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Scaling Lean in Primary Care: Impacts on System Performance
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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
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.
The observed variations in physician and patient satisfaction point to areas for further research. First, data from longer post-Lean time periods than those reported here are needed to assess more complete effects of Lean in all clinics and whether reactions to the Lean redesigns remained stable over time.39 Second, by combining our findings with qualitative data or more fine-grained quantitative data, we can examine specific physician- and patient-level perceptions underlying their responses to the closed-ended satisfaction questions reported here. Third, availability of nonphysician satisfaction data at the clinic level would allow comparison of primary care staff satisfaction results across implementation phases (ie, pilot, beta, all remaining clinics). Last, a logic or program model identifying the steps and underlying organizational and social psychological mechanisms would help specify important stages of the Lean initiative—such as staff and leadership participation in workflow redesign, management communication of expected practice changes, practice-level coaching, and staff implementation of redesigns—at which quality, efficiency, and satisfaction outcomes could then be assessed.40 Such a model could be used as a guiding framework for an in-depth process evaluation of the intermediate results at each step of the change process.41


Organizations ranging from private hospitals and physician practices to government health systems and agencies, including the Veterans Health Administration and CMS, are now implementing Lean to improve efficiency and value. Despite its growing popularity, few studies have addressed the concerns of healthcare leaders and practitioners, including whether Lean can help delivery systems identify waste and redesign care processes to enhance multiple performance outcomes simultaneously—particularly in FFS ambulatory settings where the vast majority of healthcare is delivered. Moreover, questions remain as to whether productivity gains achieved through Lean will undermine quality and worsen already high levels of discontent among primary care providers. Our findings indicate that an ambulatory care system can develop and scale Lean redesigns with largely beneficial consequences. These results may lead other delivery system leaders to innovate using Lean management techniques, and, if the findings replicate in other systems, they may further enhance support for Lean learning among public and private payers. Additionally, our study underscores the need for careful analysis of both desired effects and the potential unintended consequences of implementing Lean to improve value in healthcare.


The authors would like to thank Mr Eric Wong, MS, and Ms Maayan Yakir, BS, for analytic support and assistance with the preparation of this manuscript.

Author Affiliations: Palo Alto Medical Foundation Research Institute (DYH, HSL, MCM), Mountain View, CA; Agency for Healthcare Research and Quality (MIH), Rockville, MD.

Source of Funding: The research reported in this paper was funded by the Agency for Healthcare Research and Quality under its ACTION II contract HHSA2902010000221, Task Order 2. The views expressed in this paper are solely those of the authors and do not represent any US government agency or any institutions with which the authors are affiliated.

Author Disclosures: Drs Hung and Luft and Ms Martinez are employed by the study organization, but the Research Institute exists as an independent unit and all research is conducted without being subject to review and approval by the organization. Dr Harrison reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. 

Authorship Information: Concept and design (DYH, MIH, HSL); acquisition of data (DYH); analysis and interpretation of data (DYH, HSL, MIH); drafting of the manuscript (DYH, MIH, HSL, MCM); critical revision of the manuscript for important intellectual content (DYH, MIH, HSL, MCM); obtaining funding (DYH); administrative, technical, or logistic support (MCM); and supervision (DYH, HSL). 

Address Correspondence to: Dorothy Hung, PhD, MA, MPH, Associate Scientist, Palo Alto Medical Foundation Research Institute, 2350 W El Camino Real #447, Mountain View, CA 94040. E-mail:

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