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 HS2452901

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

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

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

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

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

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)

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)

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)

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)

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)

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

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