Case Studies

Hypoglycemia Resolution Improvement with Lean Six Sigma Techniques and Nursing Team Collaboration


Hypoglycemia can cause considerable harm to patients including the potential for falls, seizures, coma, and contributes to increased mortality and length of stay. The goal was to decrease the time it takes to resolve a hypoglycemic blood glucose reading to 30 minutes in a cardiovascular surgical unit using Lean Six Sigma methodologies. Process defects were identified in communication of hypoglycemia events among nursing team members, initiating evidence-based treatment and clarity in the expectations for rechecking hypoglycemic readings. Key improvements included: (1) Implementation of a new process with time-sensitive expectations for each nursing team role; (2) Revisions to the hypoglycemia treatment order to clarify treatment and follow-up; and (3) Development of a dashboard to communicate process and outcome measure results. The pilot unit decreased the number of minutes it took to resolve a hypoglycemic event from an average of 117 minutes (May 2013) to 23 minutes (Oct 2013), an 80 percent reduction in the time to resolution, exceeding our initial goal.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state.  These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

  • Safe
  • Timely
  • Effective
  • Efficient
  • Equitable
  • Patient-centered

(The Institute of Medicine's six aims for improvement.)

Additional Resources

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