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Sustainment of Lean Redesigns for Primary Care Teams

Hung, Dorothy Y., PhD, MA, MPH; Gray, Caroline P., PhD; Truong, Quan A., MPH; Harrison, Michael I., PhD

doi: 10.1097/QMH.0000000000000200
Lean Methodology

Background: Quality improvements are notoriously followed by “backsliding” or relapse to the status quo. This mixed-methods study examined the sustainment of Lean workflow redesigns for primary care teams several years after being implemented in a large, ambulatory care delivery system.

Methods: We conducted qualitative interviews of 57 leaders and frontline providers, and fielded post-Lean implementation surveys to 1164 physicians and staff in 17 primary care clinics across the system. We analyzed interviews and conducted independent sample t tests to identify key factors that facilitated the sustainment of new workflows among primary care teams. All analyses were conducted after Lean redesigns were implemented and scaled across the system in 3 consecutive phases.

Results: Adherence to Lean redesigns was highest in the pilot clinic, despite having the longest postdesign measurement period. Members of the pilot clinic reported greatest participation in designing workflows, were most highly engaged in quality improvement efforts, and held most favorable beliefs about Lean changes. Adherence to redesigns was lowest among clinic members in the second phase of implementation; these members also reported highest levels of burnout.

Conclusions: Staff participation in Lean redesign is a key to facilitating buy-in and adherence to changes. Change ownership and continued availability of time for improvement activities are also critical to the long-term success of Lean implementation in primary care.

Palo Alto Medical Foundation Research Institute, Palo Alto, California (Dr Hung and Ms Truong); Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Menlo Park, California (Dr Gray); and Agency for Healthcare Research and Quality, Center for Delivery, Organization, and Markets, Rockville, Maryland (Dr Harrison).

Correspondence: Dorothy Y. Hung, PhD, MA, MPH, Palo Alto Medical Foundation Research Institute, 795 El Camino Real, Ames Bldg, Palo Alto, CA 94301 (

The research reported in this article was funded by the Agency for Healthcare Research and Quality under its ACTION II contract HHSA2902010000221, Task Order 2.

The views expressed in this article are solely those of the authors and do not represent any US government agency or any institutions with which the authors are affiliated.

The authors declare no conflicts of interest.

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