1. Effect of Lean redesigns on time working among primary care physicians
HCSRN 2019 Conference April 9, 2019
Dorothy Hung, Ph.D., Su-Ying Liang, Ph.D., Quan Truong, M.P.H., Hal Luft, Ph.D.
Palo Alto Medical Foundation Research Institute
Funded by the Agency for Healthcare Research and Quality
1 R01 HS

2. Background Physicians face inefficiencies, demanding workloads,
burnout
Lean techniques can be used to
improve quality and efficiency
Few studies examine Lean impacts on time physicians spend delivering patient care
We used 6 years of EHR data to reconstruct daily work patterns, identify changes after Lean redesign

3. Lean in PAMF Primary Care
Standardization of equipment, supplies in exam rooms
Call management for
phone triage, response
Co-location of care teams in shared workspace
Workflows redesigns:
Daily huddles
Agenda-setting
Joint inbox management
5S of Workspace
Call Management
Frontline Continuous Improvement
Workflow (“Flow”) Redesign

4. Methods Study Population Study Period Study Design 316 PCPs
17 clinics, 46 depts
15M daily EHR transactions
Study Period
January 2011 – December 2016
Lean implemented in 3 phases
Study Design
Stepped-wedge, interrupted time series (ITS) analysis

5. Analysis Unit of observation for ITS data Physician-Month
Segmented regression using GLMM
Defined post-Lean period as 3 distinct time segments
to account for non-linearity in trends
1st year post-Lean, 2nd year post-, 3rd year & beyond
Main effects and covariates
Changes during each post-Lean period
Patient appt types and physician workloads

6. PCP Time Working Total hours each day
Total hours each day, excluding office visits
Time spent with patients during visits
Time spent after the last patient visit
Remote work each day
Remote work after the last patient visit

7. Physicians worked per day…
❖ >9 hours, including activities at the desk, during patient appointments, and remotely ❖ 6 hrs 46 mins with patients during office visits ❖ 2 hrs 10 min outside of office visit time ❖ 1.5 hours after the last patient visit of the day ❖ 30 min remote work, mostly after last visit of day (27m)

8. Hours working each day Main Effects Coefficient (LOG) Std. Error
T Stat.
P-value
Pre-Lean Intercept
10.078
0.054
187.23
<.0001
Pre-Lean Slope
-0.001
0.001
-0.82
0.421
1st year Post-Lean Intercept
0.006
0.010
0.56
0.583
1st year Post-Lean Slope
-0.002
-2.32
0.028
3rd year Post-Lean Intercept
-0.011
0.012
-0.91
0.363
3rd year Post-Lean Slope
1.33
0.184
Baseline
Gradual impact:
0.2% decrease in time
(significantly different
from baseline)
No significant difference
(from 1st year post-Lean)

9. Hours working each day, excl. visits
Main Effects
Coefficient
(LOG)
Std. Error
T Stat.
P-value
Pre-Lean Intercept
9.120
0.088
103.43
<.0001
Pre-Lean Slope
-0.002
0.002
-0.83
0.414
1st year Post-Lean Intercept
-0.068
0.030
-2.26
0.032
1st year Post-Lean Slope
-0.001
0.003
-0.30
0.770
3rd year Post-Lean Intercept
-0.052
-1.65
0.100
3rd year Post-Lean Slope
0.004
1.60
0.109
Baseline
Immediate impact:
6.6% decrease in time
Sustained impact
(no sig. difference
from 1st year post)

10. Hours working after the last patient visit
Main Effects
Coefficient
(LOG)
Std. Error
T Stat.
P-value
Pre-Lean Intercept
8.546
0.108
79.52
<.0001
Pre-Lean Slope
-0.003
0.002
-1.14
0.264
1st year Post-Lean Intercept
-0.077
0.030
-2.55
0.017
1st year Post-Lean Slope
0.000
0.003
0.15
0.883
3rd year Post-Lean Intercept
-0.063
0.037
-1.70
0.088
3rd year Post-Lean Slope
0.004
1.47
0.143
Baseline
Immediate impact:
7.4% decrease in time
Sustained impact
(no sig. difference)

11. Hours seeing patients during visits
Main Effects
Coefficient
(LOG)
Std. Error
T Stat.
P-value
Pre-Lean Intercept
9.388
0.414
22.68
<.0001
Pre-Lean Slope
0.007
0.015
0.45
0.654
1st year Post-Lean Intercept
0.030
0.047
0.65
0.524
1st year Post-Lean Slope
-0.009
-0.57
0.574
3rd year Post-Lean Intercept
-0.010
0.017
-0.58
0.562
3rd year Post-Lean Slope
0.002
0.001
1.26
0.209
Baseline
No impact
(no different
from baseline)
Null effect sustained
(no different from
1st year post-Lean)

12. Summary
❖ 6.6% decrease in hours beyond time spent with patients during office visits
❖ 7.4% decrease in time spent working each day after the last patient visit
❖ 0.2% gradual decrease in total hours working each day
These decreases were observed after Lean redesign, and were sustained over a 3+ year period
❖ No change in number of hours that physicians spent caring for patients during office visits

13. Conclusions
Findings align with previous research on Lean efficiencies in primary care.
Most alleviation was time spent on indirect patient care and administrative duties.
Results re: time in office visits indicates no effect on direct patient care.
Future studies underway on encounter time and patient experience during office visits