--- title: "Scaling Lean in primary care: impacts on system performance. | Sutter Health" description: "Lean redesigns can benefit primary care patients, physicians, and staff without negatively impacting the quality of clinical care." url: "https://www.sutterhealth.org/research/publications/scaling-lean-primary-care-system-perf-impact-1055312322" --- 1. [Home](https://www.sutterhealth.org/) / 2. [Research](https://www.sutterhealth.org/research) / 3. [Research publications](https://www.sutterhealth.org/research/publications) / 4. Scaling Lean in primary care: impacts on system performance. # Scaling Lean in primary care: impacts on system performance. Hung DY, Harrison MI, Martinez MC, & Luft HS. _Am J Manag Care. 23(3):161-168._ 2017-03-01 ## Abstract OBJECTIVES: We examined a wide range of performance outcomes after Lean methodology-a leading strategy to enhance efficiency and patient value-was implemented and scaled across all primary care clinics in a nonprofit, ambulatory care delivery system. STUDY DESIGN: Using a stepped wedge approach, we assessed changes associated with the phased introduction of Lean-based redesigns across 46 primary care departments in 17 different clinic locations. Longitudinal analysis of operational metrics included: workflow efficiency, physician productivity, operating expenses, clinical quality, and satisfaction among patients, physicians, and staff. METHODS: We used interrupted time series analysis with generalized linear mixed models to estimate Lean impacts over time. Projected outcomes in the absence of changes (ie, counterfactuals) were compared with observed outcomes after Lean redesigns were implemented, and mean differences were assessed using 95% bias-corrected bootstrap confidence intervals (CIs). RESULTS: We observed systemwide improvements in workflow efficiencies (eg, 95% CI, 5.8-10.4) and physician productivity (95% CI, 3.9-27.2), with no adverse effects on clinical quality. Patient satisfaction increased with respect to access to care (95% CI, 15.2-20.7), handling of personal issues (95% CI, 2.1-6.9), and overall experience of care (95% CI, 11.0-17.0), but decreased with respect to interactions with care providers (95% CI, -13.4 to -5.7). Departmental operating costs decreased, and annual staff and physician satisfaction scores increased particularly among early adopters, with key improvements in employee engagement, connection to purpose, relationships with staff, and physician time spent working. CONCLUSIONS: Lean redesigns can benefit primary care patients, physicians, and staff without negatively impacting the quality of clinical care. Study results may lead other delivery system leaders to innovate using Lean techniques and may further enhance support for Lean learning among public and private payers. [PubMed abstract](https://www.ncbi.nlm.nih.gov/pubmed/28385026) ## 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 ### [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 ### [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 ### [Changes in healthcare utilization after lifestyle intervention for weight loss](https://www.sutterhealth.org/research/publications/changes-in-healthcare-utilization-for-weight-loss-1055312948) Sudat, Sylvia Changes in healthcare utilization after lifestyle intervention for weight loss \[published online ahead of print 2023 Oct 29\]. Am J Prev Med. 2023;S07 2023 Oct 29 - Publication ### [Overcoming challenges to adoption of shared medical appointments.](https://www.sutterhealth.org/research/publications/challenges-to-adoption-of-shared-medical-appts-1055312762) McCuistion MH, Stults CD, Dohan D, Frosch DL, Hung DY, Tai-Seale M. Popul Health Manag. 17(2):100-5. doi: 10.1089/pop.2013.0035. Epub 2013 Oct 24. 2014 Apr 01 - Publication ### [Creating a “Zone of Openness” at the Doctor’s Office.](https://www.sutterhealth.org/research/publications/create-a-zone-of-openness-at-the-doctors-office-1055312775) Tai-Seale M. Patient-Centered Outcomes Research Institute website. 2013 Sep 10 [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/scaling-lean-primary-care-system-perf-impact-1055312322#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":"Scaling Lean in primary care: impacts on system performance."}]} ``` ```json {"@context":"https://schema.org","@type":"MedicalScholarlyArticle","@id":"https://www.sutterhealth.org/research/publications/scaling-lean-primary-care-system-perf-impact-1055312322#medicalscholarlyarticle","name":"Scaling Lean in primary care: impacts on system performance.","headline":"Scaling Lean in primary care: impacts on system performance.","abstract":"OBJECTIVES: We examined a wide range of performance outcomes after Lean methodology-a leading strategy to enhance efficiency and patient value-was implemented and scaled across all primary care clinics in a nonprofit, ambulatory care delivery system. STUDY DESIGN: Using a stepped wedge approach, we assessed changes associated with the phased introduction of Lean-based redesigns across 46 primary care departments in 17 different clinic locations. Longitudinal analysis of operational metrics included: workflow efficiency, physician productivity, operating expenses, clinical quality, and satisfaction among patients, physicians, and staff. METHODS: We used interrupted time series analysis with generalized linear mixed models to estimate Lean impacts over time. Projected outcomes in the absence of changes (ie, counterfactuals) were compared with observed outcomes after Lean redesigns were implemented, and mean differences were assessed using 95% bias-corrected bootstrap confidence intervals (CIs). RESULTS: We observed systemwide improvements in workflow efficiencies (eg, 95% CI, 5.8-10.4) and physician productivity (95% CI, 3.9-27.2), with no adverse effects on clinical quality. Patient satisfaction increased with respect to access to care (95% CI, 15.2-20.7), handling of personal issues (95% CI, 2.1-6.9), and overall experience of care (95% CI, 11.0-17.0), but decreased with respect to interactions with care providers (95% CI, -13.4 to -5.7). Departmental operating costs decreased, and annual staff and physician satisfaction scores increased particularly among early adopters, with key improvements in employee engagement, connection to purpose, relationships with staff, and physician time spent working. CONCLUSIONS: Lean redesigns can benefit primary care patients, physicians, and staff without negatively impacting the quality of clinical care. 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