Gawande: What hospitals can learn from…the Cheesecake Factory?

As it consolidates, health industry moves toward restaurant chain model

The "casual dining sector" has turned basic ideas into a multi-billion dollar industry, renowned writer and surgeon Atul Gawande argues in the New Yorker this month—but hospitals are struggling to implement many of the same, simple principles.

 According to Gawande, restaurants like the Cheesecake Factory take ideas that "start out in elite, upscale restaurants in major cities" and "reengineer them for affordable delivery to millions." Moreover, the restaurants provide hundreds of quality items on their menu and excellent customer service, all at a low cost.

Similarly, health organizations "are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality." However, Gawande writes, "Unlike the Cheesecake Factory, we haven't figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable."

How the Cheesecake Factory does it

Gawande highlights standardization and tight oversight as main factors in the Cheesecake Factory's success:

  • Standardization: Every item on the Cheesecake Factory's menu has detailed production instructions that leave some room for "tacit knowledge" that staff cooks acquired as they rise through the ranks. When the company adds new items to the menu, it tests the product to determine whether it can be created at a low cost without compromising quality. The company then follows a centralized process for teaching the new recipes to cooks at hundreds of locations nationwide.
  • Oversight: Each Cheesecake Factory kitchen is overseen by a manager who monitors for quality, waste, and pacing. At the same time, the company uses computer analytics to predict customer traffic and maintain a 97.5% efficiency rate with groceries (throwing away no more than 2.5% of all groceries purchased).

How health care could do it

According to Gawande, the U.S. health care industry is moving toward creating "Cheesecake Factories for health care," but needs to get stakeholders on board to bring the model to scale.

"Doctors and patients have not had a positive experience with outsiders second-guessing decisions," Gawande notes, "How will they feel about managers trying to tell them what the 'best practices' are?"

Gawande details an example of a Cheesecake Factory-like model in health care, at his own hospital: Brigham and Women's Hospital orthopedic surgeon John Wright, who has become the facility's "kitchen manager" for knee replacement surgeries.

  • Wright has helped the hospital improve quality and cut hospitals by gathering caregivers from across the hospital to develop a standardized model for knee replacements.
  • Together, they determined which anesthesia to administer, which implants to use, physical therapy guidelines, and every other step in the process.
  • For example, they eliminated the use of continuous passive-motion machines, which are used to flex and extend the patients knee as they lie in bed. Large studies suggested they had few benefits and caregivers at the hospital found that patients who used them fared less well.

Gawande details a similar effort to standardize and oversee ICU care at the Steward Health Care System in Boston through telemedicine.

Bringing the Cheesecake Factory model to scale in health care

Gawande notes that bringing the Cheesecake Factory model to scale in health care could have unintended consequences.

For example, although chain restaurant workers produce significant value, the industry has devalued them. "The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating," Gawande says, asking, "Can we avoid this as we revolutionize health care?"

Regardless, Gawande concludes, "The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that's probably the way it should be" (Gawande, New Yorker, 8/13).

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