Using lean thinking to improve hypertension in a community health centre: a quality improvement report

BACKGROUND: Achieving better care at lower cost in the US healthcare safety net will require federally qualified health centres (FQHC) to implement new models of team-based population healthcare. Lean thinking may offer a way to reduce the financial risk of practice transformation while increasing the likelihood of sustained improvement. OBJECTIVE: To demonstrate system-level improvement in hypertension control in a large FQHC through the situational use of lean thinking and statistical process control. SETTING: Lynn Community Health Center, the third largest FQHC in Massachusetts, USA. PARTICIPANTS: 4762 adult patients with a diagnosis of hypertension. INTERVENTION: First, we created an organisation-wide focus on hypertension. Second, we implemented a multicomponent hypertension care pathway. The lean tools of strategy deployment, standardised work, job instruction, Plan-Do-Study-Adjust, 5S and visual control were used to overcome specific obstacles in the implementation. MEASUREMENTS: The primary outcome was hypertension control, defined as last measured blood pressure <140/90. Statistical process control was used to establish baseline performance and assess special cause variation resulting from the two-step intervention. RESULTS: Hypertension control improved by 11.6% from a baseline of 66.8% to a 6 month average of 78.2%. LIMITATIONS: Durability of system changes has not been demonstrated beyond the 14-month period of the intervention. The observed improvement may underestimate the effect size of the full hypertension care pathway, as two of the five steps have only been partially implemented. CONCLUSIONS: Success factors included experienced improvement leaders, a focus on engaging front-line staff, the situational use of lean principles to make the work easier, better, faster and cheaper (in that order of emphasis), and the use of statistical process control to learn from variation. The challenge of transforming care delivery in the safety net warrants a closer look at the principles, relevance and potential impact of lean thinking in FQHCs.