The other day, our 20-year-old son Max, afflicted with a painful throat abscess and its aftermath, was a patient in a suburban Maryland hospital. He smiled for the first time in days when he started feeling hungry and called the cafeteria from his bed, asking about available menu options.
Max was surprised at the range of possibilities, even though his diet was limited to soft food. "Desserts, too? And cookies, and cake?" he asked, stunned. Yes, no problem.
Our son didn't go for the desserts after all. Still, when he finished eating his meatloaf, and macaroni and cheese, he said, "Really good. Yummy."
Only a month earlier, we all were in Florida, where we dined one evening at the Cheesecake Factory in Coconut Grove outside of Miami. I remember Max exclaiming, "Really great, I'm stuffed."
Surely, there is no comparison between the high-quality Cheesecake Factory food and the better-than-average fare of the hospital, he remarked later. Then again, controlling infections and repairing throats is not the Cheesecake Factory's line of work. Nor is scrumptious food a specific hospital specialty.
But over the past month, there's been a lot of "food for thought" debate about how the highly regarded restaurant chain attained excellence, and whether hospitals can be mentioned in the same breath—not for the food, but for their overall line of work.
That debate was prompted by physician Atul Gawande's piece in the New Yorker on the lessons that can be learned from the Cheesecake Factory about consistent care at a reasonable cost.
Criticizing healthcare delivery, 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 unreal." Gawande, MD, is a surgeon at Boston's Brigham and Women's Hospital and professor of surgery at Harvard Medical School.
Was my son in a facility that should be run more like the Cheesecake Factory?
Indeed, Gawande's article has prompted much debate. Some say it points to exactly what healthcare needs to do in order to revamp fix itself by developing standards and more effective protocols. Others maintain the comparison is purely bunk, because the food service and healthcare industries don't mix.
One of the most interesting commentaries was from Steve Denning of Forbes,who noted that the notion that the Cheesecake Factory model or any other model is the best prospect for change in healthcare is to "fail to realize that the U.S. healthcare is a collection of different problems that will require different solutions, not a single model."
James Merlino, MD, the Cleveland Clinic's chief patient experience officer and vice president of the hospital's digestive disease institute, doesn't completely buy the whole Cheesecake Factory idea, either. But he supports most of it.
Healthcare in general "needs to be figuring out how we can reproduce things we do consistently, reliably, [and] in a precise manner that is cost effective," Merlino adds. "No question, it's the future, and 80% of the (Gawande) analogy is correct."
Then there's that 20% that the Cheesecake Factory model can't deliver, and that's the human element, Merlino says. "You can't take somebody out of fellowship into positions at Cleveland Clinic and expect the infrastructure to carry them," he adds.
A personal experience
I thought of those different models and the delicate balance of healthcare delivery, while we spent a day and night over the weekend in our son's hospital room.
It was a surprise to us that Max landed in the hospital Friday after battling a sore throat for days. On Thursday, his physician recommended an ear, nose and throat specialist do a procedure. After seemingly successful outpatient surgery, my son, who was battling dehydration, was immediately shaken with violent chills, and later, intense sweats.
The doctor matter-of-factly said we could drive him to the emergency department for IV rehydration, if we wanted, or we could go home and see how he did. We thought our son looked awful, so we opted for the hospital, which the ENT contacted to inform of our arrival.
I dropped off my wife and son and went back to work. When I showed up again an hour later at the hospital, my wife hurriedly told me my son's temperature had spiked to 104.8%, his heartbeat raced to the high 170s. He was whisked back to a bed, where doctors and nurses surrounded him to work on him "stat!"
The situation could have been serious. Their care stabilized him within an hour, as his fever and heart rate lowered with treatment. Our son stayed at the hospital two nights before he was allowed to go home. And when she called our house to check on him, my son's primary care physician told us it could have been a life-and-death matter.
I was seeing healthcare up close and personal and it wasn't pretty.
Why didn't the ENT suspect anything when our son was shaking with chills in his office after this dreadful procedure to remove the abscess? What would have happened if we had driven him home instead of going straight to the ED?
During the hospital stay, other things popped up: some nurses were incredibly nice and helpful; others were brusque. The staff told Max they wouldn't wake him up until the early morning, but instead put on lights at 3, 4 and 5 a.m. to check on him.
Before he was discharged, nurses advised seeing another doctor because his blood work indicated double the level of liver enzymes compared to normal. "Are you sure?" I asked the nurse. She called the physician on duty. "Oh, it's OK," she said later, apparently coming up with a cause for the elevated numbers after conferring with him.
It was an episode of healthcare showing initiation, teamwork, and purpose, but with some small, and not-so-small miscues along the way. Despite Max's big, one-bed room, and the dimly lighted hallways, and the flat screen TV and Wi-Fi access, some things were out of kilter. Not a lot, but enough to spike our concern.
Still, this was a hospital and health system trying. Outside the rooms of stroke patients were signs warning the staff that these patients had a tendency to fall. There were notes from the CEO on every floor asking for comment about the patient experience.
Our ENT doc followed up with a call to the hospital to ask how Max was doing.
And we were sent home with instructions, and a trifold invitation from the CEO to write our story—but I'm doing it here.
Even in that short time in the hospital, I witnessed the "variability of care"—those moments when a hospital has a chance to work smoothly in an assembly line fashion like the Cheesecake Factory. It worked beautifully in the ED.
Afterward, it was a tad more difficult. That's because healthcare must rely on vulnerabilities of the human condition, for better or worse. It reflects the frailties of the staff, not necessarily the patient. But the food was good.
A big hospital's take on the Cheesecake Factory
That double-edged sword, and the hope for efficiencies and the expectations of staff, are among the reasons that Merlino, the Cleveland Clinic's chief patient experience officer, doesn't see the whole Cheesecake Factory idea as being the answer for what ails healthcare.
Top officials of the Cleveland Clinic read the New Yorker article and evaluated it, while weighing the hospital's own procedures, Merlino says.
Looking at the article through a "data" microscope, Merlino says that its proposals to link healthcare to "reliability, precision, and operational efficiency" is certainly needed and being developed in healthcare. "That's about 80% right," he says.
But about 20% of the Cheesecake story is off the mark, Merlino says,
because there is an element in healthcare that involves experience among staff, involvement and passion, "that differentiates this kind of custom approach" from a restaurant chain, and can't be duplicated.
"When you get into complicated disease management, I may be biased because I'm a surgeon, but nobody behaves like everybody else, that's where skill and experience play a role," he adds.
"They can't come up in an assembly-line mindset. There may be up the road some diagnostic treatment computer that functions like some Star Wars machine. There's no question, 50 or 60 years from now, it will come to that. Now, there is still a requirement of the skill level and very important experience for a delivery of customized care that doesn't just roll off the assembly line."
At Cleveland Clinic, there are at least a dozen high-volume surgeons, "who are grounded by this tremendous process," Merlino adds. "But you can't put anybody in that role and you still have the skill mix and skill experience to make it a customized approach in healthcare to take care of the very sickest of patients. There's that highly skilled piece to manage patients, with experience that you can't get off the assembly line to do cookie cutter medicine."
Merlino caught himself, "yeah, cookie cutter."
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
