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

Abstract

BackgroundAchieving 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.ObjectiveTo demonstrate system-level improvement in hypertension control in a large FQHC through the situational use of lean thinking and statistical process control.SettingLynn Community Health Center, the third largest FQHC in Massachusetts, USA.Participants4762 adult patients with a diagnosis of hypertension.InterventionFirst, 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.MeasurementsThe 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.ResultsHypertension control improved by 11.6% from a baseline of 66.8% to a 6 month average of 78.2%.LimitationsDurability 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.ConclusionsSuccess 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.

Health Care Delivery Interventions for Hypertension Management in Underserved Populations in the United States: A Systematic Review

“…Interventions that used EMR alone showed only very small reductions in BP (1.71 mm Hg reduction in systolic/1.13 reduction in DBP (−2.88 to −0.54) P =0.004. 42 EMR interventions that were designed to be a part of a larger team-based effort and included clinical support systems ( 34,36,45 ) or a QI methodology yielded greater reduction in BP (range, 10.9–16 mm Hg reduction). Furthermore, an intervention combining EMR and nurse-led education intervention was associated with more SBP reduction than using EMR alone (−5.6 mm Hg [95% CI, 0.3–6.9 mm Hg).…”

“…29,31 Two observational studies also had high attrition rates (>20%), 39,40 and several studies also lacked independent blind assessment. [40][41][42][43] Overall, risk of bias was moderate given difficulty of blinding patients and providers due to the nature of the interventions (Figures 2 and 3).…”

“…This registry would be integrated into the EMR to alert providers that a patient was not meeting goal therapy and action needed to be taken. 35,36,42 Some EMRs would then include specialized order sets or panels to facilitate ordering.…”

Fatores associados à adesão de adultos/idosos ao tratamento da hipertensão arterial na atenção básica [Factors associated with adult/elderly adherence to the treatment of arterial hypertension in primary care] [Factores asociados con la adherencia de adultos/ancianos al tratamiento de la hipertensión arterial en atención primaria]

“…Entre os estudos que corroboram com esse achado, encontra-se pesquisa conduzida para avaliar a eficácia das ações realizadas por equipe multiprofissional no controle de hipertensão, em população de 4.762 hipertensos. Concluiu-se redução nos níveis pressóricos e aumento no controle em pacientes acompanhados por equipe da atenção primária, capacitada na resolução de problemas, composta por médico, enfermeiro, nutricionista, educador físico, fisioterapeuta e psicólogo 24 .…”

Lean and Safety Management: a Project to Improve the Continuity of Care for Chronic Patients

“…Although HLM counts several experiences in the last twenty years literature, the analysis of the integration between hospital and territorial care represents a novelty for this methodology. Indeed, just few attempts of chronic pathways improvements from primary care to hospital and vice versa have been reported in the empirical HLM literature (Paccagnella, Mauri and Spinella, 2012;Patton et al, 2015;Sampalli et al, 2015;Kutz et al, 2018;Van Eeghen, Littenberg and Kessler, 2018;Lee et al, 2019;Kelendar, Faisal and Mohammed, 2020).…”