Today it’s hard to find a health care professional who doesn’t want to “put the patient first,” practice “patient centered care,” or make the patient “part, or even the center, of the healthcare team.” Bring up current problems with clinical practice (be they managerial, insurance company, or regulatory) and you will inevitably hear health care professionals talk about the importance of the doctor/patient, nurse/patient relationship.
Nurses, in particular, are adamant that they are members of THE Caring Profession and that their fundamental role is to be THE patient advocate. (This formulation does nothing enhance teamwork since it drives physicians, PTS, OTs and other non- RNs crazy. “What does that make me?” they may retort, “The patient’s enemy?”) Patient-centeredness, and the sanctity of the patient/clinician relationship is the talk everyone is talking.
When you start actually probing and physicians and nurses (as well as others in health care) describe the real life patient (rather than the patient as abstraction), things start to get a bit more complicated. It’s amazing how quickly so many of these patients – who were absolutely revered a few minutes earlier — suddenly become “difficult,” when clinicians start discussing actual patient encounters. Read more >>
Yesterday I wrote about a conjugal culinary episode and its connection to patient safety. What I left out was the fact that my husband and I — novice and expert — failed to share the same mental model of the situation with which we were dealing. In healthcare — and marriage — you have to form teams and the hallmark of a team is that you share the same mental model. The AHRQ/DOD team curriculum TeamSTEPPS defines a shared mental model as “The mental picture or sketch of the relevant facts and relationships defining an event, situation, or problem.” It goes on to say that “shared mental models are sustained by the following:
The process of planning, team decision-making, and vocalizing.” (TeamSTEPPS 06.1 Situation Monitoring, p17.)
This is, of course, totally true. But another thing that a shared mental model depends on is experience. No expert can share the whole universe of consequences and implications that they envision and have gathered from years of mistake/success making. This is why it is so important to have the right blend of experts and novices at the bedside. Of course, it’s also important for the expert to explain as much as possible to the novice so that he or she can do the job correctly. I probably could have explained things to my husband in a way that helped him understand what was at stake. What one constantly has to be aware of is the fact of inexperience — or experience — and how that affects what the information that we need to share in order to create the shared mental model upon which high reliability depends.
The other evening, as we were having company for dinner, my husband burned the roasting pan. Completely and irremediably. I was cooking a roast and asked him to keep an eye on it while I went out to get a haircut. “Make sure you don’t let it get burned,” I instructed. I gave him a quick how-to on basting and left the stock near the stove. When I got back an hour later, he was sitting in the kitchen working on his laptop. As soon as I walked in the door I could smell the burnt odor. “What’s burning?” I asked. “Not the roast,” he assured me. That was true. It was the pan the roast was in that was burnt. I had a fit. He was furious. “Look the roast isn’t at all burnt,” he said defensively, as I pulled it out of the pan and stuck the latter, crusted in black in the sink. I continued to fume, he to feel injured. He felt he had done his job. I had mentioned nothing about the pan. The roast wasn’t burnt, and he was being ill used. He scraped off the charred remains, injuring the pan permanently. (It was an old one, coated with Teflon, that I liked but probably shouldn’t have been using. But now, scratched, with Teflon surely flaking off, I would have to get rid of it.) We continued cooking the roast in another pan. My sauce — which was to be made with the pan drippings — would have to be done some other way. I pulled it off. We had a nice dinner with friends, and the next I tried to do a debrief about the whole mess. Ordinarily, I wouldn’t be writing about such domestic trivia on a blog largely devoted to healthcare but what I found out about and reflected on does have something to do with our current health care dilemmas. Read more >>
Please look at my facebook page. I took a series of photos yesterday in the large, 1000 bed hospital in Utrecht, the Netherlands. Many Americans think that national health care systems in Europe deliver substandard care in a terrible environment. Nothing could be further from the truth. Since a picture is worth a thousand words, these pictures document what can happen when money in the healthcare system is devoted to care not profit.
The Cheesecake Factory isn’t health care’s answer
By Suzanne Gordon
| September 11, 2012
A Cheesecake Factory at the North Shore Mall in Peabody.
In their drive to cut costs and produce better patient outcomes, American health care policy makers and administrators are embracing a variety of work re-organization schemes borrowed from other industries. Some boast of their “Toyota lean” approach to health care delivery. Others have looked to Disney World for new ideas. The newest business model being touted is the chain restaurant The Cheesecake Factory.
Earlier this month, Boston’s own Atul Gawande, a well-known surgeon and writer about health care, surprised many readers of The New Yorker by praising The Cheesecake Factory for demonstrating how the US health care system could provide more standardized, high-quality patient care.
According to Gawande, the “delicious” fare served by over 180,000 employees in its more than 2000 restaurants represents just the kind of reliable, innovative product that would better fit the budgets of cost-conscious health care providers — and meet the needs of their “customers” — in the competitive new world of US medicine.
He admits, in passing, that “the front-line worker” at the Cheesecake Factory and similar chains “now generates unprecedented value but receives little of the wealth he is creating.” But because firms like these “have learned to increase the capabilities and efficiency of the human beings who work for them,” the Cheesecake Factory model of food preparation and service “represents our best prospect for change” in health care, he argues. Although standardization is long overdue in health care, it is questionable if this particular model of standardization addresses the needs and complexities of health care.
Because of its continuing deficiencies in this area, the Restaurant Opportunities Centers (ROC), a nationwide restaurant workers group, gave the chain a very low rating in its 2012 “Diners’ Guide” to ethical eating. The guide named the Cheesecake Factory as one of the worst employers in the industry. At a restaurant worker protest in Baltimore in May, ex-Cheesecake Factory worker Raquel Rojas spoke for many when she told a local reporter that a her former employer “treated us like machines — like we didn’t have any emotions or needs.”
It is hard to consider the Cheesecake Factory’s record of process innovation while divorcing it from its product. Dr. Gawande, who has written about the costs of obesity-linked cardiac problems in some of his other writings, does acknowledge that the food at the Cheesecake Factory, ” was sweeter, fatter and bigger than it had to be.” At the same time, he lauds the chain for providing “goods and services of greater variety, better quality, and lower cost than would otherwise be available.”
It is troubling to learn that a respected patient safety advocate like Gawande — someone who has long written about enhancing patient safety and reducing health care costs — would assert that The Cheesecake Factory produces a quality product. Just last year, The Center for Science and the Public Interest gave the chain one of its “Extreme Eating” awards for its Farmhouse Cheeseburger, which weighs in at 1,530 calories, 36 grams of saturated fat and 3,210 milligrams of sodium. As Bonnie Liebman of the Center put it, chains like the Cheesecake Factory seem intent on “targeting the remaining one out of three Americans who are still normal weight in order to boost their risk of obesity, diabetes, heart attacks, and cancer.”
In “The End of Overeating: Taking Control of the Insatiable American Appetite,” Dr. David Kessler, former head of the Food and Drug Administration, addresses the obesity crisis that is costing the US over $147 million annually . He singles out The Cheesecake Factory for manipulating the fat and sugar content of its food to encourage over-consumption. Even some business analysts in favor of standardization health care argue that a restaurant chain that has contributed so heavily to obesity can hardly be considered our “best prospect for change.”
As we search for ways to control health care costs while still providing quality care, there are some high reliability industries, like aviation, that do provide promising models for change. The Cheesecake Factory — with its history of violations of basic worker rights and almost anti-lean cuisine — just isn’t one of them.
. Suzanne Gordon is a health care journalist and coeditor of “First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.’’