Improving diabetes control using lean six sigma quality improvement in an endocrine clinic in a large accountable care organization

Usha Kollipara, Mario Rivera-Bernuy, Joseph Putra, Jessica Burks, Amber Meyer, Shayla Ferguson, Carolyn Nelson, Jackie Mutz, Sasan Mirfakhraee, Puneet Bajaj, Asra Kermani, Jason S Fish, Sadia Ali

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


This article describes a quality improvement project to reduce the number of patients with diabetes who have poor glycemic control in a large tertiary care endocrinology clinic. The project used the Lean Six Sigma Define-Measure-Analyze-Improve-Control process improvement methodology to develop clinic workflow processes for obtaining A1C measurements in a timely manner to facilitate interventions to improve glycemic control. The percentage of patients with poorly controlled diabetes (A1C >9.0% or missing value in the past 12 months) significantly improved from 26.4% at baseline to 16% (P <0.001), and the proportion of patients with an A1C test within 3-6 months of an appointment improved from 76 to 92%. Diabetes is a leading cause of death and disability. Clinical trials show that improved glycemic control, as evidenced by reduced A1C, correlates with a reduction in developing diabetes complications (1). There are many barriers for improving glycemic control in clinical practice, including failure to follow clinical guidelines for monitoring diabetes and therapeutic inertia (2,3). Patients who have their A1C tested less frequently than every 6 months tend to have poorer glycemic control (4). The American Diabetes Association recommends A1C testing quarterly in patients whose therapy has changed or who are not meeting glycemic goals and at least twice yearly in those who are meeting treatment goals (5). Various quality improvement (QI) methodologies are being used in health care, including in the diabetes care arena (6-8). These tools include the Lean Six Sigma Define- Measure-Analyze-Improve-Control (DMAIC) methodology, Plan/Do/Study/Act cycles, and performance benchmarking. Lean Six Sigma QI tools have been widely used in non-health care industries (9). Their use in health care is increasing, and previous applications have included improvement of care quality in a hospital setting, prescription errors, and waste control (10,11). Kutz et al. (12) used Lean Six Sigma methodology to demonstrate that standardization of accepted care practices for patients with diabetes improved compliance with diabetes care bundle completion and patient outcomes in a primary care setting. Our clinic is part of a large accountable care organization (ACO) serviced by a population health services company, with performance goals and payments tied to quality measures. The 2018 Centers for Medicare & Medicaid Services (CMS) Shared Savings Program for the ACO included poor control of diabetes as a performance measure (13). Hence, a reliable method for improving poor control of diabetes became imperative. The aim of our project was to design and implement best practices to reduce the percentage of patients with poor glycemic control defined as an A1C >9.0% (or missing value), from 26.4% in May 2018 to 22.0% by December 2019.

Original languageEnglish (US)
Pages (from-to)57-63
Number of pages7
JournalClinical Diabetes
Issue number1
StatePublished - Jan 1 2021

ASJC Scopus subject areas

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism


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