Addressing social and cultural needs with lean management in a national sample of US physician practices

Policy Points This national study of US physician practices finds that lean management, an approach to operational excellence and continuous quality improvement, can support integration of social and cultural services in primary care. The Centers for Medicare & Medicaid Services and commercial payers can expand programs including value-based, two-sided risk and global budget payment models that incentivize social screening and follow-up, language assistance, and workforce training to improve quality for vulnerable populations while reducing inequities in health care. The Centers for Medicare & Medicaid Services may also consider requirements that physician practices implement operational or performance excellence systems, such as lean management for quality and process improvement, as a condition for participating in value-based programs. 

CONTEXT: Health-related social needs-including stable housing, food security, and interpersonal safety-and patient race, ethnicity, and language (REAL) are key contributors to health equality. Although primary care practices are well positioned to connect patients with resources and provide ongoing support, integrating interventions into clinical workflows remains challenging. This study examines how lean management, a quality improvement approach that emphasizes standardized work processes and respect for people, can support practices in addressing the needs of diverse populations. 

METHODS: We leveraged data gathered from a nationally representative sample of 1,245 US physician practices. Key independent variables included lean implementation and practice use of specific techniques such as value stream mapping, daily management systems with standard work, and rapid-cycle process improvement. We conducted multivariate regressions to assess relationships between the extent of lean implementation and availability of social and cultural support in primary care. FINDINGS: Practices that implemented lean displayed 2.72 times the odds of having social screening, referral, and follow-up systems in place (95% CI, 1.20-6.19), and 2.85 times the odds of training providers on how to care for underserved populations (95% CI, 1.53-5.28). These practices also offered more language assistance (odds ratio [OR], 2.16; 95% CI, 1.22-3.82), routine collection of patient REAL data (OR, 3.75; 95% CI, 1.98-7.09), and more confidently addressed issues of race and/or discrimination among patients and staff (β: 0.12, P = .040). Value stream mapping, care team huddles, daily management, rapid-cycle improvement, and use of analytic tools were associated with higher odds of all sociocultural support measures, except for clinician representativeness of patients in terms race/ethnicity. 

CONCLUSIONS: Lean management can support efforts to address patient needs by facilitating social risk intervention and culturally responsive care. Attending to social and cultural needs in US physician practices may improve patient experiences and health outcomes, while reducing avoidable health care costs for individuals and populations.