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Contextual Conditions and Performance Improvement in Primary Care

Hung, Dorothy Y., PhD, MA, MPH; Harrison, Michael I., PhD; Liang, Su-Ying, PhD; Truong, Quan A., MPH

Quality Management in Healthcare: April/June 2019 - Volume 28 - Issue 2 - p 70–77
doi: 10.1097/QMH.0000000000000198
Original Research

Background: Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns.

Methods: We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes.

Results: Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support.

Conclusions: Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change.

Palo Alto Medical Foundation Research Institute, Palo Alto, California (Drs Hung and Liang and Ms Truong); 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.

© 2019Wolters Kluwer Health | Lippincott Williams & Wilkins