Contextual Conditions and Performance Improvement in Primary Care

Dorothy Y. Hung, Michael I. Harrison, Su Ying Liang, Quan A. Truong

Research output: Contribution to journalArticlepeer-review

11 Scopus citations


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.

Original languageEnglish
Pages (from-to)70-77
Number of pages8
JournalQuality Management in Health Care
Issue number2
StatePublished - 1 Apr 2019
Externally publishedYes

Bibliographical note

Publisher Copyright:
© 2019 Wolters Kluwer Health, Inc. All rights reserved.


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.

FundersFunder number
Agency for Healthcare Research and QualityHHSA2902010000221


    • organizational management
    • patient care team
    • primary health care
    • professional burnout
    • total quality management
    • workflow


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