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A recipe for an improved healthcare system

April 18, 2013
by Shannon Brys, Associate Editor
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It’s no secret that the healthcare world is changing vastly and rapidly across the country. Atul Gawande, who practices general and endocrine surgery at Brigham and Women’s Hospital in Boston, said in remarks at the 2013 National Council Conference that the current scene is “extraordinarily exciting.” However, he also noted that the field must begin shifting to more streamlining and standardization of care in order to be successful.

Gawande, who has been a staff writer for The New Yorker magazine since 1998, focused much of his discussion on a recent article that he published about the standardization in the restaurant industry serving as an example to the healthcare field. In the article, he describes The Cheescake Factory and asks how that industry can have such a seamless process when it comes to ordering, cooking, preparing and serving food, while medical professionals routinely adopt so many different ways to treat a person for the same condition, such as a heart attack.

“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,” he wrote in the article. “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.”

Gawande describes a conversation with Dave Luz, the regional manager for the eight Cheesecake Factories in the Boston area.  After trying to find care for his sick mother and experiencing a whirlwind of doctors with conflicting opinions and orders, unfriendly nurses, and prescriptions that he was told had “doubtful benefit,” Luz was exhausted and frustrated. Gawande asked Luz what he would do if he were the manager of a neurology unit or a cardiology clinic.  Luz’s response: To research and study what the best people are doing, figure out how to standardize it, and disperse it to everyone to execute.

Gawande, who is also Professor of Surgery at Harvard Medical School and Professor in the Department of Health Policy and Management at the Harvard School of Public Health, suggested that “we are moving towards a new set of values” that will displace autonomy as the highest value in medical practice. These values include:

·        Humility. “The willingness to recognize that no matter how great the doctor is trained and experienced, that we will fail. No matter who we are.”

·        Discipline. “The recognition that doing certain things the same way every time is going to be far more successful than inventing it constantly on the fly.”

·        Teamwork. “The recognition that everybody has a set of skills that add up to being the change that a patient requires. We are all caregivers— from the person at the front who takes a phone call, to the person who manages and assesses how well all of this comes together.”

To make systems work in healthcare, Gawande said two capabilities are important: the ability to recognize failure and the ability to broadly assess a community’s needs. It is essential, he said, to understand which people or groups have the greatest needs, what their care ought to look like, and what pieces are still missing from the puzzle.

Aside from advances made in the form of new or renovated hospital buildings and new technologies, Gawande noted, “We’re seeing new winners.  Primary care and behavioral health are getting attention they just haven’t received for a long time.” He stressed the importance of not losing sight of the patient despite the many changes swirling around in the care environment.

“I don’t think we will lose our way as long as we remember one basic thing: There’s nothing wrong in the care of patients that cannot be solved by caring about the patients,” he said.

Because of the many, constant changes, he has come to realize that the amount of knowledge needed to care for patients “has simply exceeded” the capability of anybody to handle it on his or her own.

So too has the complexity of medical practice, he said, citing a colleage who had conducted research at Johns Hopkins Hospital to determine the number of professionals required to take care of a typical patient. At the time of the study, many years ago, the answer was about 2.3 full-time professionals. He explained that it was mostly “nursing time” with a small amount of time for a clinician to set the plan for that day.

By the year 2000, an identical study found that more than 15 people were involved in the care of a single patient. Despite improvements in care and recovery rates, Gawande maintained that having 15 professionals involved in care could not be a positive sign.

“Our fundamental value in healthcare has been the autonomy of the professionals. But when you have 15-30 professionals touching a person over the course of months or a year, and every one of them doing their own thing, the experience of a patient is a breakdown,” he expressed.