Patrick J. Skerrett

The Cheesecake Factory: a model for health care?

In a new essay entitled “Big Med,” physician-author Atul Gawande muses in The New Yorker if The Cheesecake Factory and other successful chain restaurants could serve as a model for improving health care.

Gawande, a surgeon at Brigham and Women’s Hospital and professor of surgery at Harvard Medical School, was having dinner with his children and some of their friends at a Cheesecake Factory. Everyone was happy with their reasonably-priced food and, as Gawande writes, “it was delicious.” What’s more, nothing smacked of mass production. A conversation with a line cook confirmed that most everything was made from scratch. He 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.”

The experience prompted Dr. Gawande to meet with managers, cooks, and other workers at a Boston-area Cheesecake Factory to see how it delivers good food and a good dining experience time after time. He then goes on to compare the restaurant’s procedures with what goes on in hospitals. As a case study, he uses total knee replacement surgery, something his mother had recently undergone.

Gawande believes that standardization can and should be brought to areas of medicine, and that doctors can benefit from the same kind of training and coaching used in other industries. He concludes that

“Essentially, we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring.”

It’s a provocative argument from someone who is part of big medicine and who is also a keen observer of how it works. If you are interested in our health care system, I recommend that you read the article. Let us know if you agree or disagree with Dr. Gawande.

Comments:

  1. non profit denver

    This is a really funny comparison, and sad at the same time. To think that people get better quality of service from a place like the cheesecake factory over a hospital is crazy.

  2. Arnold L. Goldman DVM, MPH

    The phrase “centralized control” says it all.
    Go tell someone their mother’s prognosis/demographic doesn’t warrant some curative treatment and she’s required to get the
    palliative instead.

    The “doctor-patient” relationship is an individual one that provides medical care to the individual. There’s no such thing as “health-care”, only doctors and patients. The rest is just there as infrastructure.

    Keep your “centralized control.” It’ll work about as well as other government run industries…doctor as government worker, yeah that will attract the best and brightest.

  3. Donald W. Light

    Comment on Atul Gawande’s BIG MED in The New Yorker Aug 13, 2012

    For the past three years I’ve had the privilege of teaching at Stanford about how other affluent countries have produced higher quality outcomes than in the U.S. at substantially lower costs. Few of them have anything to do with the Cheesecake Factory and running a quality restaurant chain. While Atul Gwande’s article BIG MED has some interesting details further in, the analogy with the Cheesecake Factory will mislead readers, I fear.

    The examples to feature of well-measured quality outcomes, clear protocols, well-coordinated teams, and incentives that reward better quality at lower cost are the remarkable achievements of Kaiser Permanente, Group Health of Puget Sound, the Veterans Health Administration, Marshfield, and Intermountain. Local examples from Boston, unfortunately, don’t come close. And when we read that the orthopedic surgeon, John Ready, is so tied in with a knee-implant manufacturer that he says “I’m my rep’s livelihood,” we know we are knee-deep in high-margin, cost-inflating medicine. In few other countries would are such relationships allowed to develop, for obvious reasons.

    Gwande writes that “…good ideas still take an appallingly long time to trickle down,” but does not explain why. What readers need to learn is how the organization of American medicine and incentives work against those good ideas. It’s not that physicians are not smart or flexible, but rather they will lose power or profit or prestige implementing cost-saving ways to increase quality. The budget-based, well-organized exemplars I mentioned, where physician-managers spend a year getting a new good idea into practice, deserve emulation. Only that would eliminate opportunities for more revenues and profits.

    The most exciting development I know in ICU quality is taking place at the Mario Negri Institute in Bergamo, Italy. One team at this famous non-profit research institute has persuaded the heads of 163 ICUs across the nation to develop clinical outcome measures and to track their performances. Each year, median scores rise and several hundred more critically ill patients live who would not have the year before. As Gwande points out in his description of Dr. Ernst trying to do the same in 4 ICUs (with no systematic evidence of clinical gain), the Mario Negri achievement since 2005 is remarkable. Now they are funded to teach ICUs in four other nations how to give better care to the sickest patients, but the United States is not among them. Let’s read more about how they do it, as part of a non-profit dedication to patient care, rather than to market share and revenues.

    Donald W. Light, Ph.D.
    Network Fellow, Edmond J. Safra Center for Ethics, Harvard University
    Professor of comparative health systems, University of Medicine & Dentistry of New Jersey

  4. Jim Bouman

    One could wish that the misbegotten burg of McAllen Texas, and all of its physicians would be interested in seeing a transformation along these lines of their health care “system”.

    [Why? Can someone please tell me why we insist on calling the current hodge-podge a “system”?]. There is nothing systemic about it. NOTHING.

  5. Dawn Bell

    Dr. Gawande’s metaphor strikes home–so many issues/points are raised in this article, but I’ll focus on just one I could especially relate to–Mr. Luz’s experience with his elderly mother. The patient’s experience in our healthcare “system” is often abysmal, marked by lack of coordination and communication which certainly impacts the perception of quality if not actual quality. Doctors need systems of care to support what they do. Patients desperately need systems that are comprehensible, navigable and more importantly responsive to their needs. Will “big box” hospitals help with this? I think so. We’re at the beginning of a tectonic shift in medicine where the hospital will solidify its role as the center of healthcare delivery (and accountability). Eventually they will employ nearly all healthcare providers and will have enormous leverage on how medicine is practiced. Christina Monti sees it–be the change.

    • Jim Bouman

      And that will require the abandonment of fee-for-service, aka “piecework”, remuneration. Health care is simply too crucial to our long term survival, both as individuals and as a society.
      After Dr Gawande’s experience with the White House and its fumbling attempt under Hillary Clinton to bring some (not much)reality to health care I hesitate to propose this:
      Atul Gawande as chief architect of a USA Health System. But, we need him, we need his ideas and realistic assessment of what must come next in medicine in America.

  6. Neil Ravin, MD

    The problem is the American healthcare system is not a single corporation where a decision is made and, for better or for worse, the direction flows down the chain of command.
    American doctors have the individual responsibility to critically assess the “guidelines” which come out of various organizations and to decide whether or not these are likely to be beneficial to their patients. This means most agree to give aspirin to patients with myocardial infaction, but in many instances the “best practice” of today is poor practice tomorrow–e.g., never give a beta blocker to a patient with CHF; or sustain pregnancy with DiEthylStilbesterol (DES), or even discharge no CHF patient from hospital on spironolactone, or treat patients with bone density T scores below 2.5 SD with bisphosphonates. The problem Dr. Gawande sees is simply a lack of communication, dissemination of information. The problem is more complex–critical thinking requires the physician to say “No,” sometimes, and that may benefit patients.

    • Peter

      Yes, I am agree with MR.Neil Ravin. “American healthcare system is not a single corporation where a decision is made and, for better or for worse, the direction flows down the chain of command.”

  7. JZP

    Have you looked into calorie count and portion size at Cheesecake Factory? Just because foods are made on premises doesn’t mean they are healthy. I agree non-processed is a step in the right direction but we’ve got a long way to go.