Two Perspectives on Standardization and Efficiency, and a Suggested Synthesis

A recent New Yorker article talks about possible lessons for the health care system from the highly efficient production and management system of middle range chain restaurants like Cheesecake Factory.

To show me how a Cheesecake Factory works, [the host] took me into the kitchen of his busiest restaurant, at Prudential Center, a shopping and convention hub. The kitchen design is the same in every restaurant, he explained. It’s laid out like a manufacturing facility, in which raw materials in the back of the plant come together as a finished product that rolls out the front. Along the back wall are the walk-in refrigerators and prep stations, where half a dozen people stood chopping and stirring and mixing. The next zone is where the cooking gets done—two parallel lines of countertop, forty-some feet long and just three shoe-lengths apart, with fifteen people pivoting in place between the stovetops and grills on the hot side and the neatly laid-out bins of fixings (sauces, garnishes, seasonings, and the like) on the cold side. The prep staff stock the pullout drawers beneath the counters with slabs of marinated meat and fish, serving-size baggies of pasta and crabmeat, steaming bowls of brown rice and mashed potatoes. Basically, the prep crew handles the parts, and the cooks do the assembly.

Computer monitors positioned head-high every few feet flashed the orders for a given station. Luz showed me the touch-screen tabs for the recipe for each order and a photo showing the proper presentation. The recipe has the ingredients on the left part of the screen and the steps on the right. A timer counts down to a target time for completion. The background turns from green to yellow as the order nears the target time and to red when it has exceeded it.

The article goes on to urge the same kind of efficiency and attention to detail for medicine.  The obvious question is whether there are lessons for the legal system too — and there must be.  I have long advocated protocols, outcome measures, and better managemnt.

But, here is the other perspective that must be integrated into any solution.  A piece in today’s New York Times on doctor burnout:

Now, in what is the first study of burnout among fully trained doctors from a wide range of specialties, it appears that the young are not the only ones who are vulnerable. Doctors who have been practicing anywhere from a year to several decades are just as susceptible to becoming burned out as students and trainees. And the implications of their burnout — unlike that of their younger counterparts, who are often under supervision — may be more devastating and immediate.

Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. The researchers then compared the doctors’ responses with those of nearly 3,500 people working in other fields and found that even after adjusting for variables like gender, age, number of hours worked and amount of education, the doctors were still more likely to suffer from burnout.

.   .   .

The doctors’ burnout appeared to have little to do with hours worked or even the ability to balance personal life with work. Instead, the only factor predictive of a higher risk was practicing a specialty that offered front-line access to care. More than half of the doctors in family medicine, emergency medicine and general internal medicine experienced some form of burnout.

The study casts a grim light on what it is like to practice medicine in the current health care system. A significant proportion of doctors feel trapped, thwarted by the limited time they are allowed to spend with patients, stymied by the ever-changing rules set by insurers and other payers on what they can prescribe or offer as treatment and frustrated by the fact that any gains in efficiency offered by electronic medical records are so soon offset by numerous, newly devised administrative tasks that must also be completed on the computer.

In this setting, “doctors are losing their inspiration,” Dr. Shanafelt said, “and that is a very frightening thing.”

Can these two perspectives be integrated?

I think it is unavoidable that standardization, routinization, and lack of room for opportunity for human contact reward run risks of burnout, loss of critical staff, and bad outcomes.  I also think it is critical that we need to find ways to bring the lessons of data and efficiency to legal practice and the courts.

The synthesis has to include the following elements;

  • Using data to give tools to professionals, rather than to remove their discretion — protocols are critical, but they are the beginning of the discussion, not the end.
  • We must continue to allow for individual connection between advocate and client (I had a recent medical experience in which the doctor thanked me for being such a good patient — I am sure that propelled both of us into a much better rest of the day.)
  • Team responsibility — different skills are needed, and tasks should be assigned based on skill and cost, but the team must work together.  Shared achievement is a spur to improvement.
  • Outcome measures must be shared through the team and the institution to create a sense of shared learning and achievement.  I have always tried to abolish the phrase (and the concept) Management Information System — can you think of anything less likely to get staff support.

Other thoughts?


About richardzorza

I am deeply involved in access to justice and the patient voice movement.
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2 Responses to Two Perspectives on Standardization and Efficiency, and a Suggested Synthesis

  1. Claudia Johnson says:

    Very good contrast. Some of the risks the article identify exist in legal hotlines already. Depending on how a legal hotline is staffed and managed, lawyers and staff working in a hotline could become burned out and dissatisfied for some of the same reasons. I think that programs that set up high volume practices (hotlines, large group clinics) need to keep an eye on creating a routine, schedule, protocols and resources that keep staff motivated. You are absolutely right that sharing outcomes is vital–if a case that comes in through the hotline eventually ends up in front of the state Supreme Court–the hotline needs to be recognized for identifying the case for appeal.

    You are also right on being thoughtful about the requirements that are put on the professionals proving care and hold and keep the patient/client relationship and all the other administrative tasks required to comply w/rules, regulations, and internal protocol. As much as possible, standard operating procedures need to take costs into accounts. Do you really want your most expensive/experienced resources checking all the boxes, or checking MORE boxes in your CMS? When I managed the hotline at Bay Legal, I really kept an eye on these demands. If every county office, every adminsitrative deparment wants yet another box–to them it is only one box, but to the practioner providing the care, at the end of the day, the one box becomes knowing how that box is checked in as many counties as are covered, or by as many funding streams–and it becomes overhwhelming. So, administrative support needs to be provided and non practitioners may be a good way to ensure all the boxes are checked, forms filled etc. Instead of worrying about checking10 boxes that could vary across 182 cities and 30 funding codes, they now may have time built into their schedule to read an discuss an appeal, or read a new law or regulation, or connect with another group to share best practices–keeping the team focussed on the law and improving their legal knowledge, skills, expertize, rather than becoming proficient in checking boxes.

    The Cheesecake anology is helpful in that at the of the day, the value of a practice, is about the quality of services provided at every step, from intake to end of the case. It is important to focus on providing respectful environments and interactions to potential clients and clients. This includes having comfortable offices and waiting areas, minimizing waiting times, and phone queues, being explicit about what a program will do and not do, and then when a case is accepted and the legal work is being done, keeping the client informed of the progress, etc. In this regard, I do think the ABA standards get all of this right–technology needs to be part of the equation as is in a restaurant–it can help manage the client flow and delivery of services. Restaurants know that the chef cooks, the servers serve tables, and the bar tender tends the bar–they don’t have the chef running around between the tables, the kitchen, or worrying about stained table cloths. The same applies to legal services.

  2. Richard, In my ebook, Start and Grow Your Limited Scope Representation Practice, I addressed this very idea! There are lessons that LSR practitioners in particular can learn not only from the medical sector but other businesses as well.

    Date: Fri, 24 Aug 2012 14:03:37 +0000 To:

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