ANNALS OF HEALTH CARE
BIG MED
Restaurant chains have managed to
combine quality control, cost control, and innovation. Can health care? by Atul Gawande
AUGUST 13, 2012 New Yorker (FiDA bold and highlight added)
Medicine has long resisted the
productivity revolutions that transformed other industries. But the new chains
aim to change this.
It was Saturday night, and I was at the
local Cheesecake Factory with my two teen-age daughters and three of their
friends. You may know the chain: a hundred and sixty restaurants with a
catalogue-like menu that, when I did a count, listed three hundred and eight
dinner items (including the forty-nine on the “Skinnylicious” menu), plus a
hundred and twenty-four choices of beverage. It’s a linen-napkin-and-tablecloth
sort of place, but with something for everyone. There’s wine and wasabi-crusted
ahi tuna, but there’s also buffalo wings and Bud Light. The kids ordered mostly
comfort food—pot stickers, mini crab cakes, teriyaki chicken, Hawaiian pizza,
pasta carbonara. I got a beet salad with goat cheese, white-bean hummus and
warm flatbread, and the miso salmon.
The place is huge, but it’s invariably
packed, and you can see why. The typical entrée is under fifteen dollars. The
décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian
columns, earth-tone murals, vaulted ceilings. The waiters are efficient and
friendly. They wear all white (crisp white oxford shirt, pants, apron,
sneakers) and try to make you feel as if it were a special night out. As for
the food—can I say this without losing forever my chance of getting a
reservation at Per Se?—it was delicious.
The chain serves more than eighty
million people per year. I pictured semi-frozen bags of beet salad shipped from
Mexico, buckets of precooked pasta and production-line hummus, fish from a box.
And yet nothing smacked of mass production. My beets were crisp and fresh, the
hummus creamy, the salmon like butter in my mouth. No doubt everything we
ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake
Factory knows its customers. The whole table was happy (with the possible exception
of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).
I wondered how they pulled it off. I
asked one of the Cheesecake Factory line cooks how much of the food was
premade. He told me that everything’s pretty much made from scratch—except the
cheesecake, which actually is from a cheesecake factory, in Calabasas,
California.
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.
It’s easy to mock places like the
Cheesecake Factory—restaurants that have brought chain production to
complicated sit-down meals. But the “casual dining sector,” as it is known,
plays a central role in the ecosystem of eating, providing three-course,
fork-and-knife restaurant meals that most people across the country couldn’t
previously find or afford. The ideas start out in élite, upscale restaurants in
major cities. You could think of them as research restaurants, akin to research
hospitals. Some of their enthusiasms—miso salmon, Chianti-braised short ribs,
flourless chocolate espresso cake—spread to other high-end restaurants. Then
the casual-dining chains reëngineer them for affordable delivery to millions.
Does health care need something like this?
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. Pizza Hut alone runs one in eight pizza restaurants in the country. The
Cheesecake Factory’s major competitor, Darden, owns Olive Garden, LongHorn
Steakhouse, Red Lobster, and the Capital Grille; it has more than two thousand
restaurants across the country and employs more than a hundred and eighty
thousand people. We can bristle at the idea of chains and mass production, with
their homogeneity, predictability, and constant genuflection to the
value-for-money god. Then you spend a bad night in a “quaint” “one of a kind”
bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t
keep the hot water running, and it’s right back to the Hyatt.
Medicine, though, had held out against
the trend. Physicians were always predominantly self-employed, working alone or
in small private-practice groups. American hospitals tended to be
community-based. But that’s changing. Hospitals and clinics have been forming
into large conglomerates. And physicians—facing escalating demands to lower
costs, adopt expensive information technology, and account for performance—have
been flocking to join them. According to
the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an
extraordinary turnabout from a decade ago, when a majority were independent.
They’ve decided to become employees, and health systems have become chains.
I’m no exception. I am an employee of
an academic, nonprofit health system called Partners HealthCare, which owns the
Brigham and Women’s Hospital and the Massachusetts General Hospital, along with
seven other hospitals, and is affiliated with dozens of clinics around eastern
Massachusetts. Partners has sixty thousand employees, including six thousand
doctors. Our competitors include CareGroup, a system of five regional
hospitals, and a new for-profit chain called the Steward Health Care System.
Steward was launched in late 2010, when
Cerberus—the multibillion-dollar private-investment firm—bought a group of six
failing Catholic hospitals in the Boston area for nine hundred million dollars.
Many people were shocked that the Catholic Church would allow a corporate
takeover of its charity hospitals. But the hospitals, some of which were more
than a century old, had been losing money and patients, and Cerberus is one of those
firms which specialize in turning around distressed businesses.
Cerberus has owned controlling stakes
in Chrysler and GMAC
Financing and currently has stakes in Albertsons grocery stories, one of
Austria’s largest retail bank chains, and the Freedom Group, which it built
into one of the biggest gun-and-ammunition manufacturers in the world. When it
looked at the Catholic hospitals, it saw another opportunity to create profit
through size and efficiency. In the past year, Steward bought four more
Massachusetts hospitals and made an offer to buy six financially troubled
hospitals in south Florida. It’s trying to create what some have called the
Southwest Airlines of health care—a network of high-quality hospitals that would
appeal to a more cost-conscious public.
Steward’s aggressive growth has made
local doctors like me nervous. But many health systems, for-profit and
not-for-profit, share its goal: large-scale, production-line medicine. The way
medical care is organized is changing—because the way we pay for it is
changing.
Historically, doctors have been paid
for services, not results. In the
eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten
shekels of silver every time he performed a procedure for a patrician—opening
an abscess or treating a cataract with his bronze lancet. It also instructed
that if the patient should die or lose an eye, the surgeon’s hands be cut off.
Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped.
Since then, we’ve generally been paid for what we do, whatever happens. The
consequence is the system we have, with plenty of individual
transactions—procedures, tests, specialist consultations—and uncertain
attention to how the patient ultimately fares.
Health-care reforms—public and
private—have sought to reshape that system. This year, my employer’s new
contracts with Medicare, BlueCross BlueShield, and others link financial reward
to clinical performance. The more the hospital exceeds its cost-reduction and
quality-improvement targets, the more money it can keep. If it misses the
targets, it will lose tens of millions of dollars. This is a radical shift. Until now, hospitals and medical groups
have mainly had a landlord-tenant relationship with doctors. They offered us
space and facilities, but what we tenants did behind closed doors was our
business. Now it’s their business, too.
The theory the country is about to test
is that chains will make us better and more efficient. The question is how. To
most of us who work in health care, throwing a bunch of administrators and
accountants into the mix seems unlikely to help. Good medicine can’t be reduced
to a recipe.
Then again neither can good food: every
dish involves attention to detail and individual adjustments that require human
judgment. Yet, some chains manage to achieve good, consistent results thousands
of times a day across the entire country. I decided to get inside one and find
out how they did it.
Dave Luz is the regional manager for
the eight Cheesecake Factories in the Boston area. He oversees operations that
bring in eighty million dollars in yearly revenue, about as much as a
medium-sized hospital. Luz (rhymes with “fuzz”) is forty-seven, and had started
out in his twenties waiting tables at a Cheesecake Factory restaurant in Los
Angeles. He was writing screenplays, but couldn’t make a living at it. When he
and his wife hit thirty and had their second child, they came back east to
Boston to be closer to family. He decided to stick with the Cheesecake Factory.
Luz rose steadily, and made a nice living. “I wanted to have some business
skills,” he said—he started a film-production company on the side—“and there
was no other place I knew where you could go in, know nothing, and learn top to
bottom how to run a business.”
To show me how a Cheesecake Factory
works, he took me into the kitchen of his busiest restaurant, at Prudential
Center, a shopping and convention hub. The kitchen design is the same in every
restaurant, he explained. It’s laid out like a manufacturing facility, in which
raw materials in the back of the plant come together as a finished product that
rolls out the front. Along the back wall are the walk-in refrigerators and prep
stations, where half a dozen people stood chopping and stirring and mixing. The
next zone is where the cooking gets done—two parallel lines of countertop,
forty-some feet long and just three shoe-lengths apart, with fifteen people
pivoting in place between the stovetops and grills on the hot side and the neatly
laid-out bins of fixings (sauces, garnishes, seasonings, and the like) on the
cold side. The prep staff stock the pullout drawers beneath the counters with
slabs of marinated meat and fish, serving-size baggies of pasta and crabmeat,
steaming bowls of brown rice and mashed potatoes. Basically, the prep crew handles the parts, and the
cooks do the assembly.
Computer monitors positioned head-high
every few feet flashed the orders for a given station. Luz showed me the
touch-screen tabs for the recipe for each order and a photo showing the proper
presentation. The recipe has the ingredients on the left part of the screen and
the steps on the right. A timer counts down to a target time for completion.
The background turns from green to yellow as the order nears the target time
and to red when it has exceeded it.
I watched Mauricio Gaviria at the
broiler station as the lunch crowd began coming in. Mauricio was twenty-nine
years old and had worked there eight years. He’d got his start doing simple
prep—chopping vegetables—and worked his way up to fry cook, the pasta station,
and now the sauté and broiler stations. He bounced in place waiting for the
pace to pick up. An order for a “hibachi” steak popped up. He tapped the screen
to open the order: medium-rare, no special requests. A ten-minute timer began.
He tonged a fat hanger steak soaking in teriyaki sauce onto the broiler and
started a nest of sliced onions cooking beside it. While the meat was grilling,
other orders arrived: a Kobe burger, a blue-cheese B.L.T. burger, three “old-fashioned”
burgers, five veggie burgers, a “farmhouse” burger, and two Thai chicken wraps.
Tap, tap, tap. He got each of them grilling.
I brought up the hibachi-steak recipe
on the screen. There were instructions to season the steak, sauté the onions,
grill some mushrooms, slice the meat, place it on the bed of onions, pile the
mushrooms on top, garnish with parsley and sesame seeds, heap a stack of
asparagus tempura next to it, shape a tower of mashed potatoes alongside, drop
a pat of wasabi butter on top, and serve.
Two things struck me. First, the
instructions were precise about the ingredients and the objectives (the steak
slices were to be a quarter of an inch thick, the presentation just so), but
not about how to get there. The cook has to decide how much to salt and baste,
how to sequence the onions and mushrooms and meat so they’re done at the same
time, how to swivel from grill to countertop and back, sprinkling a pinch of
salt here, flipping a burger there, sending word to the fry cook for the
asparagus tempura, all the while keeping an eye on the steak. In producing
complicated food, there might be recipes, but there was also a substantial
amount of what’s called “tacit knowledge”—knowledge that has not been reduced
to instructions.
Second, Mauricio never looked at the
instructions anyway. By the time I’d finished reading the steak recipe, he was
done with the dish and had plated half a dozen others. “Do you use this recipe
screen?” I asked.
“No. I have the recipes right here,” he
said, pointing to his baseball-capped head.
He put the steak dish under warming
lights, and tapped the screen to signal the servers for pickup. But before the
dish was taken away, the kitchen manager stopped to look, and the system
started to become clearer. He pulled a clean fork out and poked at the steak.
Then he called to Mauricio and the two other cooks manning the grill station.
“Gentlemen,” he said, “this steak is
perfect.” It was juicy and pink in the center, he said. “The grill marks are
excellent.” The sesame seeds and garnish were ample without being excessive.
“But the tower is too tight.” I could see what he meant. The mashed potatoes
looked a bit like something a kid at the beach might have molded with a bucket.
You don’t want the food to look manufactured, he explained. Mauricio fluffed up
the potatoes with a fork.
I watched the kitchen manager for a
while. At every Cheesecake Factory
restaurant, a kitchen manager is stationed at the counter where the food comes
off the line, and he rates the food on a scale of one to ten. A nine is near-perfect.
An eight requires one or two corrections before going out to a guest. A seven
needs three. A six is unacceptable and has to be redone. This inspection
process seemed a tricky task. No one likes to be second-guessed. The kitchen
manager prodded gently, being careful to praise as often as he corrected.
(“Beautiful. Beautiful!” “The pattern of this pesto glaze is just right.”) But
he didn’t hesitate to correct.
“We’re getting sloppy with the
plating,” he told the pasta station. He was unhappy with how the fry cooks were
slicing the avocado spring rolls. “Gentlemen, a half-inch border on this next
time.” He tried to be a coach more than a policeman. “Is this three-quarters of
an ounce of Parm-Romano?”
And that seemed to be the spirit in
which the line cooks took him and the other managers. The managers had all
risen through the ranks. This earned them a certain amount of respect. They in
turn seemed respectful of the cooks’ skills and experience. Still, the oversight is tight, and this seemed
crucial to the success of the enterprise.
The managers monitored the pace,
too—scanning the screens for a station stacking up red flags, indicating orders
past the target time, and deciding whether to give the cooks at the station a
nudge or an extra pair of hands. They watched for waste—wasted food, wasted
time, wasted effort. The formula was Business 101: Use the right amount of
goods and labor to deliver what customers want and no more. Anything more is
waste, and waste is lost profit.
I spoke to David Gordon, the company’s
chief operating officer. He told me that the Cheesecake Factory has worked out a staff-to-customer ratio that keeps
everyone busy but not so busy that there’s no slack in the system in the event of
a sudden surge of customers. More difficult is the problem of wasted food.
Although the company buys in bulk from regional suppliers, groceries are the
biggest expense after labor, and the most unpredictable. Everything—the
chicken, the beef, the lettuce, the eggs, and all the rest—has a shelf life. If
a restaurant were to stock too much, it could end up throwing away hundreds of
thousands of dollars’ worth of food. If a restaurant stocks too little, it will
have to tell customers that their favorite dish is not available, and they may
never come back. Groceries, Gordon said, can kill a restaurant.
The company’s target last year was at
least 97.5-per-cent efficiency: the managers aimed at throwing away no more
than 2.5 per cent of the groceries they bought, without running out. This
seemed to me an absurd target. Achieving it would require knowing in advance
almost exactly how many customers would be coming in and what they were going
to want, then insuring that the cooks didn’t spill or toss or waste anything.
Yet this is precisely what the organization has learned to do. The chain-restaurant industry has produced
a field of computer analytics known as “guest forecasting.”
“We have forecasting models based on
historical data—the trend of the past six weeks and also the trend of the
previous year,” Gordon told me. “The predictability of the business has become
astounding.” The company has even learned how to make adjustments for the
weather or for scheduled events like playoff games that keep people at home.
A computer program known as Net Chef
showed Luz that for this one restaurant food costs accounted for 28.73 per cent
of expenses the previous week. It also showed exactly how many chicken breasts
were ordered that week ($1,614 worth), the volume sold, the volume on hand, and
how much of last week’s order had been wasted (three dollars’ worth). Chain
production requires control, and they’d figured out how to achieve it on a mass
scale.
As a doctor, I found such control alien—possibly from a
hostile planet. We don’t have patient forecasting in
my office, push-button waste monitoring, or such stringent, hour-by-hour
oversight of the work we do, and we don’t want to. I asked Luz if he had ever thought about the contrast when he went to
see a doctor. We were standing amid the bustle of the kitchen, and the look on
his face shifted before he answered.
“I have,” he said. His mother was seventy-eight. She had
early Alzheimer’s disease, and required a caretaker at home. Getting her
adequate medical care was, he said, a constant battle.
Recently, she’d had a fall, apparently after fainting, and
was taken to a local emergency room. The doctors ordered a series of tests and
scans, and kept her overnight. They never figured out what the problem was. Luz
understood that sometimes explanations prove elusive. But the clinicians didn’t
seem to be following any coördinated 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 Luz the results.
A nurse came at ten the next morning and said that his
mother was being discharged. But his mother’s nurse was on break, and the
discharge paperwork with her instructions and prescriptions hadn’t been done.
So they waited. Then the next person they needed was at lunch. It was as if the
clinicians were the customers, and the patients’ job was to serve them.
“We didn’t get to go until 6 P.M., with a tired, disabled lady and a long drive home.” Even
then she still had to be changed out of her hospital gown and dressed. Luz
pressed the call button to ask for help. No answer. He went out to the ward
desk.
The aide was on break, the secretary said. “Don’t you dress
her yourself at home?” He explained that he didn’t, and made a fuss.
An aide was sent. She was short with him and rough in
changing his mother’s clothes. “She was manhandling her,” Luz said. “I felt
like, ‘Stop. I’m not one to complain. I respect what you do enormously. But if
there were a video camera in here, you’d be on the evening news.’ I sent her
out. I had to do everything myself. I’m stuffing my mom’s boob in her bra. It
was unbelievable.”
His mother was given instructions to check with her doctor
for the results of cultures taken during her stay, for a possible urinary-tract
infection. But when Luz tried to follow up, he couldn’t get through to her
doctor for days. “Doctors are busy,” he said. “I get it. But come on.” An
office assistant finally told him that the results wouldn’t be ready for
another week and that she was to see a neurologist. No explanations. No chance
to ask questions.
The neurologist, after giving her a two-minute exam,
suggested tests that had already been done and wrote a prescription that he
admitted was of doubtful benefit. Luz’s family seemed to encounter this kind of
disorganization, imprecision, and waste wherever his mother went for help.
“It is unbelievable to me that they would not manage this
better,” Luz said. I asked him what he would do if he were the manager of a
neurology unit or a cardiology clinic. “I don’t know anything about medicine,”
he said. But when I pressed he thought for a moment, and said, “This is pretty
obvious. I’m sure you already do it. But I’d study what the best people are doing,
figure out how to standardize it, and then bring it to everyone to execute.”
This is not at all the normal way of
doing things in medicine. (“You’re scaring me,” he said, when I told him.) But
it’s exactly what the new health-care chains are now hoping to do on a mass
scale. They want to create Cheesecake Factories for health care. The question
is whether the medical counterparts to Mauricio at the broiler station—the
clinicians in the operating rooms, in the medical offices, in the
intensive-care units—will go along with the plan. Fixing a nice piece of steak
is hardly of the same complexity as diagnosing the cause of an elderly
patient’s loss of consciousness. Doctors and patients have not had a positive
experience with outsiders second-guessing decisions. How will they feel about
managers trying to tell them what the “best practices” are?
In
March, my mother underwent a total knee replacement, like at least six hundred
thousand Americans each year. She’d had a partial knee replacement a decade
ago, when arthritis had worn away part of the cartilage, and for a while this
served her beautifully. The surgeon warned, however, that the results would be
temporary, and about five years ago the pain returned.
She’s
originally from Ahmadabad, India, and has spent three decades as a
pediatrician, attending to the children of my small Ohio home town. She’s
chatty. She can’t go through a grocery checkout line or get pulled over for
speeding without learning people’s names and a little bit about them. But she
didn’t talk about her mounting pain. I noticed, however, that she had developed
a pronounced limp and had become unable to walk even moderate distances. When I
asked her about it, she admitted that just getting out of bed in the morning
was an ordeal. Her doctor showed me her X-rays. Her partial prosthesis had worn
through the bone on the lower surface of her knee. It was time for a total knee
replacement.
This
past winter, she finally stopped putting it off, and asked me to find her a
surgeon. I wanted her to be treated well, in both the technical and the human
sense. I wanted a place where everyone and everything—from the clinic secretary
to the physical therapists—worked together seamlessly.
My
mother planned to come to Boston, where I live, for the surgery so she could
stay with me during her recovery. (My father died last year.) Boston has three hospitals in the top rank
of orthopedic surgery. But even a doctor doesn’t have much to go on when it
comes to making a choice. A place may have a great reputation, but it’s
hard to know about actual quality of care.
Unlike some countries, the United States doesn’t have a monitoring system that
tracks joint-replacement statistics. Even within an institution, I found,
surgeons take strikingly different approaches. They use different makes of
artificial joints, different kinds of anesthesia, different regimens for
post-surgical pain control and physical therapy.
In
the absence of information, I went
with my own hospital, the Brigham and Women’s Hospital. Our big-name orthopedic
surgeons treat Olympians and professional athletes. Nine of them do knee
replacements. Of most interest to me, however, was a surgeon who was not one of
the famous names. He has no national recognition. But he has led what is now a
decade-long experiment in standardizing joint-replacement surgery.
John
Wright is a New Zealander in his late fifties. He’s a tower crane of a man, six
feet four inches tall, and so bald he barely seems to have eyebrows. He’s
informal in attire—I don’t think I’ve ever seen him in a tie, and he is as apt
to do rounds in his zip-up anorak as in his white coat—but he exudes
competence.
“Customization should
be five per cent, not ninety-five per cent, of what we do,” he told me. A few years
ago, he gathered a group of people from every specialty involved—surgery,
anesthesia, nursing, physical therapy—to formulate a single default way of
doing knee replacements. They examined every detail, arguing their way through
their past experiences and whatever evidence they could find. Essentially, they
did what Luz considered the obvious thing to do: they studied what the best
people were doing, figured out how to standardize it, and then tried to get
everyone to follow suit.
They
came up with a plan for anesthesia based on research studies—including giving
certain pain medications before the patient entered the operating room and
using spinal anesthesia plus an injection of local anesthetic to block the main
nerve to the knee. They settled on a postoperative regimen, too. The day after a
knee replacement, most orthopedic surgeons have their patients use a continuous
passive-motion machine, which flexes and extends the knee as they lie in bed.
Large-scale studies, though, have suggested that the machines don’t do much
good. Sure enough, when the members of Wright’s group examined their own
patients, they found that the ones without the machine got out of bed sooner
after surgery, used less pain medication, and had more range of motion at
discharge. So Wright instructed the hospital to get rid of the machines, and to
use the money this saved (ninety thousand dollars a year) to pay for more
physical therapy, something that is proven to help patient mobility. Therapy,
starting the day after surgery, would increase from once to twice a day, including
weekends.
Even more startling,
Wright had persuaded the surgeons to accept changes in the operation itself;
there was now, for instance, a limit as to which prostheses they could use.
Each of our nine knee-replacement surgeons had his preferred type and brand.
Knee surgeons are as particular about their implants as professional tennis
players are about their racquets. But the hardware is easily the biggest cost
of the operation—the average retail price is around eight thousand dollars, and
some cost twice that, with no solid evidence of real differences in results.
Knee
implants were largely perfected a quarter century ago. By the
nineteen-nineties, studies showed that, for
some ninety-five per cent of patients, the implants worked magnificently a
decade after surgery. Evidence from the Australian registry has shown that not
a single new knee or hip prosthesis had a lower failure rate than that of the
established prostheses. Indeed, thirty per cent of the new models were likelier
to fail. Like others on staff, Wright has advised companies on implant
design. He believes that innovation will lead to better implants. In the
meantime, however, he has sought to limit the staff to the three lowest-cost
knee implants.
These
have been hard changes for many people to accept. Wright has tried to figure
out how to persuade clinicians to follow the standardized plan. To prevent
revolt, he learned, he had to let them deviate at times from the default
option. Surgeons could still order a passive-motion machine or a preferred
prosthesis. “But I didn’t make it easy,” Wright said. The surgeons had to enter
the treatment orders in the computer themselves. To change or add an implant, a
surgeon had to show that the performance was superior or the price at least as
low.
I
asked one of his orthopedic colleagues, a surgeon named John Ready, what he
thought about Wright’s efforts. Ready was philosophical. He recognized that the
changes were improvements, and liked most of them. But he wasn’t happy when
Wright told him that his knee-implant manufacturer wasn’t matching the others’
prices and would have to be dropped.
“It’s
not ideal to lose my prosthesis,” Ready said. “I could make the switch. The
differences between manufacturers are minor. But there’d be a learning curve.”
Each implant has its quirks—how you seat it, what tools you use. “It’s probably
a ten-case learning curve for me.” Wright suggested that he explain the
situation to the manufacturer’s sales rep. “I’m my rep’s livelihood,” Ready
said. “He probably makes five hundred dollars a case from me.” Ready spoke to
his rep. The price was dropped.
Wright
has become the hospital’s kitchen manager—not always a pleasant role. He told
me that about half of the surgeons appreciate what he’s doing. The other half
tolerate it at best. One or two have been outright hostile. But he has
persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent
of their implants, giving the hospital bargaining power that has helped slash
its knee-implant costs by half. And the start-to-finish standardization has led
to vastly better outcomes. The distance patients can walk two days after
surgery has increased from fifty-three to eighty-five feet. Nine out of ten
could stand, walk, and climb at least a few stairs independently by the time of
discharge. The amount of narcotic pain medications they required fell by a
third. They could also leave the hospital nearly a full day earlier on average
(which saved some two thousand dollars per patient).
My
mother was one of the beneficiaries. She had insisted to Dr. Wright that she
would need a week in the hospital after the operation and three weeks in a
rehabilitation center. That was what she’d required for her previous knee
operation, and this one was more extensive.
“We’ll
see,” he told her.
The
morning after her operation, he came in and told her that he wanted her getting
out of bed, standing up, and doing a specific set of exercises he showed her.
“He’s pushy, if you want to say it that way,” she told me. The physical
therapists and nurses were, too. They
were a team, and that was no small matter. I counted sixty-three different
people involved in her care. Nineteen were doctors, including the surgeon
and chief resident who assisted him, the anesthesiologists, the radiologists
who reviewed her imaging scans, and the junior residents who examined her twice
a day and adjusted her fluids and medications. Twenty-three were nurses,
including her operating-room nurses, her recovery-room nurse, and the many ward
nurses on their eight-to-twelve-hour shifts. There were also at least five
physical therapists; sixteen patient-care assistants, helping check her vital
signs, bathe her, and get her to the bathroom; plus X-ray and EKG
technologists, transport workers, nurse practitioners, and physician
assistants. I didn’t even count the bioengineers who serviced the equipment
used, the pharmacists who dispensed her medications, or the kitchen staff
preparing her food while taking into account her dietary limitations. They all
had to coördinate their contributions, and they did.
Three
days after her operation, she was getting in and out of bed on her own. She was
on virtually no narcotic medication. She was starting to climb stairs. Her knee
pain was actually less than before her operation. She left the hospital for the
rehabilitation center that afternoon.
The biggest complaint
that people have about health care is that no one ever takes responsibility for
the total experience of care, for the costs, and for the results. My mother
experienced what happens in medicine when someone takes charge. Of course, John
Wright isn’t alone in trying to design and implement this kind of systematic
care, in joint surgery and beyond. The Virginia Mason Medical Center, in
Seattle, has done it for knee surgery and cancer care; the Geisinger Health
Center, in Pennsylvania, has done it for cardiac surgery and primary care; the
University of Michigan Health System standardized how its doctors give blood
transfusions to patients, reducing the need for transfusions by thirty-one per
cent and expenses by two hundred thousand dollars a month. Yet, unless such
programs are ramped up on a nationwide scale, they aren’t going to do much to
improve health care for most people or reduce the explosive growth of
health-care costs.
In medicine, good
ideas still take an appallingly long time to trickle down. Recently, the
American Academy of Neurology and the American Headache Society released new
guidelines for migraine-headache-treatment. They recommended treating severe
migraine sufferers—who have more than six attacks a month—with preventive
medications and listed several drugs that markedly reduce the occurrence of
attacks. The authors noted, however, that previous guidelines going back more
than a decade had recommended such remedies, and doctors were still not
providing them to more than two-thirds of patients. One study examined how long
it took several major discoveries, such as the finding that the use of
beta-blockers after a heart attack improves survival, to reach even half of
Americans. The answer was, on average, more than fifteen years.
Scaling good ideas
has been one of our deepest problems in medicine. Regulation has had its place,
but it has proved no more likely to produce great medicine than food inspectors
are to produce great food. During the era of managed care, insurance-company
reviewers did hardly any better. We’ve been stuck. But do we have to be?
Every six months, the Cheesecake Factory puts out a new
menu. This means that everyone who works in its restaurants expects to learn
something new twice a year. The March, 2012,
Cheesecake Factory menu included thirteen new items. The teaching process is
now finely honed: from start to finish, rollout takes just seven weeks.
The ideas for a new dish, or for
tweaking an old one, can come from anywhere. One of the Boston prep cooks told
me about an idea he once had that ended up in a recipe. David Overton, the
founder and C.E.O. of the Cheesecake Factory, spends much of his time sampling
a range of cuisines and comes up with many dishes himself. All the ideas,
however, go through half a dozen chefs in the company’s test kitchen, in
Calabasas. They figure out how to make each recipe reproducible, appealing, and
affordable. Then they teach the new recipe to the company’s regional managers
and kitchen managers.
Dave Luz, the Boston regional manager,
went to California for training this past January with his chief kitchen
manager, Tom Schmidt, a chef with fifteen years’ experience. They attended lectures,
watched videos, participated in workshops. It sounded like a surgical
conference. Where I might be taught a new surgical technique, they were taught
the steps involved in preparing a “Santorini farro salad.” But there was a
crucial difference. The Cheesecake
instructors also trained the attendees how to teach what they were learning. In
medicine, we hardly ever think about how to implement what we’ve learned. We
learn what we want to, when we want to.
On the first training day, the kitchen
managers worked their way through thirteen stations, preparing each new dish,
and their performances were evaluated. The following day, they had to teach
their regional managers how to prepare each dish—Schmidt taught Luz—and this
time the instructors assessed how well the kitchen managers had taught.
The managers returned home to replicate
the training session for the general manager and the chief kitchen manager of
every restaurant in their region. The training at the Boston Prudential Center
restaurant took place on two mornings, before the lunch rush. The first day,
the managers taught the kitchen staff the new menu items. There was a lot of
poring over the recipes and videos and fussing over the details. The second
day, the cooks made the new dishes for the servers. This gave the cooks some
practice preparing the food at speed, while allowing the servers to learn the
new menu items. The dishes would go live in two weeks. I asked a couple of the
line cooks how long it took them to learn to make the new food.
“I know it already,” one said.
“I make it two times, and that’s all I
need,” the other said.
Come on, I said. How long before they
had it down pat?
“One day,” they insisted. “It’s easy.”
I asked Schmidt how much time he
thought the cooks required to master the recipes. They thought a day, I told
him. He grinned. “More like a month,” he said.
Even a month would be enviable in
medicine, where innovations commonly spread at a glacial pace. The new
health-care chains, though, are betting that they can change that, in much the
same way that other chains have.
Armin Ernst is responsible for
intensive-care-unit operations in Steward’s ten hospitals. The I.C.U.s he
oversees serve some eight thousand patients a year. In another era, an I.C.U.
manager would have been a facilities expert. He would have spent his time
making sure that the equipment, electronics, pharmacy resources, and nurse
staffing were up to snuff. He would have regarded the I.C.U. as the doctors’
workshop, and he would have wanted to give them the best possible conditions to
do their work as they saw fit.
Ernst, though, is a doctor—a new kind
of doctor, whose goal is to help disseminate good ideas. He doesn’t see the I.C.U. as a doctors’ workshop. He sees
it as the temporary home of the sickest, most fragile people in the country.
Nowhere in health care do we expend more resources. Although fewer than one in
four thousand Americans are in intensive care at any given time, they account for four per cent of
national health-care costs. Ernst believes that his job is to make sure
that everyone is collaborating to provide the most effective and least wasteful
care possible.
He looked like a regular doctor to me.
Ernst is fifty years old, a native German who received his medical degree at
the University of Heidelberg before training in pulmonary and critical-care
medicine in the United States. He wears a white hospital coat and talks about
drips and ventilator settings, like any other critical-care specialist. But he
doesn’t deal with patients: he deals with the people who deal with patients.
Ernst says he’s not telling clinicians
what to do. Instead, he’s trying to get
clinicians to agree on precise standards of care, and then make sure that they
follow through on them. (The word “consensus” comes up a lot.) What I
didn’t understand was how he could enforce such standards in ten hospitals
across three thousand square miles.
Late one Friday evening, I joined an
intensive-care-unit team on night duty. But this team was nowhere near a
hospital. We were in a drab one-story building behind a meat-trucking facility
outside of Boston, in a back section that Ernst called his I.C.U. command
center. It was outfitted with millions of dollars’ worth of technology. Banks
of computer screens carried a live feed of cardiac-monitor readings,
radiology-imaging scans, and laboratory results from I.C.U. patients throughout
Steward’s hospitals. Software monitored the stream and produced yellow and red
alerts when it detected patterns that raised concerns. Doctors and nurses
manned consoles where they could toggle on high-definition video cameras that
allowed them to zoom into any I.C.U. room and talk directly to the staff on the
scene or to the patients themselves.
The command center was just a few
months old. The team had gone live in only four of the ten hospitals. But in
the next several months Ernst’s “tele-I.C.U.”
team will have the ability to monitor the care for every patient in every
I.C.U. bed in the Steward health-care system.
A doctor, two nurses, and an
administrative assistant were on duty in the command center each night I
visited. Christina Monti was one of the nurses. A pixie-like thirty-year-old
with nine years’ experience as a cardiac intensive-care nurse, she was covering
Holy Family Hospital, on the New Hampshire border, and St. Elizabeth’s Medical
Center, in Boston’s Brighton neighborhood. When I sat down with her, she was
making her rounds, virtually.
First, she checked on the patients she
had marked as most critical. She reviewed their most recent laboratory results,
clinical notes, and medication changes in the electronic record. Then she made
a “visit,” flicking on the two-way camera and audio system. If the patients
were able to interact, she would say hello to them in their beds. She asked the
staff members whether she could do anything for them. The tele-I.C.U. team
provided the staff with extra eyes and ears when needed. If a crashing patient
diverts the staff’s attention, the members of the remote team can keep an eye
on the other patients. They can handle computer paperwork if a nurse falls
behind; they can look up needed clinical information. The hospital staff have an OnStar-like button in every room that they
can push to summon the tele-I.C.U. team.
Monti also ran through a series of
checks for each patient. She had a reference list of the standards that Ernst
had negotiated with the people running the I.C.U.s, and she looked to see if
they were being followed. The standards covered basics, from hand hygiene to
measures for stomach-ulcer prevention. In every room with a patient on a
respirator, for instance, Monti made sure the nurse had propped the head of the bed up at least thirty degrees, which makes
pneumonia less likely. She made sure the breathing tube in the patient’s
mouth was secure, to reduce the risk of the tube’s falling out or becoming
disconnected. She zoomed in on the medication pumps to check that the drips
were dosed properly. She was not looking
for bad nurses or bad doctors. She was looking for the kinds of misses that
even excellent nurses and doctors can make under pressure.
The concept of the remote I.C.U.
started with an effort to let specialists in critical-care medicine, who are in
short supply, cover not just one but several community hospitals. Two hundred
and fifty hospitals from Alaska to Virginia have installed a version of the tele-I.C.U.
It produced significant improvements in outcomes and costs—and, some
discovered, a means of driving better practices even in hospitals that had
specialists on hand.
After five minutes of observation,
however, I realized that the remote I.C.U. team wasn’t exactly in command; it
was in negotiation. I observed Monti perform a video check on a middle-aged man
who had just come out of heart surgery. A soft chime let the people in the room
know she was dropping in. The man was unconscious, supported by a respirator
and intravenous drips. At his bedside was a nurse hanging a bag of fluid. She
seemed to stiffen at the chime’s sound.
“Hi,” Monti said to her. “I’m Chris.
Just making my evening rounds. How are you?” The bedside nurse gave the screen
only a sidelong glance.
Ernst wasn’t oblivious of the issue. He
had taken pains to introduce the command center’s team, spending weeks visiting
the units and bringing doctors and nurses out to tour the tele-I.C.U. before a
camera was ever turned on. But there was no escaping the fact that these were
strangers peering over the staff’s shoulders. The bedside nurse’s chilliness wasn’t hard to understand.
In a single hour, however, Monti had caught a number of
problems. She noticed, for example, that a
patient’s breathing tube had come loose. Another patient wasn’t getting
recommended medication to prevent potentially fatal blood clots. Red alerts
flashed on the screen—a patient with an abnormal potassium level that could cause
heart-rhythm problems, another with a sudden leap in heart rate.
Monti made sure that the team wasn’t
already on the case and that the alerts weren’t false alarms. Checking the
computer, she figured out that a doctor had already ordered a potassium infusion
for the woman with the low level. Flipping on a camera, she saw that the
patient with the high heart rate was just experiencing the stress of being
helped out of bed for the first time after surgery. But the unsecured breathing
tube and the forgotten blood-clot medication proved to be oversights. Monti
raised the concerns with the bedside staff.
Sometimes they resist. “You have got to
be careful from patient to patient,” Gerard Hayes, the tele-I.C.U. doctor on
duty, explained. “Pushing hard on one has ramifications for how it goes with a
lot of patients. You don’t want to sour whole teams on the tele-I.C.U.” Across the country, several hospitals have
decommissioned their systems. Clinicians have been known to place a gown over
the camera, or even rip the camera out of the wall. Remote monitoring will
never be the same as being at the bedside. One nurse called the command center
to ask the team not to turn on the video system in her patient’s room: he was
delirious and confused, and the sudden appearance of someone talking to him
from the television would freak him out.
Still, you could see signs of change. I
watched Hayes make his virtual rounds through the I.C.U. at St. Anne’s
Hospital, in Fall River, near the Rhode Island border. He didn’t yet know all
the members of the hospital staff—this was only his second night in the command
center, and when he sees patients in person it’s at a hospital sixty miles
north. So, in his dealings with the on-site clinicians, he was feeling his way.
Checking on one patient, he found a few
problems. Mr. Karlage, as I’ll call him, was in his mid-fifties, an alcoholic
smoker with cirrhosis of the liver, severe emphysema, terrible nutrition, and
now a pneumonia that had put him into respiratory failure. The I.C.U. team
injected him with antibiotics and sedatives, put a breathing tube down his
throat, and forced pure oxygen into his lungs. Over a few hours, he stabilized,
and the I.C.U. doctor was able to turn his attention to other patients.
But stabilizing a sick patient is like
putting out a house fire. There can be smoldering embers just waiting to
reignite. Hayes spotted a few. The ventilator remained set to push breaths at
near-maximum pressure, and, given the patient’s severe emphysema, this risked
causing a blowout. The oxygen concentration was still cranked up to a hundred
per cent, which, over time, can damage the lungs. The team had also started
several broad-spectrum antibiotics all at once, and this regimen had to be dialled
back if they were to avoid breeding resistant bacteria.
Hayes had to notify the unit doctor. An
earlier interaction, however, had not been promising. During a video check on a
patient, Hayes had introduced himself and mentioned an issue he’d noticed. The unit doctor stared at him with folded
arms, mouth shut tight. Hayes was a former Navy flight surgeon with twenty
years’ experience as an I.C.U. doctor and looked to have at least a decade on
the St. Anne’s doctor. But the doctor was no greenhorn, either, and gave him
the brushoff: “The morning team can deal with that.” Now Hayes needed to call
him about Mr. Karlage. He decided to do it by phone.
“Sounds like you’re having a busy
night,” Hayes began when he reached the doctor. “Mr. Karlage is really turning
around, huh?” Hayes praised the doctor’s work. Then he brought up his three
issues, explaining what he thought could be done and why. He spoke like a consultant brought in to help. This went over better.
The doctor seemed to accept Hayes’s suggestions.
Unlike a mere consultant, however,
Hayes took a few extra steps to make sure his suggestions were carried out. He
spoke to the nurse and the respiratory therapist by video and explained the
changes needed. To carry out the plan, they needed written orders from the unit
doctor. Hayes told them to call him back if they didn’t get the orders soon.
Half an hour later, Hayes called Mr. Karlage’s
nurse again. She hadn’t received the orders. For all the millions of dollars of
technology spent on the I.C.U. command center, this is where the plug meets the
socket. The fundamental question in medicine is: Who is in charge? With the
opening of the command center, Steward was trying to change the answer—it gave
the remote doctors the authority to issue orders as well. The idea was that
they could help when a unit doctor got too busy and fell behind, and that’s
what Hayes chose to believe had happened. He entered the orders into the
computer. In a conflict, however, the on-site physician has the final say. So
Hayes texted the St. Anne’s doctor, informing him of the changes and asking if
he’d let him know if he disagreed.
Hayes received no reply. No “thanks” or
“got it” or “O.K.” After midnight, though, the unit doctor pressed the video
call button and his face flashed onto Hayes’s screen. Hayes braced for a
confrontation. Instead, the doctor said, “So I’ve got this other patient and I
wanted to get your opinion.”
Hayes suppressed a smile. “Sure,” he
said.
When he signed off, he seemed ready to
high-five someone. “He called us,” he marvelled. The command center was gaining
credibility.
Armin Ernst has big plans for the
command center—a rollout of full-scale treatment protocols for patients with
severe sepsis, acute respiratory-distress syndrome, and other conditions;
strategies to reduce unnecessary costs; perhaps even computer forecasting of
patient volume someday. Steward is already extending the command-center concept
to in-patient psychiatry. Emergency rooms and surgery may be next. Other health
systems are pursuing similar models. The command-center concept provides the
possibility of, well, command.
Today, some ninety “super-regional”
health-care systems have formed across the country—large, growing chains of
clinics, hospitals, and home-care agencies. Most are not-for-profit. Financial
analysts expect the successful ones to drive independent medical centers out of
existence in much of the country—either by buying them up or by drawing away
their patients with better quality and cost control. Some small clinics and
stand-alone hospitals will undoubtedly remain successful, perhaps catering to
the luxury end of health care the way gourmet restaurants do for food. But
analysts expect that most of us will gravitate to the big systems, just as we
have moved away from small pharmacies to CVS and Walmart.
Already, there have been startling
changes. Cleveland Clinic, for example, opened nine regional hospitals in
northeast Ohio, as well as health centers in southern Florida, Toronto, and Las
Vegas, and is now going international, with a three-hundred-and-sixty-four-bed
hospital in Abu Dhabi scheduled to open next year. It reached an agreement with
Lowe’s, the home-improvement chain, guaranteeing a fixed price for cardiac
surgery for the company’s employees and dependents. The prospect of getting
better care for a lower price persuaded Lowe’s to cover all out-of-pocket costs
for its insured workers to go to Cleveland, including co-payments, airfare,
transportation, and lodging. Three other companies, including Kohl’s department
stores, have made similar deals, and a dozen more, including Boeing, are in
negotiations. Big Medicine is on the way.
Reinventing medical care could produce
hundreds of innovations. Some may be as
simple as giving patients greater e-mail and online support from their
clinicians, which would enable timelier advice and reduce the need for
emergency-room visits. Others might involve smartphone apps for coaching
the chronically ill in the management of their disease, new methods for getting
advice from specialists, sophisticated systems for tracking outcomes and costs,
and instant delivery to medical teams of up-to-date care protocols. Innovations
could take a system that requires sixty-three clinicians for a knee replacement
and knock the number down by half or more. But most significant will be the
changes that finally put people like John Wright and Armin Ernst in charge of making care coherent, coördinated, and
affordable. 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.
Yet it seems strange to pin our hopes
on chains. We have no guarantee that Big
Medicine will serve the social good. Whatever the industry, an increase in
size and control creates the conditions for monopoly, which could do the
opposite of what we want: suppress innovation and drive up costs over time. In
the past, certainly, health-care systems that pursued size and market power
were better at raising prices than at lowering them.
A
new generation of medical leaders and institutions professes to have a
different aim. But a lesson of the past century is that government can influence the behavior of big corporations, by
requiring transparency about their performance and costs, and by enacting rules
and limitations to protect the ordinary citizen. The federal government has
broken up monopolies like Standard Oil and A.T. & T.; in some parts of the
country, similar concerns could develop in health care.
Mixed
feelings about the transformation are unavoidable. There’s not just the worry
about what Big Medicine will do; there’s also the worry about how society and
government will respond. For the changes to live up to our hopes—lower costs
and better care for everyone—liberals
will have to accept the growth of Big Medicine, and conservatives will have to
accept the growth of strong public oversight.
The vast savings of
Big Medicine could be widely shared—or reserved for a few. The clinicians who
are trying to reinvent medicine aren’t doing it to make hedge-fund managers and
bondholders richer; they want to see that everyone benefits from the savings
their work generates—and that won’t be automatic.
Our new models come
from industries that have learned to increase the capabilities and efficiency
of the human beings who work for them. Yet the same industries have also tended
to devalue those employees. 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. Can we avoid this as we
revolutionize health care?
Those of us who work in the health-care
chains will have to contend with new protocols and technology rollouts every
six months, supervisors and project managers, and detailed metrics on our
performance. Patients won’t just look
for the best specialist anymore; they’ll look for the best system. Nurses
and doctors will have to get used to delivering care in which our own
convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward
people for taking the time and expense to teach the next generations of
clinicians. All this will be an enormous upheaval, but it’s long overdue,
and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U.
nurse, why she wanted to work in a remote facility tangling with staffers who
mostly regarded her with indifference or hostility, she told me, “Because I
wanted to be part of the change.”
And we are seeing glimpses of this
change. In my mother’s rehabilitation center, miles away from where her surgery
was done, the physical therapists adhered to the exercise protocols that Dr.
Wright’s knee factory had developed. He didn’t have a video command center, so
he came out every other day to check on all the patients and make sure that the
staff was following the program. My mother was sure she’d need a month in
rehab, but she left in just a week, incurring a fraction of the costs she would
have otherwise. She walked out the door using a cane. On her first day at home
with me, she climbed two flights of stairs and walked around the block for
exercise.
The critical question is how soon that
sort of quality and cost control will be available to patients everywhere
across the country. We’ve let
health-care systems provide us with the equivalent of greasy-spoon fare at
four-star prices, and the results have been ruinous. 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. ♦
I
