by Gwen Moritz
Posted 9/3/2012 12:00 am
Updated 2 years ago
In the 1957 romantic comedy "Desk Set," Spencer Tracy plays a rumpled efficiency expert assigned to computerize a national television network's research department, managed by brainiac Katharine Hepburn. It was a delightful movie - it's Hepburn and Tracy, after all - that now seems almost pre-historic with its blinking, room-sized computer spewing punch cards.
An efficiency expert was already a fearsome character by 1957; the 1950 comedy "Cheaper by the Dozen" made sport of the structured family life of efficiency pioneers Frank and Lillian Gilbreth in the early 20th century. In "Desk Set," Hepburn and her small staff of cinch-waisted single women spend weeks in mortal fear that the new computer means impending unemployment. (I guarantee that this recent headline in The City Wire, the Fort Smith online news site, sent a shudder through a bunch of journalists: "Northwest Arkansas Newspapers hires efficiency firm.")
I thought of all this as I read in The New Yorker one of the most thought-provoking articles I've read in years: "Big Med," by surgeon and journalist Atul Gawande. The subtitle sums up Dr. Gawande's thesis: "Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?" I read the 10,000-word article twice even before I learned that St. Vincent Health System and the University of Arkansas for Medical Sciences were talking about some kind of "affiliation."
Gawande describes in fascinating detail the inner workings of a restaurant chain that many of us have visited in bigger cities, the Cheesecake Factory. The Cheesecake Factory kitchen that he visited in Boston used $1,614 worth of chicken in a given week and wasted about $3 worth of it. New recipes perfected in the company's test kitchens are taught to regional managers and kitchen managers who teach them to a nationwide army of line chefs who roll them out to eager customers in seven weeks.
"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," Gawande wrote. "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 idea of reducing health care to a production line and treatment to a recipe feels wrong. But in an incredibly effective piece of writing, Gawande snaps the reader back to pragmatic reality by contrasting the customer-focused efficiency of the Cheesecake Factory with the hospital experience one of the chain's regional managers had when his 78-year-old mother experienced a fainting spell.
"The doctors ordered a series of tests and scans, and kept her overnight. They never figured out what the problem was. ... [T]he clinicians didn't seem to be following any coordinated plan of action. The emergency doctor told the family one plan, the admitting internist described another, and the consulting specialist a third. Thousands of dollars had been spent on tests, but nobody ever told [the regional manager] the results."
This elderly woman was officially released from the hospital at 10 a.m., but she didn't actually get to leave until 6 p.m. because of one delay after another - someone on break, someone else at lunch, incomplete paperwork. As someone who has navigated hospitals with elderly parents, I found the tale depressingly believable.
To the Cheesecake Factory regional manager, the hospital seemed to be crying out for standardization of best practices. And that, according to Gawande, is exactly what the biggest health care chains are trying to do.
For instance, Brigham & Women's Hospital in Boston, the chain-owned hospital where Gawande is on staff, has standardized knee replacements - including limiting the replacement models that the surgeons can use. By buying more units of fewer models, the hospital has been able to demand bulk discounts and to wring out lower prices even when purchasing what might be called "a la carte" knee replacements.
Yes, there will be resistance to imposed efficiencies. A standard recipe can be applied to standard ingredients, but patients are not standardized, so Cheesecake Factory efficiency is probably not a realistic goal for health care. Still, adopting best practices on routine procedures, focusing on the customer experience and using market forces to control costs makes perfect sense - and eventually could be as routine as the office computer that was such a threat to Katharine Hepburn.