| 1. Hemoglobin A1C | |
| 1A. Process outcome (date) | Every 12 months |
| 1B. Intermediate patient outcome (level) | <8% |
| 2. Blood pressure (systolic and diastolic) | |
| 2A. Process outcome (date) | Every 12 months |
| 2B. Intermediate patient outcome (level) | Systolic <140, diastolic <90 |
| 3. Low-density lipoprotein cholesterol | |
| 3A. Process outcome (date) | Every 12 months |
| 3B. Intermediate patient outcome (level) | <100 mg/dL |
| 4. Protein-to-creatinine ratio | |
| 4A. Process outcome (date) | Every 12 months |
| 4B. Intermediate patient outcome (level) | <30 mg/mmol |
| 5. Angiotensin-converting enzyme and angiotensin receptor blocker | |
| 5A. Process outcome (date) | Every 12 months |
| 5B. Intermediate patient outcome (date) | Every 12 months |
| 6. Albumin-to-creatinine ratio | |
| 6A. Process outcome (date) | Every 12 months |
| 6B. Intermediate patient outcome (date) | <30 mg/dL |