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Using lean thinking to improve hypertension in a community health centre: a quality improvement report
  1. Patrick Lee1,2,3,
  2. Linhchi Pham4,
  3. Stephen Oakley3,
  4. Kimberly Eng3,
  5. Elena Freydin3,5,
  6. Tayla Rose3,6,
  7. Alyssa Ruiz3,
  8. Joyce Reen3,
  9. Deborah Suleyman3,
  10. Vanna Altman3,
  11. Kara Keating Bench3,
  12. Alice Lee7,
  13. Kiame Mahaniah3,4
  1. 1 Medicine, North Shore Medical Center, Salem, Massachusetts, USA
  2. 2 Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Lynn Community Health Center, Lynn, Massachusetts, USA
  4. 4 Tufts University School of Medicine, Boston, Massachusetts, USA
  5. 5 School of Nursing, Salem State University, Salem, Massachusetts, USA
  6. 6 Department of Pharmacy and Health Systems Sciences, Northeastern University School of Pharmacy, Boston, Massachusetts, USA
  7. 7 Lean Enterprise Institute, Cambridge, Massachusetts, USA
  1. Correspondence to Dr Patrick Lee; ptlee{at}


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.

  • quality management
  • statistical process control
  • care pathways
  • disease management
  • cardiovascular disease
  • primary care
  • general practice
  • lean thinking

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  • Contributors PL, LP, SO, KE, EF, TR, AR, JR, DS, VA, KKB, AL and KM contributed to the planning and implementation of the work described in the article. PL and LP wrote the manuscript with support from TR. PL, LP, SO, KE, EF, TR, AR, JR, DS, VA, KKB, AL and KM reviewed drafts and approved the final manuscript for submission. PL is responsible for overall content of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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