A Brave Analogy from Dr. Atul Gawande


A number of readers have sent me a link to the latest  New Yorker missive from Dr. Atul Gawande (whose work I greatly admire). It's titled “Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?

The piece makes a number of good points about the need to improve healthcare delivery. But, Gawande is I'm sure, in many medical circles, being criticized for saying healthcare should learn from…. The Cheesecake Factory.

I haven't eaten at a Cheesecake Factory in many years. I remember a huge menu and giant portions (with a “breakfast burrito the size of a football,” said frequent blog commenter Karthik Chandramouli). I tend to prefer local restaurants, at home or on the road, but the chain is wildly popular and successful. So, they are doing something right.

Gawande has written many wonderful  New Yorker pieces and his books are amazing. Gawande has argued that healthcare can (and must) learn from aviation, construction, manufacturing,pit crews, farming, and the U.S. nuclear navy. I agree with him that there are many lessons to be learned about Lean and, more generally, high-reliability organizations.

Before getting into the details of his latest piece, I can just imagine the indignant eye rolling about the Cheesecake Factory piece that is taking place in doctor's lounges and hospital executive suites:

  • We're different in healthcare, we're not a restaurant.
  • How dare you compare the assembly of food to surgery.
  • That food is sugary, fatty, oversized, and contributes to our healthcare and obesity crises.

That's not me saying that… but I'm sure it's being said.

Gawande writes:

I'd come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven't figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.

Gawande writes about the operational efficiencies and quality checks that are built into the CCF kitchen. Cooks have detailed standardized work, but (as in many Lean settings), they don't have to always have the document right in front of their face once they are trained. The food is inspected and feedback is given on the proper appearance of the food. CCF is careful in their training and rollout of new processes and menu items.  CCF also does a very good job of predicting customer volumes and ordering food accordingly, to keep waste to a minimum.

Gawande points out many of these things don't happen in healthcare (or at least often enough).

He writes about how hospital systems are becoming larger conglomerates, hoping to get economies of scale and buying power. Leading organizations like the Cleveland Clinic are expanding into other cities and states. This growth, consolidation, and expansion could lead to lower costs and better quality – and it might put more pressure on other healthcare organizations to improve (much as Toyota and Honda forced the “Detroit Three” to improve… but it took a while).

Gawande writes:

Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth

He places a lot of faith in size. But, you can't just get bigger… you need great processes and customer focus.

For every Toyota, there's a GM or a Chrysler. Did Chrysler get better when they were bought by Daimler??

For every Southwest (which is now huge), there's a Delta. Is Delta more cost effective now that they bought Northwest? Is service better? I know Jamie Flinchbaugh would say “NO!!” (if you see his many complaints on his twitter feed).

It's a long piece… there's more I could comment on (including his story about a friend's mother who received horrible service/care at a hospital), but I'm curious to hear your thoughts and reactions about Gawande's piece. What are you hearing about it in your hospital??

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Mark — good comments. I’m a huge fan of Atul Gawande. Folks shouldn’t get hung up on the irrationality of comparing TCF to heart surgery … that is not what he is trying to do with this article. He is a great communicator, and he is trying to tell stories that people can relate to and provide some context to a seemingly infinitely complex healthcare system. Standard work, checklists, visibility to costs, clear process metrics, continuous process improvement — these are things that many many other industries have put into place with great effectiveness and impact. It’s time healthcare does as well … past time actually.

    • Earl – thanks for the comment! I agree that people shouldn’t get too hung up on the comparison, any more than comparing a hospital to a factory. I’m just predicting the kneejerk reactions that are probably taking place.

      Healthcare needs more widespread adoption of everything you listed there, to be sure! We have some health systems making great progress — and we need the rest to follow… now!

  2. Anonymous comment shared with me:

    “As someone in an enormous health system there is very little to no knowledge sharing/learning for an organization this large that cares for so many people. Tons of knowledge that sits in silos, so folks can be confined to “doing what they’ve always done.” I don’t see a huge benefit to our size from an Ops standpoint to our size–the only benefit we gain is contracting/pricing….for now.”

  3. Here’s a potential downfall of being a big hospital chain:

    Hospital Chain Inquiry Cited Unnecessary Cardiac Work

    But the nurse’s complaint was far from the only evidence that unnecessary – even dangerous – procedures were taking place at some HCA hospitals, driving up costs and increasing profits.

    HCA, the largest for-profit hospital chain in the United States with 163 facilities, had uncovered evidence as far back as 2002 and as recently as late 2010 showing that some cardiologists at several of its hospitals in Florida were unable to justify many of the procedures they were performing. Those hospitals included the Cedars Medical Center in Miami, which the company no longer owns, and the Regional Medical Center Bayonet Point. In some cases, the doctors made misleading statements in medical records that made it appear the procedures were necessary, according to internal reports.

    Questions about the necessity of medical procedures – especially in the realm of cardiology – are not uncommon. None of the internal documents reviewed calculate just how many such procedures there were or how many patients might have died or been injured as a result. But the documents suggest that the problems at HCA went beyond a rogue doctor or two.

    So I’ll amend my post to say you need not just size, but also great processes…. and great ETHICS.

  4. Interesting.

    When I went into the Cheesecake Factory Yesterday. I had waited 6 weeks for a reservation. I could have gotten into a general restaurant sooner, but those specialists take longer to get in. It took 15 minutes for them to look up my dining insurance card, and then found out that I actually had a $10 copay, not a $5 copay. They didn’t accept credit cards, so I had to go to an ATM, and then wait when they gave my table away.
    Plus they didn’t tell me until after I ordered that my chicken picata was not covered in my policy…
    (Note: There’s a much longer, amusing, story floating around somewhere that compares flying with the healthcare industry.)

  5. I’ve loved Dr. Gawande’s work, but I’m wondering if he has jumped the shark with this one. Cheesecake Factory? Really? He couldn’t have chosen Legal Sea Food even if he didn’t want to venture further than the Prudential Center for his research? ;-)

  6. We need more leaders like Dr Gawande in healthcare. Tomorrows healthcare climate will require out of the box thinking and the realization that no longer is it possible to do things the way we have “always done them”. Not only will the future require standardization of care but standardization of process.

  7. A counterpoint commentary to Dr. Gawande’s piece:

    LINK (Fierce Healthcare).

    The end of the piece:

    He used the Cheesecake Factory comparison for an obvious reason–it sounds a little ridiculous on the surface, and therefore would draw in readers.

    A much more relevant discussion would have been a potential seat at the table for the Lean process, which drove the transformation of Toyota’s automotive assembly lines during the 1970s and 80s. Among the primary reasons American and Korean cars are no longer the junkpiles they were 25 years ago is because they adopted Lean techniques in their factories.

    Building a single car requires the delivery, coordination and installation of some 20,000 parts, including advanced electronics. It also requires a strong relationship between hourly labor and salaried management. There are many parallels to healthcare delivery there.

    Lean is indeed being slowly being adopted at hospitals. I had the privilege recently of speaking at length with Larry Hegland, M.D., who used Lean to prepare the Ministry Health system in Wisconsin for an onslaught of RAC audits.

    Put simply, the Lean process when applied to healthcare creates a much better–and palatable–image of efficiency than that of the Cheesecake Factory. Hopefully, the good doctor will revisit this topic down the line with that in mind.

  8. I’m sure many people shuddered at the thought of their health care being associated with a “chain” or their hospical as the next Wal-Mart.

    I believe the focus on size due to the purchasing power and financial constraints has lead to the acquisitions of hospitals into larger systems, however, i didn’t take that as the reason for the chain focus.

    My takeaway of using Cheesecake, besides to capture the reader and to make it relatiable, is that a chain can be seen as a microcosm of how good ideas are disseminated and continuous improvement, which does not occur as quickly or frequently in health care. As he mentions, it is not just within the US or within a system but within the same hospital and same practice that you find a lack of collaboration to find the most effective and least wasteful way to deliver care.

  9. I don’t think size is the only key, as Dr. Gawande avers. Indeed, I’m having a hard time swallowing his size-and-innovation link. I understand his point that size potentially provides resources for innovation and improvement, but I’m not sure it’s a slam dunk.

    One of my parents has gone through cancer treatments during the past nine years . The hospital system began to consolidate seriously about two to three years ago and to reorganize its newly in-house activities to make them more efficient, at least theoretically. Don’t ask my parent about the “benefits” of this process. From the customer’s perspective, the place is more bureaucratic and more difficult to deal with than ever before. They may have reduced “muda,” but it sure wasn’t from the patient perspective. (Actually, I don’t think this system has publicly expressed any devotion to lean thinking at all).

  10. we shouldn’t confuse consolidation with efficiency. Combining bad practices from 2 or 3 different institutions can make things much worse for our patients. When you combine a registration system that can’t update data, a copay collection system that has no accountability, various EMR systems that don’t exchange data, a bill that is not customer-friendly and staff members who have just had benefits decreased and a co-worker laid off, you don’t get good results or satisfied patients.

      • As a rule, though, bigger gives you more opportunities to be better. First, you can take the best practices of all the different entities that are combined. Second, you have more minds to apply to problems. Third, the costs of buying the right equipment for the job are easier to justify (i.e. a bigger clinic can justify an on-site X-ray or lab equipment that a small on can’t afford). Fourth, you can develop more internal experts (i.e. have an internal lean team to rotate leaders through). Fifth, you have the flexibility to pull cross-functional teams for projects and not shut down the operation.

        I’m sure there are more reasons, but the proof is in the pudding. There aren’t a lot of big clinics splitting into smaller clinics, and they would be doing that if patients were fleeing for the better experience in smaller operations.

        • Thanks for the comment, Jeff. You’re right that there are some ways in which bigger can be better.

          The current drivers toward bigger practices and health systems seem to be driven by economics (better negotiating leverage against others), not the drive for better service.

          If patients preferred smaller clinics, and if smaller clinics provided better service, I bet the trend would still be toward consolidation in healthcare delivery.


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