Date of Paper/Work


Type of Paper/Work

Systems Change Project

Degree Name

Doctor of Nursing Practice



First Advisor

Rozina Bhimani


Diabetes is one of the most serious public health problems of the twenty first century (Albright, 2007; Glasgow et al., 1999). The rate of increase in the occurrence of diabetes and its complications has placed a tremendous burden on the American health care system and threatens to affect close to one third of the population in the next thirty years. Diabetes complications markedly reduce the quality and length of life and contribute to enormous health care costs. Several large studies have shown that effective treatments and practices may substantially reduce the impact of diabetes (Herman, 2007).

Performance measures for diabetes have been in place since the late 1990s (Murphy, Chapel, & Clary, 2004). There is evidence that control of outcome measures such as LDL-cholesterol, blood pressure and HgbA1c have a positive impact on reducing the severity and progression of diabetes. The systems change project was developed to pilot a facilitator model for system change using evidence based quality measures to improve diabetes outcomes in a small primary care clinic. Results of the project showed significant improvement in the effects of clinicians (random effects) on diabetes outcome measures (fixed effects) for LDL-cholesterol (p = 0.017), HgbA1c (p = 0.004), and tobacco nonuse (p = 0.0051). The change in percent composite outcome measures for diabetes was also significant (p = 0.01). The hierarchical generalized linear model was used to account for provider impact on patient outcomes. Response to the facilitator model was generally positive as a means of promoting a quality improvement initiative in diabetes, encouraging a multidisciplinary model of chronic disease management and enhancing the use of organizational systems to plan and track patient care.