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.
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).
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??