What does management of a large restaurant chain have in common with the U.S. health care system? Not as much as it should, according to Atul Gawande, a physician and avid proponent of improving the way health care is delivered. In a recent article in the New Yorker, Gawande describes how the Cheesecake Factory has figured out how to control costs and maintain quality while also advancing innovation, which he contrasts with the health care system, where “costs are soaring, service is typically mediocre, and quality is unreliable.”
Gawande says many of the Cheesecake Factory’s strategies for success can be applied in the medical field. He describes how the restaurant chain has standardized preparation of an extensive variety of menu items, including using a standard set of steps to prepare each item. The instructions for the food prep staff and cooks are specific, but still rely on “tacit knowledge” or know-how. In other words, there’s a cook book, but the cooks have to be able to use their own judgment to successfully prepare each item.
In medicine, Gawande asserts, physicians have historically relied heavily on know-how, and have often eschewed guidelines as “cook book medicine.” But there are many conditions and procedures for which evidence supports the use of a standardized care protocol, where variation should be the exception rather than the rule.
Changes in the organization of the health care system and the way providers are reimbursed might lead to greater adoption of such protocols, or cook books. Physicians are leaving independent practice in large numbers to become hospital employees, forging a closer link among the various providers in the health care system. And changing payment models—moving from payment for each service provided to paying for patient outcomes—are providing an incentive for hospitals to ensure that physicians are following evidence-based guidelines and providing care efficiently.
Gawande describes how, in one health system, care delivered in the intensive care units (ICUs) of multiple hospital sites is supported by a video “command center.” The command center is staffed by physicians and nurses who keep tabs on the care provided to patients in the ICUs and, when necessary, step in—remotely—to correct problems. While the on-site physicians and nurses are trusted to follow established guidelines and use good judgment, the command center staff serves as back-up, to ensure critical steps aren’t missed, and potentially disastrous errors are caught.
Some physicians have pushed back, unaccustomed to being told how to practice or having someone checking their work. Even at the Cheesecake Factory, though, work is double-checked by a manager who ensures the quality of each meal—and that’s just dinner. Because of the remote ICU command center, lives have been saved, pure and simple.
It may take a period of adjustment for physicians and hospitals to find a balance between relying on know-how and using cook books. But as health systems begin to look more like chains, taking lessons from places like the Cheesecake Factory can help them act more like chains, where innovation is more rapidly disseminated and much greater control is exerted over costs and quality.
By Amanda Menzies