Kiana Heron

Date of Award


Document Type

Doctor of Nursing Practice (DNP)

Degree Name

Doctor of Nursing Practice (DNP)



Committee Chair

Haley Hoy

Committee Member

Brandi Burris


Hypertension--Treatment, Medical protocols, Evidence-based medicine


Healthcare Effectiveness Data and Information Set (HEDIS) is a standardized patient outcomes performance measure that evaluates the quality of health plans, prevention, and treatment of disease. A HEDIS hypertension measurement of 95% for hypertension control is the goal of facilities wishing to remain competitive for continued Centers for Medicare and Medicaid Services (CMS) reimbursement and procurement of new member insurance plans. An evidence-based protocol has been shown to improve hypertension management as well as HEDIS scores and subsequently improve patient outcomes. An evidence-based protocol was implemented at a rural primary care facility in the Southeastern United States. The practice provides primary care to adult patients aged 18 years and older diagnosed with essential hypertension in an office setting. Stakeholders were briefed on an evidenced-based hypertension protocol and presented data from the existing HEDIS registry. The project lead administered a pre-training hypertension awareness and skills assessment and hypertension protocol training every two weeks for a month. After training had been completed, the evidenced-based hypertension protocol was implemented by clinical staff and providers for 12 weeks. After 12 weeks of implementation, the post-implementation HEDIS registry data, assessment, and skills scores were obtained. For the primary outcome, the host site HEDIS hypertension score rose from 68 pre-intervention to 75 post-intervention. The pre-intervention staff awareness score was 3.09, representing a medium level of staff awareness of hypertension management knowledge. The awareness score increased to 4.20 post-intervention, demonstrating an improvement in a high level of staff awareness. The post-intervention awareness scores of all five individual clinical staff members all improved from their pre-intervention scores. The post-intervention blood pressure skills showed improvement with all staff members earned a passing score of 80% or higher. This project supports the use of an evidence-based hypertension protocol to improve hypertension management in primary care.

Available for download on Monday, February 17, 2025