eight weeks, as this was a primary goal of the pilot program, it is assumed that if implemented for a longer period than the practicum period, HbA1C target attainment for all patients enrolled in the pilot program will be achieved. There were also a few unexpected findings, including patients reporting transportation barriers for all in-person scheduled visits (67% completion of in-person scheduled visits), which indicated that patients would greatly benefit from telehealth use for follow-up, as it would allow for an equitable, accessible way to provide continued nurse-led follow-up care to patients who may have faced transportation barriers in accessing the healthcare organization in person.

Strengths, limitations, opportunities, and barriers (SWOP) analysis of a quality improvement project also provides an evaluative perspective of the internal validity and external applicability of a quality improvement project in a similar clinical setting. Key advantages of the project were high staff competency improvement, high compliance with the follow-up system (89.2%), accurate EHR documentation, interprofessional clinical team collaboration, and introducing the recognised clinical practice guidelines by the ADA. These elements contributed to the credibility of the design of the intervention. QIPs that had high fidelity to intervention protocols (e.g., following protocols as described), and systematic competency development and EHR monitoring showed more consistent, valid, and generalizable outcomes; those that did not show such systematic accountability structures did not. The positive outcomes of multidisciplinary structured quality improvement initiatives that result in a validated follow-up protocol and monitoring via an EHR are ongoing. The issues with this quality improvement project were that (1) 8 weeks was the time for the project; (2) it was challenging to assess how sustainable this HbA1c improvement was. In addition, there was a small number of participants from the nursing staff (n = 8), decreasing the power, and only one clinic location was represented, limiting the generalizability of the findings to other clinical locations. While implementing, potential for scaling up the standardized ADA follow-up protocol with other chronic disease populations receiving care at the outpatient clinic, for peer-supported digital messaging of targeted follow-up content to further engage patients between clinic visits, and for dissemination of project results through peer-reviewed publication to create evidence base was identified.

Sustaining change occurs after the project is planned by the organization, is written into the organizational agreement to sustain the changes, and is built into the flow of people’s daily work and the accountability process for practice. The clinic will incorporate the structured ADA diabetes follow-up protocol into a routine procedure of nursing, working to assist with the protocol. To ensure protocol adherence in the future, the EHR dashboards, automated appointment reminders, and fidelity checklists will remain as part of the ongoing operations infrastructure (APRN, personal communication, November 2025). Ensuring the change in practice is maintained in clinical routine and culture in the organisation requires a structured outpatient intervention to be monitored, adjusted, and followed for at least 1 year after implementation to achieve this (Jahed et al., 2025). Important elements of successful protocols are best encapsulated in formalised policies for long-term sustainability in quality improvement of chronic disease management (Endalamaw et al., 2024). New roles being developed to focus on outcome sustainability will include a Diabetes Protocol Coordinator to monitor EHR dashboard metrics and to schedule periodic quarterly competency checks of nursing personnel (APRN, personal communication, November 2025). Results of the quality improvement initiative will be shared through internal project reports, conference presentations, and peer-reviewed publications, which will help fortify the organization’s efforts on the standardized diabetes follow-up model and help inspire other sites with similar outpatient primary care practices that serve a diverse adult population to replicate it.

Recommendations

Results of Quality Improvement efforts based on evidence will yield additional understanding that would not only be relevant to its implementation, but also to future research and practice in nursing. Future practice recommendations are that the timeframe of the intervention was only for 8 weeks, so future studies should be conducted to determine how sustainable HbA1c levels are after the 8-week practicum. In addition, the protocol should be extended to other chronic disease groups within the same outpatient setting to have a larger effect on the organization and allocate more resources. Replication studies at other centers with a larger and more diverse nursing population should be included in future studies to determine the effectiveness of such a protocol when used in larger populations. One aspect that requires more studies is cost-effectiveness analyses, obtaining the number of fewer hospitalizations due to a standardized follow-up. The use of digital messaging, with peer support, will lead to better support for patients’ self-management and engagement between sessions (Nagra et al, 2024). The Culturally Responsive Curriculum Development and Digital Equity research will enable the identification of digital access gaps of underserved populations. Of these, one of the most important steps towards achieving glycemic equity and improving the quality of outpatient primary care to a diverse adult population will be the ongoing implementation of continuing well-supported, structured nurse-led diabetes follow-up programs.

Summary

Key findings from a QI project are an important method of substantiating the clinical significance, organizational relevance, and scholarly value of the clinical intervention used. Nursing staff competency scores increased from 59.0% to 85.4%, patient adherence increased to 89.2% after 8 weeks of the ADA diabetes follow-up, and patients’ HbA1c levels decreased by 1.52%. Summarizing, the implementation of the ADA protocol into clinical practice resulted in a clinical and measurable overall improvement in glycemic control, productivity of nursing, and follow-up adherence. The clinic’s organizational mission of providing patient-centred, evidence-based, and accessible primary care has advanced through a newly created diabetes follow-up process, putting into practice improved interprofessional care coordination, and creating EHR-integrated monitoring processes as a streamlined flow in the clinic. Ongoing staff feedback and ongoing performance tracking further help maintain accountability throughout ongoing clinical implementation. The project goals and outcomes were consistent with the clinic’s strategic goals involving value-based care delivery, quality of care for those with chronic conditions, and health equity goals for the population of people in the several urban communities served by the practicum site. Last, the nurse-driven protocol created with the ADA can and should be reproduced, extended to other clinics like the one in this study, and will help assure continued glycemic improvements in other clinics/ambulatory care settings. Last, interprofessional working in an organizational context with the support of evidence-based QI has significant and sustainable clinical outcomes relevant to the organization’s mission, as well as to national standards for excellence in chronic disease management.