Changing healthcare as we do it: with evidence and cheesecake?

Jens Chapman

Dr Atul Gawande, Associate Professor at Harvard School of Medicine and practicing General and Endocrine Surgeon at the Brigham and Women’s Hospital in Boston, has gained a fair bit of attention in North America with his lectures, articles, and bestselling publications, such as Complications, Better, and Checklist Manifesto, which all deal with the need to renew our thinking regarding patient safety and quality control. Recently, he took this theme one step further in an article titled “Big Med,” published in The New Yorker in the August 13, 2012 issue [1]. He took a novel approach by looking behind the scenes of several large high-quality restaurant chains and retailers in North America to identify their secrets to success. Without oversimplifying his message too much, he found mainly two factors to be of cardinal importance: adaptive standardization and effective quality control. At a certain high-end restaurant chain, freshly made first-rate cheesecake served consistently at every location despite an ever-changing menu laid the foundation for its sustained and ongoing success. In his article, Dr Gawande then translated the principles behind the success of this particular restaurant chain to healthcare. He demonstrated how these same underlying principles of quality control and adaptive standardization were incrementally being applied by several large, recently formed hospital chains in the United States. To exemplify this, he described a visit to a centralized ICU monitoring unit, which through video and complete data control was trying to assure best possible and standardized treatment for all ICU patients throughout the hospitals of a large, new healthcare system. This was no different from the restaurant chain, which used centralized high-end video monitoring and mentoring of its kitchen staff to assure best possible cheesecakes to be produced throughout its more than 150 restaurants. No room for improvisation, no need for improvisation—the product is as good as it can get and the customers are obviously happy.

While it is way too premature to judge even the early results of transferring some lessons of the restaurant industry and business world to healthcare, the principles behind the next wave of quality improvement are emerging very clearly: (1) evidence-based standardization of routine or common care problems, and (2) continued quality improvement hardwired into all standard procedures.

Currently, spine care, with its high-priced care and the substantial impact of spinal disorders on patient quality-of-life, has become a prime target for ‘cost-cutting’ in attempts at reining in healthcare expenses in many countries. As much as we seek and espouse individualized care over an abstracted ‘cookie-cutter’ approach, our field definitely deserves closer scrutiny as to its inconsistent and wholly unsystematic approach toward common disorders. Two articles in this issue of EBSJ exemplify this present-day malaise in spine care in two areas: sacroiliac pain and degenerative scoliosis. Both are clearly troubling to our patients and cannot be ignored, yet we are still far away from having a consensus on systematic assessment or treatment. After reading these two articles, I am sure that you would agree that we should be willing to restructure our current amorphous improvisational and perhaps somewhat helpless undertakings toward these two common disorders and assume a more structured and consistent approach.

The associated emerging reality is that of the need for cost containment in healthcare. The restaurants and business enterprises described in Dr Gawande’s article have been so successful in part because of their profitability based on a simple premise: “A great and consistent product every time—no room for error.”

While it is clear that a simple transfer of the business world’s profit motif to the medical realm would be unwise, we clearly and rapidly need to advance our understanding of healthcare economics, especially in spine care, in order to better support the need and value of our interventions. A recent publication by Perez and Jarvik titled “Evidence-based imaging and effective utilization: lessons in neuroradiology” again underscores the perilous chain reaction set off by vague indications for advanced neuroimaging that set off a whole series of additional healthcare utilizations and instill a feeling of impairment in our patients [2]. In this vein, I hope you will find the introduction to cost in healthcare in Science in Spine by Nora B Henrikson, PhD, MPH, and Andrea C Skelly, PhD, MPH, in this issue of EBSJ to be of great interest and will consider it a “must read.”

Clearly, the challenge is here: We need to stride toward more consistency in our approach toward everyday spine problems, and we need to push for internationally acceptable standards of care. What it takes to demonstrate the value of spine care is a better understanding of what metrics should be obtained to demonstrate quality and outcomes and where we can safely standardize patient management to allow for better assessment of outcomes and “quality control.” It is the unique potential for large, global organizations like AOSpine in collaboration with national or specialty organizations to move our field forward. New endeavors, such as Knowledge Forum and our Global Spine courses and meetings are the venues to make this happen. Please do join us.

Jens Chapman

Editor-in-chief

• References

• 1 Gawande A. 2012; Big Med: restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?. The New Yorker Aug 13: 53-63 Available at www.newyorker.com/reporting/2012/08/13/
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• 2 Perez FA, Jarvik JG. 2012; Evidence-based imaging and effective utilization: lessons in neuroradiology. Neuroimaging Clin N Am 22 (3) 467-476