--- title: "Accept Lean redesigns in primary care: contextual analysis. | Sutter Health" description: "Lean acceptance was influenced by time & intensity of exposure to changes, \"top-down\" vs \"bottom-up\" implementation styles, and degrees of employee engagement." url: "https://www.sutterhealth.org/research/publications/accept-lean-redesign-prim-care-contextual-analysis-1055312514" --- 1. [Home](https://www.sutterhealth.org/) / 2. [Research](https://www.sutterhealth.org/research) / 3. [Research publications](https://www.sutterhealth.org/research/publications) / 4. Accept Lean redesigns in primary care: contextual analysis. # Acceptance of Lean redesigns in primary care: A contextual analysis. Hung D, Gray C, Martinez M, Schmittdiel J, & Harrison MI. _Health Care Manage Rev. \[Epub ahead of print\] Send to:_ 2016-03-02 ## Abstract BACKGROUND: Lean is a leading change strategy used in health care to achieve short-term efficiency and quality improvement while promising longer-term system transformation. Most research examines Lean intervention to address isolated problems, rather than to achieve broader systemic changes to care delivery. Moreover, no studies examine contextual influences on system-wide Lean implementation efforts in primary care. PURPOSE: The aim of this study was to identify contextual factors most critical to implementing and scaling Lean redesigns across all primary care clinics in a large, ambulatory care delivery system. METHODOLOGY/APPROACH: Over 100 interviews and focus groups were conducted with frontline physicians, clinical staff, and operational leaders. Data analysis was guided by a modified Consolidated Framework for Implementation Research (CFIR), a popular implementation science framework. On the basis of expert recommendations, the modified framework targets factors influencing the implementation of process redesigns. This modified framework, the CFIR-PR, informed our identification of contextual factors that most impacted Lean acceptance among frontline physicians and staff. FINDINGS: Several domains identified by the CFIR-PR were critical to acceptance of Lean redesigns. As part of the implementation process, acceptance was influenced by time and intensity of exposure to changes, "top-down" versus "bottom-up" implementation styles, and degrees of employee engagement in developing new workflows. Important factors in the inner setting were the clinic's culture and style of leadership, along with availability of information about Lean's effectiveness. Last, implementation efforts were impacted by individual and team characteristics regarding changed work roles and related issues of professional identity, authority, and autonomy. PRACTICE IMPLICATIONS: This study underscores the need for change leaders to consider the contextual factors that surround efforts to implement Lean in primary care. As Lean redesigns are scaled across a system, special attention is warranted with respect to the implementation approach, internal clinic setting, and implications for professional roles and identities of physicians and staff. [PubMed abstract](http://www.ncbi.nlm.nih.gov/pubmed/26939032) ## Research topics - [Health Services](https://www.sutterhealth.org/research-search-results?query=%22%5C%22Health+Services%5C%22%22) ## Related publications [View all publications](https://www.sutterhealth.org/research-search-results?verticalKey=research_publication) - Publication ### [Sustainment of Lean redesigns for primary care teams.](https://www.sutterhealth.org/research/publications/sustaining-lean-redesigns-in-primary-care-1055312397) Hung DY, Gray CP, Truong QA, Harrison MI. Qual Manag Health Care. 28(1):15-24. doi: 10.1097/QMH.0000000000000200. 2019 Jan 01 - Publication ### [Quality management and perceptions of teamwork and safety climate in European hospitals.](https://www.sutterhealth.org/research/publications/qual-mgmt-teamwork-safety-european-hospitals-1055312928) Kristensen S, Hammer A, Bartels P, Suñol R, Groene O, Thompson CA, Arah OA, Kutaj-Wasikowska H, Michel P, Wagner C. Int J Qual Health Care. pii: mzv079. \[Epub ahead of print\] 2015 Oct 06 - Publication ### [Contextual conditions and performance improvement in primary care.](https://www.sutterhealth.org/research/publications/context-for-performance-improvement-in-primary-care-1055312436) Hung DY, Harrison MI, Liang SY, Truong QA. Qual Manag Health Care. 28(2):70-77. doi: 10.1097/QMH.0000000000000198. 2019 Apr 01 - Publication ### [Promoting patient and family partnerships in ambulatory care improvement: a narrative review and focus group findings.](https://www.sutterhealth.org/research/publications/promote-pt-fam-partnership-ambulatory-care-1055312478) Johnson KE, Mroz TM, Abraham M, Figueroa Gray M, Minniti M, Nickel W, Reid R, Sweeney J, Frosch DL, Ness DL, Hsu C. Adv Ther. Epub ahead of print\] 2016 Jun 28 - Publication ### [Shared decision-making for syncope in the emergency department: a randomized controlled feasibility trial.](https://www.sutterhealth.org/research/publications/shared-decision-making-for-syncope-in-er-1055312729) Probst MA, Lin MP, Sze J, Hess EP, Breslin M, Frosch DL, Sun BC, Langan MN, Thiruganasambandamoorthy V, Richardson LD. Acad Emerg Med. doi: 10.1111/acem.13955. \[Epub ahead of print\] 2020 Mar 09 [View all publications](https://www.sutterhealth.org/research-search-results?verticalKey=research_publication) ```json {"@context":"https://schema.org","@type":"MedicalOrganization","name":"Sutter Health","@id":"https://www.sutterhealth.org/#medicalorganization","url":"https://www.sutterhealth.org","logo":"https://www.sutterhealth.org/static/images/sutter-health-logo.svg","address":{"@type":"PostalAddress","streetAddress":"2200 River Plaza Drive","addressLocality":"Sacramento","addressRegion":"CA","postalCode":"95833","addressCountry":"US"},"areaServed":{"@type":"AdministrativeArea","name":"California"},"sameAs":["https://www.facebook.com/SutterHealth","https://www.instagram.com/sutterhealth/","https://x.com/SutterHealth","https://www.youtube.com/sutterhealth","https://www.linkedin.com/company/sutter-health","https://en.wikipedia.org/wiki/Sutter_Health"]} ``` ```json {"@context":"https://schema.org","@type":"BreadcrumbList","@id":"https://www.sutterhealth.org/research/publications/accept-lean-redesign-prim-care-contextual-analysis-1055312514#breadcrumblist","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https://www.sutterhealth.org/"},{"@type":"ListItem","position":2,"name":"Research","item":"https://www.sutterhealth.org/research"},{"@type":"ListItem","position":3,"name":"Research publications","item":"https://www.sutterhealth.org/research/publications"},{"@type":"ListItem","position":4,"name":"Accept Lean redesigns in primary care: contextual analysis."}]} ``` ```json {"@context":"https://schema.org","@type":"MedicalScholarlyArticle","@id":"https://www.sutterhealth.org/research/publications/accept-lean-redesign-prim-care-contextual-analysis-1055312514#medicalscholarlyarticle","name":"Acceptance of Lean redesigns in primary care: A contextual analysis.","headline":"Accept Lean redesigns in primary care: contextual analysis.","abstract":"BACKGROUND: Lean is a leading change strategy used in health care to achieve short-term efficiency and quality improvement while promising longer-term system transformation. Most research examines Lean intervention to address isolated problems, rather than to achieve broader systemic changes to care delivery. Moreover, no studies examine contextual influences on system-wide Lean implementation efforts in primary care. PURPOSE: The aim of this study was to identify contextual factors most critical to implementing and scaling Lean redesigns across all primary care clinics in a large, ambulatory care delivery system. METHODOLOGY/APPROACH: Over 100 interviews and focus groups were conducted with frontline physicians, clinical staff, and operational leaders. Data analysis was guided by a modified Consolidated Framework for Implementation Research (CFIR), a popular implementation science framework. On the basis of expert recommendations, the modified framework targets factors influencing the implementation of process redesigns. This modified framework, the CFIR-PR, informed our identification of contextual factors that most impacted Lean acceptance among frontline physicians and staff. FINDINGS: Several domains identified by the CFIR-PR were critical to acceptance of Lean redesigns. As part of the implementation process, acceptance was influenced by time and intensity of exposure to changes, \"top-down\" versus \"bottom-up\" implementation styles, and degrees of employee engagement in developing new workflows. Important factors in the inner setting were the clinic's culture and style of leadership, along with availability of information about Lean's effectiveness. Last, implementation efforts were impacted by individual and team characteristics regarding changed work roles and related issues of professional identity, authority, and autonomy. PRACTICE IMPLICATIONS: This study underscores the need for change leaders to consider the contextual factors that surround efforts to implement Lean in primary care. 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