Big Med or wholesale medicine

A few months ago, Josep Maria Monguet published a post on this blog about the low cost medicine in India, and along these lines I thought it would be interesting to comment on an article by Atul Gawande in the New Yorker with some comparative reflections between medicine and restaurant chains. "In medicine -says Gawande- try to provide a wide range of services to millions of people at reasonable costs and an acceptable level of quality, but the reality is different: the costs continue to rise, the service we offer is mediocre and the quality, uneven. Each doctor has his own way of doing things and the variations in the results, even within the same health centre, are inexplicable.

Dave Luz, regional manager at the Cheesecake Factory in the Boston area, explains to Gawande that his mother, with advanced Alzheimer's, fell down at home the other day and has been taken to the emergency room, where doctors visited her, did various tests and kept her under observation for the night. Luz received three types of explanations: from the emergency physicians, from the internist at the observation room and from a specialist, and these were not exactly coincident. He soon realized that there was no plan involved there. The next morning, a nurse told him that his mother was fine and that they would prepare her for discharge but because the nurse in charge was having her breakfast, they would have to wait, and that process, seemingly bureaucratic lasted until the afternoon because the doctor who had to make the discharge report could not be found. To cap it all, when it was time to dress his mother, the auxiliary disappeared and Luz had to fend for himself. With the discharge papers, he would schedule a control visit to collect the results of urine tests and one to see a neurologist. A couple of weeks later, the neurologist, after an examination that lasted a couple of minutes, called for new tests (by the way some matched those that had been made in the emergency services) and prescribed some medication that, once asked what they are for he admitted they‘re useless. Dave Luz says that this kind of disorganization among professionals and circuits, this lack of an overall plan, was to be found everywhere where he had to go to accompany his mother for receiving medical care.

By contrast (at least organizational), Cheesecake Factory, Dave Luz’s  company, is a chain that serves food to 80 million people each year, with a level of homologable quality in any premises, costs contained to the millimetre and a pace of innovation that largely stems from the initiatives of its employees and, despite being clear that the object of work is not comparable, Gawande suggests two lessons to learn from his visit to the kitchens of Cheesecake Factory:

a) The figure of the process manager

His job is to assess each dish on a qualitative scale; to congratulate those who have made the highest score dishes, to propose the necessary corrections to those who failed reach an optimum and to return the defective dishes. It’s the figure of an online controller.

b) The scaling methodology 

When a new dish is approved, a team standardizes the recipe to be reproducible at all locations, the staff is trained, the learning achieved is evaluated and, in a couple of weeks, the new dish appears, with full guarantees in the menu of all the premises of the chain. At this point, I remembered the reflections of Richard Bohmer regarding the habits of high value organizations, especially those regarding planning processes to the maximum and repurposing organizations to ensure that clinical paths have the desired quality, the costs are foreseen and the input value is proportionate to the health needs of each person.

Today most renowned doctors serve little purpose if the organization where they work is not process-oriented. It’s incomprehensible that occurrences as common as a fall in the house of a lady with Alzheimer's do not have a standardized response from all providers in the health system, and, indeed, as in the case of the mother of Dave Luz, the dish ends up a little burned, late and cold and above all a lot more expensive than it could have been. 

Jordi Varela

Editor