Improving the Insulin Pump Initiation Process for Pediatric Patients with Type 1 Diabetes through Application of Lean Quality Improvement Methods

Perm J. 2018;22:17-147. doi: 10.7812/TPP/17-147.


Context: Our pediatric diabetes center initiated insulin pump therapy for more than 250 patients with type 1 diabetes in 2014, but onboarding was inefficient.

Objective: To decrease time from the decision to initiate pump therapy to the ambulatory encounter after pump start (lead time) for new pump users from 132.5 days to less than 110 days within 5 months.

Design: Define, Measure, Analyze, Improve, Control method. We identified key problems: Long wait for training classes, unclear metrics, complicated scheduling, and nonstandardized processes. We then implemented 17 changes, including shortened classes, increased class offerings and space, clarified metrics, built a reporting dashboard, designated and cross-trained staff, created appeals letter templates, and educated clinicians. At project conclusion, we established a reaction plan if the processes were not performing as designed.

Main outcome measures: Outcomes of pump orders placed before and after improvements were implemented.

Results: During this project, 229 patients initiated the pump start process. Median lead time decreased from 132.5 to 98.5 days (p = 0.007). Patients with lead time under 110 days increased from 37% to 60% (p = 0.001). There were 31 pump nonstarters, with no significant association between group and whether the patient was a starter or nonstarter (p = 0.58). Nonstarters had a longer diabetes duration (median = 3.43 vs 2.05 years, p = 0.001).

Conclusion: Project goals were met. A high proportion of patients not starting pump therapy was discovered, but this was not affected by the project. We implemented further changes and a process-monitoring system.

MeSH terms

  • Child
  • Diabetes Mellitus, Type 1 / drug therapy*
  • Humans
  • Insulin Infusion Systems*
  • Quality Improvement*
  • Time Factors