The Hospital Chain and Healthcare Pendulum

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The New Yorker recently published an article about hospital chains and their potential for improving medicine. The question the author, Dr. Atul Gawande, poses is an interesting one: Will scale and uniformity decrease patient fees and improve care?


Gawande relates hospital chains to restaurant chains, in particular the Cheesecake Factory. The comparison rings clear: Restaurant chains have productivity and uniformity down to an exact science. They purchase raw food in mass quantities and then ship it to every franchise at a lower cost than independent restaurants can manage. Restaurant chains provide consistent results and produce quality food made to order. Why couldn’t hospital chains do the same for healthcare?

It seems an obvious question. At one point in the article, Gawande follows a Cheesecake Factory regional manager, who recently had a negative hospital experience with his mother. When Gawande asks him how healthcare can improve, the manager replies, “I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

Makes sense, right?
Wait. Aren’t people and cheesecakes different?
Yes, very different. (Cheesecakes don’t have hair, for example. Well, good cheesecakes don’t.)
When I was a teenager, I worked for two independent restaurants over two summers, and in college, I worked for two fast-food franchises. It shouldn’t be a surprise that an independent entity operates differently from a franchise. Consistency on a grand scale, like franchises can provide, comes with certain trade-offs that can be viewed as good or bad. For example, an independent restaurant can offer a unique menu special more easily than a fast-food franchise. However, there’s no quality control beyond what a given restaurant decides, so bad restaurants can remain bad restaurants. Franchise quality control is apparent: for me, it meant using pre-marinated, frozen chicken breasts in giant plastic bags, and shaking spices from shiny foil pouches.
The independent and bureaucratic nature of healthcare—from the personnel to the front office—makes them slow to react in most cases. Gawande notes, “In medicine, good ideas still take an appallingly long time to trickle down…. 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.”

There are people working to help the issue, working to “study, standardize, and execute,” in the language of the Gawande's Cheesecake Factory manager. The progressive tactics range from setting standards to a remote unit electronically supervising I.C.U. staff in multiple hospitals. Gawande reports, “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.”

Spoiler Alert: Not every hospital staff member appreciates the supervision. To them, bureaucracy looks the same on a screen as it does on paper.

Picture a pendulum. In healthcare, the pendulum is historically pointed to private and bureaucratic operation, and hospital chains are working to swing it toward a mindset of standards and manufacturing.

I fear the Big-Brother nature of a new system centered on standardization, and a full, gut-check pendulum swing in that direction. I hope the boards guiding these hospital chains focus on the patient first and the factory second. There’s something so cold about uniformity—prepackaged food arriving in huge plastic bags—and it’s important to recognize the potential for losing sight of the point.

Pendulums swing, but when they come to rest, they point to the middle. The middle is seeing the issues through the eyes of patients—every child, mother, father, grandparent, and friend—looking for care. The key is serving them quality care at affordable rates, and relating to them as people.

When I go out to eat, I appreciate knowing I can get exactly what I want. But I like the option of ordering something homemade too.

What do you think? Has this been an issue in your career? Do you work in a place that’s progressive and making change? Post your comments below.

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  • Robert F
    Robert F
    What is basically described is a system that utilizes the accumulated experience of specialized individuals - gained from years at other jobs - and tries to meld them into an "efficient" universal model.  He is right to fear the Big-Brother conundrum bleeding into today's healthcare, where the patient is first and the institution second.My experience in life is that individuals have freedom of choice, and that can also be the freedom to avoid the non-optimal, non-Cheesecake Factories.....
  • Lueann R
    Lueann R
    I like healthcare and working with and people with  medical care client with drug addiction
  • Rita d
    Rita d
    while medical care as a business and/or a franchise may allow for better and cost effective ways to manage customers ( consumers)  the concept is completely offensive to my mind. it smacks of a heartless approach to medical care, which is perhaps is where American medicine is going. It is the approach to a pt and the uniqueness of their situation that allows for good practice.  It's a shame that we are entertaining this concept.  
  • Carol W
    Carol W
    Been in the medical field 40+ years. Wow! the changes that have happened. One would hardly recognize what we now call healthcare. I've had experience (mother) with the Kaiser Healthcare System and I'd have to say they really seem to have it together and are able to keep costs lower than most with affordable premiums. It has managed to stay patient centered even though they are sort of like "national" healthcare.
  • detria w
    detria w
    As a Independent Geriatric Care Manager/Transitional Care Coordinator, I see a lot of gaps in services. One way is to bring in the GMCT/TCC can be beneficial You can have a universal policies and procedures but, each patient needs an individual care program which should be implemented when the discussion of discharge is in phase one.    Based on my experiences,

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