Article Title

Correlates of High Performance After Implementing Lean Redesigns in Primary Care

Publication Date



organizations, observational studies, primary care, ambulatory/outpatient care, qualitative research, health care organizations, quality improvement


Background: This mixed-methods study leverages activities of a large ambulatory delivery system that used Lean techniques to redesign primary care workflows. Though Lean has been shown to improve quality and reduce costs, there are no studies examining organizational or provider characteristics associated with Lean improvements. We describe contextual features of primary care departments that demonstrated greatest performance improvements after implementing Lean redesigns.

Methods: We identified departments with highest post-Lean improvements on performance metrics, including: efficiency, productivity, patient satisfaction, and clinical quality. Changes in each metric were based on segmented regressions that modeled: 1) immediate change following Lean implementation, and 2) gradual change over time. Departments were identified as high performing if either of these charges were positive and statistically significant, with no decreases in other metrics. We examined bivariate associations between high-performing departments and contextual variables gathered from a survey of 860 physicians and staff, with responses aggregated to the department level. Findings were triangulated with qualitative data gathered from nearly 200 interviews and focus groups with physicians, staff and organizational leaders.

Results: High performance was associated with a high perceived history of change, as compared with low change (29.5% vs 18.9%, P < 0.05). High-performing departments also were more likely to have lower levels of provider burnout compared to those with higher burnout (30.8 vs 19%, P < 0.05). These findings are consistent with qualitative findings describing Lean changes as supporting improved care delivery: “We want to be getting our work done in a good clip and taking care of our patients … Lean gave us the framework to improve that.” While burnout was prevalent, hope was expressed that Lean redesigns may assist with workload: “Just grinding out patients … and trying to keep up with documenting … volume of e-messages, phone calls, labs … it’s just daunting. It feels like emptying the ocean with a teaspoon; it’s nonstop, and to think ‘oh, I might have help…’.”

Conclusion: Perceptions of change and provider burnout were associated with changes in performance metrics. Findings suggest that Lean redesigns may have a dual effect on performance by not only altering work processes, but potentially ameliorating burnout and allowing providers to provide more effective patient care.




June 28th, 2017


August 10th, 2017