--- title: "Context for performance improvement in primary care. | Sutter Health" description: "Findings encourage evaluation of clinic characteristics and capacity to effectively implement redesigns, helping leaders select appropriate Lean interventions." url: "https://www.sutterhealth.org/research/publications/context-for-performance-improvement-in-primary-care-1055312436" --- 1. [Home](https://www.sutterhealth.org/) / 2. [Research](https://www.sutterhealth.org/research) / 3. [Research publications](https://www.sutterhealth.org/research/publications) / 4. Context for performance improvement in primary care. # Contextual conditions and performance improvement in primary care. Hung DY, Harrison MI, Liang SY, & Truong QA. _Qual Manag Health Care. 28(2):70-77. doi: 10.1097/QMH.0000000000000198._ 2019-04-01 ## Abstract BACKGROUND: Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns. METHODS: We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes. RESULTS: Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support. CONCLUSIONS: Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change. [PubMed abstract](https://www.ncbi.nlm.nih.gov/pubmed/30921280) ![Su-Ying Liang, Ph.D.](https://dyn.mktgcdn.com/p/cRIUee_GK3HEL1Wq8svqoUApvABjlwVVA-KUHVGzuNw/fit=crop,gravity=auto,dpr=2,width=188,height=250,quality=100) Su-Ying Liang, Ph.D. Principal investigator [View profile](https://www.sutterhealth.org/research/investigators/su-ying-liang-phd-1049681030) ## 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 ### [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 ### [Recognition as a patient-centered medical home: fundamental or incidental?](https://www.sutterhealth.org/research/publications/recognition-as-a-patient-centered-medical-home-1055312554) Dohan D, McCuistion MH, Frosch DL, Hung DY, Tai-Seale M. Ann Fam Med. 11 Suppl 1:S14-8. doi: 10.1370/afm.1488 2013 May 01 - Publication ### [Accuracy of data entry of patient race/ethnicity/ancestry and preferred spoken language in an ambulatory care setting.](https://www.sutterhealth.org/research/publications/data-entry-of-pt-race-language-in-primary-care-1055312548) Azar KM, Moreno MR, Wong EC, Shin JJ, Soto C, Palaniappan LP. Health Serv Res. 47(1 Pt 1):228-40. doi: 10.1111/j.1475-6773.2011.01305 2011 Aug 24 - Publication ### [Effect of organizational culture on patient access, care continuity, and experience of primary care.](https://www.sutterhealth.org/research/publications/organizational-culture-pt-access-care-continuity-1055312407) Hung D, Chung S, Martinez M, Tai-Seale M. J Ambul Care Manage. 39(3):242-52. doi: 10.1097/JAC.0000000000000116. 2016 Jul 01 - Publication ### [Five decades of HSR-by words and figures.](https://www.sutterhealth.org/research/publications/five-decades-hsr-words-figures-1055312369) Luft HS. Health Serv Res. 52(3):908-918. doi: 10.1111/1475-6773.12717. 2017 Jun 01 [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/context-for-performance-improvement-in-primary-care-1055312436#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":"Context for performance improvement in primary care."}]} ``` ```json {"@context":"https://schema.org","@type":"MedicalScholarlyArticle","@id":"https://www.sutterhealth.org/research/publications/context-for-performance-improvement-in-primary-care-1055312436#medicalscholarlyarticle","name":"Contextual conditions and performance improvement in primary care.","headline":"Context for performance improvement in primary care.","abstract":"BACKGROUND: Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns. METHODS: We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes. RESULTS: Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support. CONCLUSIONS: Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. 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