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The American Journal of Managed Care March 2017
Impact of a Pharmacy-Based Transitional Care Program on Hospital Readmissions
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Samyukta Mullangi, MD, MBA, and Sanjay Saint, MD, MPH
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Scaling Lean in Primary Care: Impacts on System Performance
Dorothy Y. Hung, PhD; Michael I. Harrison, PhD; Meghan C. Martinez, MPH; and Harold S. Luft, PhD
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Ajit A. Dhavle, PharmD, MBA; Seth Joseph, MBA; Yuze Yang, PharmD; Chris DiBlasi, MBA; and Ken Whittemore, RPh, MBA
Effects of an Enhanced Primary Care Program on Diabetes Outcomes
Sarah L. Goff, MD; Lorna Murphy, MA, MPH; Alexander B. Knee, MS; Haley Guhn-Knight, BA; Audrey Guhn, MD; and Peter K. Lindenauer, MD, MSc
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Lucinda B. Leung, MD, MPH, and José J. Escarce, MD, PhD
Improvements in Access and Care Through the Affordable Care Act
Julie A. Schmittdiel, PhD; Jennifer C. Barrow, MSPH; Deanne Wiley, BA; Lin Ma, MS; Danny Sam, MD; Christopher V. Chau, MPH; Susan M. Shetterly, MS
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Hsueh-Fen Chen, PhD; Taiye Oluyomi Popoola, MBBS, MPH; and Sumihiro Suzuki, PhD

Scaling Lean in Primary Care: Impacts on System Performance

Dorothy Y. Hung, PhD; Michael I. Harrison, PhD; Meghan C. Martinez, MPH; and Harold S. Luft, PhD
Lean redesigns in primary care improved workflow efficiencies, physician productivity, and overall satisfaction among patients, physicians, and staff, with no adverse effects on clinical quality.
A range of clinical quality metrics were examined to determine whether changes, particularly in efficiency or productivity, adversely affected quality of care. Univariate analyses were first conducted on a range of pay-for-performance metrics, as noted previously, with significant differences initially found in metrics involving coordinated diabetes care, cervical cancer screening, chlamydia screening, and meningococcal immunization among adolescents. After adjusting for potential confounders, statistically significant differences were observed only among diabetes care metrics, where glucose and cholesterol control and rates of nephropathy screening all increased anywhere from 3.4% to 5%. Meningococcal vaccination among adolescents decreased. 

Staff and Physician Satisfaction

There is a yearly survey of all clinical and nonclinical nonphysician staff members to assess their experience of work. As these data were provided on an annual basis and only in aggregate across the organization, a counterfactual was not generated for these results (shown in the eAppendix). Overall staff satisfaction in all primary care clinics, as measured by the composite score, increased between surveys conducted at baseline and after Lean was implemented. Across specific domains, nearly all dimensions of primary care staff satisfaction improved, with the largest being in credible leadership, followed by the domains of employee engagement, connection to purpose, growth and development, healthy partnerships, and empowerment and autonomy. All domains, except for pay and benefits, showed improvements following implementation of Lean redesigns. 

Physician satisfaction data were available by clinic location, allowing more detailed assessments based on the clinic’s phase of Lean implementation (Table 2). When examined in aggregate, ignoring phase, physician satisfaction scores remained virtually unchanged. However, overall physician satisfaction in the pilot and beta clinics increased by approximately 2%, but decreased by nearly 4% in the last clinics to implement Lean redesigns. Physicians in the pilot phase reported improved satisfaction in areas targeted by Lean, including leadership and communication, perception of administrators, time spent working, and relationships with staff members. Physicians in the beta clinics did not report improved perceptions of leadership or administrators, but reported improved relationships with staff, available resources, time spent working, and quality of care. Physicians in the remaining clinics displayed smaller changes in Lean-targeted areas, with slight decreases in satisfaction with leadership and communication and time spent working, as well as slight increases in perceptions of administration and quality of care. A summary of all study results is displayed in Table 3.


Process Changes Underlying Improvements in Efficiency, Productivity, and Patient Satisfaction

Using a stepped wedge design, we assessed the changes associated with the phased introduction of Lean redesigns in 17 primary care clinics at a nonprofit, ambulatory care delivery system. Study findings are consistent with the intent of changes that were implemented as part of the organizational initiative. Although Lean was initiated with strong support from executive leadership, the Lean approach is to solicit extensive input from frontline physicians and staff to identify wasted resources, including excessive time spent by staff and physicians in delivering patient care. In this organization, the Lean approach led to a focus on creating new workflows and reassigning tasks among all care team members. Chief among these changes was a new role for medical assistants who, as “flow managers,” maintained a constant flow of work by directly addressing tasks they were trained to handle and preparing all other patient care items for the physician to address. Such changes aimed to create a just-in-time approach to workflow, including real-time completion of visit documentation and avoidance of work task “batching.”

These workflow changes resulted in tangible improvements among the examined metrics on efficiency and may have also increased productivity as measured by physician wRVUs generated per month. Physician compensation was largely based on wRVUs throughout the study period (ie, the financial incentive for productivity was always present), so workflow efficiencies likely facilitated physicians’ abilities to accommodate more patients into their clinic schedules. The finding of increased efficiency and productivity is consistent with previous reports in other settings where the “system” was capacity constrained. For example, Lean intervention in emergency departments led to increases in physician wRVUs and improved workflow, as measured by reduced patient wait times and the proportion of patients leaving without being seen.20,21 

We observed significantly higher patient satisfaction in the domains of access to care, handling of personal issues, and overall satisfaction. Improvements in perceived access aligned with our objective findings on workflow efficiencies. Patient satisfaction with the handling of personal issues, which included the cleanliness of the practice, protection of patient safety and privacy, and sensitivity to patient needs, reflected Lean standardization activities that focused on the proper ordering and maintaining of patient exam rooms and all spaces where patient care is provided. However, patients reported lower satisfaction with their interactions with care providers. This domain consisted of survey items assessing the perceived concern for patient questions or worries; explanation of medical problems, medications, and follow-up care; and time spent with the patient. 

Decreases in patient satisfaction in this domain may be related to the same work design factors that enabled provider efficiency, such as just-in-time workflows, which encourage physicians to move more quickly through each patient visit. Using medical assistants to offload physician work also impacts the patient-physician relationship and may result in less satisfying interactions. For example, with the new practice of “agenda setting” to streamline visits, patients are asked by the MA to identify priority concerns, with less urgent matters to be addressed at a future scheduled appointment. This procedure substitutes MA for physician time, implicitly places limits on the current office visit, and depends substantially on the skill of the MA in negotiating patient concerns. Patients may perceive that this agenda setting by the MA renders their care impersonal and unresponsive to the full range of their concerns.

Observations in Other Areas: Clinical Quality, Staff and Physician Satisfaction 

Clinical quality improvements were observed in measures of diabetes care, likely reflecting specific Lean redesigns (eg, co-location, shared workflows) that aimed to improve communication and coordination between care teams. The quality improvement literature frequently cites enhanced communication between care team members, use of multidisciplinary teams or nonphysician staff, and expansion or revision of professional roles as the greatest facilitators for improving diabetes outcomes relative to other strategies.22-25 The only quality area in which a decline occurred was adolescent immunization for meningococcus. However, this decline was likely related to changes in immunization guidelines that coincided with the study period. Beginning in 2011, new clinical guidelines recommend a meningococcal booster between ages 16 and 18 years following the initial injection originally given once to 11- to 12-year-old adolescents.26 Thus, over time, the criteria for completing these immunizations have become more stringent and potentially more difficult to achieve.

The greatest improvements in nonphysician primary care staff satisfaction occurred in perceptions of credible leadership, employee engagement, growth and development, connection to purpose, empowerment and autonomy, and overall staff satisfaction. This pattern is consistent with studies of Lean in hospital settings, which show positive effects on workforce satisfaction and highlight the benefits of increased participation of frontline staff in designing and implementing standard workflows.20,27-35 By participating in redesign efforts, staff members gain a better understanding of daily work processes relevant to both themselves and others and the rationale for needed changes and improvements. Ideally, employees become problem solvers rather than passive recipients of operational mandates, a role change that can be both empowering and rewarding.34,36

Satisfaction increases among physicians in clinics that implemented Lean during the first 2 phases, coupled with the decrease in satisfaction among physicians in the final phase of implementation, warrant further investigation. When the post-Lean physician satisfaction survey was administered, the pilot and beta clinics had accumulated 1 to 2 years of experience with Lean redesigns, whereas the remaining clinics had launched their redesigns as recently as 4 months prior to being surveyed. It is possible the decline in satisfaction among the physicians in this last phase reflected a period of transition and adjustment. Some disruption and discomfort accompanied all clinics’ early months of implementation, including spatial redesigns that required physicians to relinquish their offices and relocate next to their MA care team partner, as well as new workflows that called for management or delegation of tasks to nonphysicians. Benefits from such changes may only become apparent after several months of adjustment and experimentation. 

Another explanation involves differences in physician engagement with Lean implementation. Those in the last phase of clinics were much less involved with actual planning and development of Lean redesigns.37 Active involvement in identifying sources of waste and redesigning workflows—a hallmark of the Lean improvement approach—may be gratifying in itself. Research on participative decision processes and the use of participation in change management suggests that such direct engagement leads to greater commitment to new work initiatives.38 It may, therefore, be that the process of developing a Lean workflow is as important for its acceptance as the content of that workflow itself.

Suggestions for Further Research

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