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The Cheesecake Factory, A Recipe For Health Care?


Dr. Atul Gawande spends a lot of time thinking about how to make health care better. A couple of years ago his best-selling book, "The Checklist Manifesto," demonstrated how following a simple list could prevent sometimes-deadly medical mistakes. Now he's looking at a bigger picture - the entire health-care system.

This professor of public health at Harvard, in an article in this week's New Yorker, offers a surprising model. To create a more efficient health-care system offering higher-quality care, he suggests looking for tips from a restaurant chain, the Cheesecake Factory. He joined us to explain. Dr. Gawande, welcome.

DR. ATUL GAWANDE: Thank you.

MONTAGNE: So let's start by stipulating that you find the food in the Cheesecake Factory delicious, and that's a positive outcome for whatever system this restaurant chain has in place. At what point did you make a link to health care?

GAWANDE: I was fascinated by the fact that they had a new menu come out in March 2012 - for example - and that within seven weeks, they had, you know, 15 different new items that the chefs in their restaurants all across the country were cooking, and landing on people's tables. The same month, the guidelines for how patients' headaches with - people with severe migraines - should be taken care of, came out as well. And they happened to note that the last guidelines, which had several medications proven to reduce migraine headaches in patients, hadn't been followed. In fact, it had been 13 years and still, fewer than one-third of severe migraine patients had gotten the recommended care.

And that seemed, to me, fundamentally something wrong. And underlying it was this question of how good ideas spread.

MONTAGNE: So that thought gave you the idea to go to the Cheesecake Factory, and see if it could be a model - of sorts.

GAWANDE: Yeah. I just wanted to know, you know, if you walk into the kitchen, you know, what are they doing differently from what we do? And they have guidelines, like we've got; they've got recipes. But then they've got, you know, a couple interesting things going on. They have a hierarchy where they feel like, look, you know, I talked to the regional manager for the New England area. And he's responsible for hundreds of thousands of meals a year; and making sure that service is great, and that they're doing it right. And what struck me is, we haven't had that in medicine,

But there's an uncovered story, which is that while everybody's paying attention to the political battles going on in Washington, health care is changing dramatically, and they're changing in the same direction that places like the Cheesecake Factory have changed. That is, we're creating chains that feel responsible for making those results actually come to real life. And it has all the pluses and minuses of being a chain, where we are getting big medicine.

MONTAGNE: Going back to the Cheesecake Factory as a model, give us one example of what you saw; how that might apply to doctors and other medical professionals.

GAWANDE: Yes. I watched this talented young grill chef - named Mauricio - make a hibachi steak. And did he follow the recipe on the screens that they flash up in front of him? He didn't. He said, "I've got the recipe right here in my head. I know what I'm doing." And so then I puzzled over, you know, how did they make the hibachi steak end up being similar from one place to the other and, you know, get to the quality that people at the Cheesecake Factory go there for, and keep the price down?

And the answer was that there was a kitchen manager who looked at every dish that came off the line; rated it on a scale of one to 10 - and said hey, this looks good enough to go out to the customers, this one doesn't - and he coached them along towards what they were aiming for.

I tried to imagine that in my operating room - you know, someone who hour by hour, looked at everything that I was doing and then said, you know, here's what we've really got to work on; I think we've got to change this and we've got to change that and, you know, you're wasting, you know, money and resources as well. It was hard to imagine - and in some ways, frightening to imagine.

MONTAGNE: What would be the equivalent in a hospital, or a hospital group, of the kitchen manager?

GAWANDE: You know, when I - my mother ended up needing knee replacement, and I wrote about what that was like. You go looking around for a surgeon, and you get this distinct sense - as you go around and talk to different surgeons - that they all have a completely different way of doing it. They use different knee prostheses; they use different forms of anesthesia, different plans for recovery; even within the same hospital.

And I ended up sticking to, you know, my own hospital, partly because I know the folks here, but also because there is one surgeon who's decided, you know, we're really going to run like a factory. And he's gotten the nine knee surgeons here to - detail by detail, have worked out what they are all going to do. And he's kind of like the kitchen manager. He literally walks around, looking at what everybody does. And it's fascinating to watch because it's sometimes uncomfortable. People sometimes push back. He really tries to take the coach role, but he also comes down and says, you know, that approach you're taking doesn't work as well as what everybody is doing so, you know, you've got to change.

MONTAGNE: And as it turned out, your own mother's experience with knee surgery showed how the system that had been set up in your hospital, had changed things for the better.

GAWANDE: Yeah. She had actually had two knee operations, and so you've got a little bit of a comparison. Her first knee operation was actually - it wasn't a total knee replacement; was supposed to be faster recovery - everything else - and so that was what she had gone with and, you know, she was pleased with the result. She had about a month in a rehabilitation center before she was able to really be walking without a walker, and so on.

Under this kind of chain production, this factory for knee surgery, she was out of the hospital in three days, and out of a rehab within a week. She stayed even longer than, you know, she might have needed to. And she was off of needing a walker, you know, within days after that. And by making that time shorter, it ends up being markedly lower cost than it would have been otherwise, you know.

There are things to fear about the development of big medicine. There are things to be concerned about - whether they become monopolies and actually become less innovative, or raise prices rather than lower prices. We're going to have to have real oversight and transparency. But it's a challenge to people on both ends of the spectrum. For us to imagine that the complex practices of medicine are going to get better, people on the left are going to have to be comfortable with the idea of big medicine and in fact, encourage it to grow. But people on the right are going to have to be comfortable with the idea that government is going to have to play an important role in providing oversight and transparency so that we all can see, and know, how the costs really are, and how the quality really is.

MONTAGNE: Dr. Gawande, thank you very much for talking with us.

GAWANDE: It's great to be on. Thank you.

MONTAGNE: Surgeon Atul Gawande is a professor at Harvard School of Public Health, and a staff writer for The New Yorker. His article in the latest edition of the magazine is called "Big Med." Transcript provided by NPR, Copyright NPR.