Implementing Lean Quality Improvement in Primary Care: Impact on Efficiency in Performing Common Clinical Tasks
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BACKGROUND: Many primary care practices have adopted Lean techniques to reduce the amount of time spent completing routine tasks. Few studies have evaluated both immediate and sustained impacts of Lean to improve this aspect of primary care work efficiency. OBJECTIVE: To examine 3-year impacts of Lean implementation on the amount of time taken for physicians to complete common clinical tasks. DESIGN: Non-randomized stepped wedge with segmented regression and interrupted time series analysis (January 2011–December 2016). PARTICIPANTS: A total of 317 physician-led teams in 46 primary care departments in a large ambulatory care delivery system. INTERVENTION: Lean redesign was initiated in one pilot site followed by system-wide spread across all primary care departments. Redesigns included standardization of exam room equipment and supplies, streamlining of call management processes, care team co-location, and team management of the electronic inbox. MEASURES: Time-stamped EHR tracking of physicians’ completion time for 4 common tasks: (1) office visit documentation and closure of patient charts; (2) telephone call resolution; (3) prescription refill renewal; and (4) response to electronic patient messages. RESULTS: After Lean implementation, we found decreases in the amount of time to complete: office visit documentation (− 29.2% [95% CI: − 44.2, − 10.1]), telephone resolution (− 22.2% [95% CI: − 38.1, − 2.27]), and renewal of prescription refills (− 2.96% per month [95% CI: − 4.21, − 1.78]). These decreases were sustained over several years. Response time to electronic patient messages did not change significantly. CONCLUSIONS: Lean redesigns led to improvements in timely completion of 3 out of 4 common clinical tasks. Our findings support the use of Lean techniques to engage teams in routine aspects of patient care. More research is warranted to understand the mechanisms by which Lean promotes quality improvement and effectiveness of care team workflows. KEY WORDS: Lean management; primary care redesign; workflow/task completion; physician efficiency; primary care teams.
Preliminary findings based on this research were presented at professional conferences, including annual meetings hosted by AcademyHealth (June 2018) and the Health Care Systems Research Network (April 2019). Received July 29, 2019 Accepted October 13, 2020
J Gen Intern Med DOI: 10.1007/s11606-020-06317-9 © Society of General Internal Medicine 2020
INTRODUCTION
Workflow interventions are increasingly being used to improve efficiency in primary care.1 An example of this includes Lean process improvement, which aims to optimize daily workflows by minimizing waste and maximizing valueadded activities.2,3 Drawing on approaches originally developed in auto manufacturing, Lean has been widely adopted in health care as a way to optimize the delivery of health services. Positive outcomes of such intervention are observed in a variety of health settings. These outcomes include greater physician productivity and staff satisfaction,4–7 decreased hospital l
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