Article Title

Sustainment of Lean Redesigns in Primary Care Clinics

Publication Date



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


Background: While Lean is rapidly increasing in popularity within the health care sector, most studies to date focus on discrete and narrow uses of Lean techniques to solve isolated problems. In this study, we examine the implementation and sustainment of transformative Lean workflow redesigns nearly 5 years after being introduced in all primary care clinics of a large ambulatory care delivery system.

Methods: Lean redesigns were implemented in phases across 17 clinic locations of the delivery system — first in one pilot site, then in three “beta” sites, and finally all remaining “gamma” clinic sites. Our mixed-methods analysis was guided by the Consolidated Framework for Implementation Research modified for process redesign. Findings are based on 57 in-depth interviews with physicians, staff and clinic leaders, and survey responses from 860 primary care physicians and staff (74.8% response rate).

Results: We found that clinics’ initial approach to implementing Lean redesigns was critical to later sustainment. The pilot site experienced greatest successes, with diminishing results observed in gamma clinics. Facilitators of sustainment included the presence of skilled and charismatic Lean change agents, open/democratic leader engagement with frontline staff and physicians, and simple work designs that were easily adopted and maintained. Despite initial resistance, the most sustained and widely appreciated Lean changes included co-location of medical assistant/physician care teams, and “5S” reorganization and standardization of examination room supplies. According to surveys on specific workflow redesigns, care teams reported using daily huddles most of the time to carry out their work and agenda setting by medical assistants for the majority of patient visits.

Conclusion: This study highlights areas in which leaders can focus their efforts to enhance successful Lean change initiatives. Program implementers may find it easier to introduce Lean in phases rather than at a single time point. However, it is critical for sustainment that at every phase, frontline physician and staff are equally engaged in the design and implementation of new work designs.




July 11th, 2017


August 10th, 2017