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Pittsburgh

I’m struck by how many locals are here. Like Boston, if you grew up in Pittsburgh, it seems like you never leave. Lots of natives.

The importance of the city seems so obvious, now that I know what I know.

For starters, it’s location is strategic. It’s literally sits at the point of land where two great rivers, the Allegheny and the Monongahela, come together to join the Ohio River. These are massive bodies of water.

Before rail and interstate highways, how does the growing economy move its steel, industrial products and consumer products?

The rivers!

And it now makes perfect sense to me… That, where the Three Rivers join, the leadership of this area decided that this point should be commemorated as a major park.

Point Park is just that. It’s a monument to this area, where everyone can come and see why the area exists in the first place. And as a monument inside of a monument, a massive fountain stands at the point of Point Park.

As I look to the Ohio River, to my left is the train tracks. I see a massive freight train passing, with hundreds of cars. I see an incline up to Mount Washington, which overlooks the city. The inclines are a vestige of a past when it was difficult to access the hill tops. They are everywhere.

Also to my left is the Fort Pitt Tunnel, the exit from the city to the east across the M river.

Heinz Park, the stadium, over looks Point Park to the right.

So this is where it all begins. Point Park.

The city seems to grow out of Point Park, in a gradual incline from there, with the Allegheny to the left and the M to the right.

The M River is made for walking and biking.

Three Rivers heritage Trail is the bike/walking path that goes from downtown all the way up west side of the M river

Great Appalachian Trail goes up the east side of M River.

Lots of hills. Lots of green (Schenley, Point, Highland and Frick Park are extra special).

They talk here about the “Pittsburgh Renaissance”.

They mean by that the transition of Pittsburgh from being at the center of the industrial economy, with all of its disgusting grit, to being at the center of the knowledge economy, with the University of Pittsburg, Carnegie Mellon, and Duquesne university leading the way.

Fifth Ave., Forbes Avenue, and Center Street, Penn, and Liberty all connect downtown to these outer neighborhoods.

The neighborhoods are Squirrel Hill, East Liberty, Lawrenceville, the Strip District, Bloomfield, Oakland, Shadyside, and Southside. Like Atlanta, they each have their own pride and style.

Oakland is the Univ. of Pittsburgh and Carnegie Mellon and Schenley Park. Fifth Ave runs through it. The University of Pittsburgh is center stage. It’s a huge urban campus, with all of the hallmarks of classical architecture great libraries, chapels etc. But everyone knows that Carnegie-Mellon is the powerhouse – where you find the rocket fuel of the knowledge economy. It is every bit as much to Pittsburgh as MIT is to Boston.

Shadyside is a great little find. A real neighborhood, centered on Walnut Street (at Ivy). Only a mile walk to Oakland, East Liberty, and Squirrel Hill. Girasole is here – Italian upscale.

Bloomfield is “little Italy”. Not a very good little Italy, but maybe they will keep trying.

Squirrel Hill is awesome. Highly diverse. Walkable. On top of a hill. Close to everything. Great houses. A great find: Everyone Noodle, the home of soup dumplings in Pittsburgh. Place is always full. Big Jewish Community here too. Frick Park is here.

Strip District is warehouses, converted. 21st street and Penn is the center. My favorite: Wholey’s Seafood Market. It’s massive and very cool retail. Like Stew Leonard’s , only better.

Southside is bars, lots of them. The main drag is East Carson. It’s a wide, flat street that looks more like Texas than Pittsburgh. One place in particular, Hofbrahaus, is a raucous German beer hall, with steins, sausages, oom-pah-pah live music. In a section of Southside called Southside Works. At night, ask Uber to take you to the Bartram House Bakery at 2612 East Carson. Easy walk from Birmingham or Hot Metal Bridge.

Lawrenceville is restaurants, lots of them. It’s 48th – 40th. Past the Strip District near Penn. it’s a hike, but a good walk takes you from 48th to 21st.

Everyone here believes that Pittsburgh, a finalist, it’s going to land the second headquarters of Amazon.

Their attitude toward Amazon is a little bit like their attitude toward all sports, but particularly the Steelers: can do.

Co-Working – Update

In my first post on this subject, dated 1/2015, copied below, I said “This field is going to explode”.

Today’s Sunday Times published a major article on WeWork, which confirmed my suspicion.

JCR notes:
– they have 200,000 members
– they are in 20 countries
– revenue this year should to $2.3 billion
– apparently, he has convinced investors, including SoftBank and Benchmark, that it deserves a valuation around $20 billion, more than 10x IWG, its publicly traded competitor.
– they have started WeLive, its residential offering, and Rise, its gym.
– they acquired Meetup, the social network that facilitates in-person gatherings, and the Flatiron School, a coding academy.
– they bought the iconic Lord & Taylor building on Fifth Avenue in Manhattan, which is being transformed into the company’s new headquarters.
– SoftBank, the Japanese technology group led by the enigmatic billionaire Masayoshi Son, recently invested $4 billion
– in plans: WeGrow, the company’s for-profit elementary school, set to open in September.
– IWG,IWG, better known as Regus, has been around for decades. It is a publicly traded co-working company that has more members and more real estate than WeWork. IWG is valued at just $2 billion. Yet Mr. Neumann has convinced investors that WeWork is worth 10 times that figure.

Here it the article:

CREDIT: Sunday New York Times article on WeWork

The WeWork Manifesto: First, Office Space. Next, the World.

The brash, ambitious founders of WeWork, a global network of shared office spaces, want nothing less than to transform the way we work, live and play.

By DAVID GELLES
FEB. 17, 2018

On a cold February morning at the Brooklyn Navy Yard, the skeleton of a modern 15-story building was rising from a muddy construction site along the East River. As long and as tall as a cruise ship, the sleek glass structure loomed above rusty, century-old dry docks, serving notice to the industrial neighborhood that the new economy was coming.
The project, known as Dock 72, is the brainchild of WeWork, the fast-growing New York start-up valued at a whopping $20 billion. In just eight years, WeWork has built a network of 212 shared working spaces around the globe. But WeWork’s chief executive and co-founder, Adam Neumann, isn’t content to just lease out communal offices. Mr. Neumann — a lanky, longhaired 38-year-old Israeli — wants nothing less than to radically transform the way we work, live and play.

When Dock 72 is completed this year, if the aggressive timeline holds, it will represent the fullest expression of Mr. Neumann’s expansive vision to date. There will be an enormous co-working space, a luxury spa and large offices, for other companies like IBM and Verizon, that are designed and run by WeWork. There will be a juice bar, a real bar, a gym with a boxing studio, an outdoor basketball court and panoramic vistas of Manhattan. There will be restaurants and maybe even dry cleaning services and a barbershop.

It will be the kind of place you never have to leave until you need to go to sleep — and if Mr. Neumann has his way, you’ll sleep at one of the apartments he is renting nearby.

It’s an all-encompassing sort of ambition, and Mr. Neumann is the brash and idealistic pitchman. Simply by encouraging strangers to share a beer at the office, he argues, WeWork can heal our fractured society.

“How do you change the world?” Mr. Neumann asked in a recent interview. “Bring people together. Where is the easiest big place to bring people together? In the work environment.”

It may sound simplistic, but around the globe, companies are buying whatever it is that Mr. Neumann and his co-founder, Miguel McKelvey, are selling. WeWork has rapidly expanded to 20 countries, assembled a formidable executive team and attracted some 200,000 members. Big companies like JPMorgan Chase and Siemens are signing on as tenants, and revenues are growing fast, expected to top $2.3 billion this year.

WeWork last year bought the iconic Lord & Taylor building on Fifth Avenue in Manhattan, which is being transformed into the company’s new headquarters. That deal was made possible in part by a recent $4.4 billion investment from SoftBank, the Japanese technology group led by the enigmatic billionaire Masayoshi Son.

Already the company has started WeLive, its residential offering, and Rise, its gym. It acquired Meetup, the social network that facilitates in-person gatherings, and the Flatiron School, a coding academy. Still to come: WeGrow, the company’s for-profit elementary school, set to open in September. WeWork has even invested in plans to create giant wave pools for inland surfing.

A company ostensibly about co-working now employs yoga instructors, architects, teachers, environmental scientists, software engineers, molecular biologists and social psychologists.

Is it all a bit much for a young company still trying to build out its core business? “I’ve made that argument,” said Bruce Dunlevie, a WeWork board member and partner at the venture capital firm Benchmark. But, he said, “great entrepreneurs like Adam don’t listen to guys like me.”

As WeWork expands in all directions, it faces persistent questions about its rich valuation and the durability of its business model. Critics argue that the company does little more than corporate real estate arbitrage — leasing a space, spiffing it up, then subleasing it out to other tenants. The company owns hardly any properties, giving it precious few hard assets. Its growth projections strike many as unattainable, and it has missed expectations before. A number of upstarts loom as potential competitors, seeking to replicate WeWork’s success. And many WeWork tenants are unproven start-ups that could quickly fold.

IWG, a publicly traded co-working company that has more members and more real estate than WeWork, is valued at just $2 billion. Yet Mr. Neumann has convinced investors that WeWork is worth 10 times that figure.

“Adam’s explanation for the valuation of WeWork speaks for itself,” said Chris Kelly, co-founder and president of Convene, a company that offers flexible event spaces and is backed by major real estate firms. “This is not an Excel spreadsheet calculation. He believes there’s an energy behind the brand, and he’s gotten people to invest at that valuation. He has not tried to explain it in traditional financial terms.”

Indeed, to assess WeWork by conventional metrics is to miss the point, according to Mr. Neumann. WeWork isn’t really a real estate company. It’s a state of consciousness, he argues, a generation of interconnected emotionally intelligent entrepreneurs. And Mr. Neumann, with his combination of inspiration and chutzpah, wants to transform not just the way we work and live, but the very world we live in.

It’s an audacious, perhaps delusional plan for a company that made its mark by building communal desks and providing refreshments. And so far, it seems to be working.

Mr. Son, WeWork’s largest investor, is betting that the company will grow exponentially in the years to come, making his multibillion-dollar investment a veritable bargain.
“Make it 10 times bigger than your original plan,” Mr. Son told Forbes late last year. “If you think in that manner, the valuation is cheap. It can be worth a few hundred billion dollars.”

Close Communities
The notion that white-collar workers might actually like their offices is a relatively new one. From the countinghouses of industrial England to the skyscrapers of 1980s Manhattan, offices were mostly uninspiring places designed to maximize space, often with row upon row of unglamorous desks.

“The only kind of model that anyone had for laying out a large workplace was a factory,” said Nikil Saval, author of “Cubed: A Secret History of the Workplace.” “So the office was made to resemble an assembly line.”

This dreary state of affairs began to change in earnest, at least for some, during the dot-com bubble. Tech companies built playful offices with beanbags and Ping-Pong tables, making work spaces less formal. Free food became commonplace.

Raised expectations for amenities and interior design gradually seeped into the mainstream, and today, more and more employees — especially millennials — expect enlightened, unconventional offices.

Enter WeWork. With people bouncing between employers, jobs concentrated in cities and technology making it easier to work remotely, the demand for co-working was suddenly real, and ready to be monetized. Mr. Neumann, who grew up on a kibbutz in Israel, had an epiphany: Bring the communal vibe to the office.

Soon he and a friend — Mr. McKelvey, an equally tall Oregonian who grew up on a collective and was working as an architect — founded an eco-friendly co-working space in Brooklyn. They sold it, but they quickly turned around and started WeWork in 2010.
“Me and Miguel have this common ground,” Mr. Neumann said. “We both grew up in very close communities.”

WeWork didn’t invent co-working spaces, of course. IWG, better known as Regus, has been around for decades. But Mr. Neumann and Mr. McKelvey quickly hit upon a recipe that drew throngs of start-ups: an industrial chic aesthetic, some big common areas with comfy couches, free beer and piped-in pop music.

Individuals pay as little as $45 a month for occasional access to a desk in a common area. Start-ups can pay a few thousand dollars for a private room on a month-to-month basis, and some big companies pay millions of dollars a year for spaces that hold thousands of employees over multiple locations.

It’s a formula that has caught on from New York to Tel Aviv to Shanghai. In New York alone, WeWork has 49 spaces, most of them nearly full. At the WeWork in Harlem, dance companies share space with hair care start-ups in a common area adorned with murals of jazz musicians. At a WeWork in TriBeCa, fashion designers and alcohol distributors work shoulder to shoulder in a spartan space decorated with neon lighting.

For WeWork to really succeed in changing the way we all work, it is going to have to win over big corporations seeking space for thousands of employees. The strategy is an odd reversal for WeWork, which made its name catering to freelancers and start-ups.
The Weather Channel recently moved its ad sales team into an enormous WeWork in Midtown Manhattan. Barbara Bekkedahl, who runs the group, said the transition was easy and the space comfortable and stylish.
But Ms. Bekkedahl had a complaint, too, one that highlights one of the downsides of communal work space. She suggested that the hygienic and sartorial habits of some of her new office mates were lacking.

“As a TV sales team, we groom and dress for outside sales,” she said. “Some of the techie and start-up types housed at WeWork aren’t facing customers all day, so don’t always have the same standards.”

Gripes about grooming are unlikely to slow down WeWork’s business with corporate clients, especially if Mr. Neumann makes good on his promise to save them money. Because WeWork is building out so much space and buying so much furniture, Mr. Neumann says, he can renovate and operate an office for a fraction of the cost that companies would normally spend.

“We have economies of scale,” he said. “I’ll cut your operational costs between 20 to 50 percent.”

It might seem like another instance of Mr. Neumann’s talking a big game but for the fact that more and more companies — GE, HSBC, Salesforce and Microsoft among them — are signing on.
For years now, big companies have outsourced payroll processing, janitorial services and security. It’s not a stretch to imagine more of them outsourcing the design and maintenance of their offices to a company like WeWork.
“We only have 200,000 members,” Mr. McKelvey, 43, said. “That’s ridiculous. We need to have two million and then 20 million.”

More ‘We’ Than ‘Me’
Bankers and lawyers poured out of skyscrapers and made for the suburbs on a recent Monday night in Manhattan’s financial district. But at 110 Wall Street, a building controlled entirely by WeWork, the party was just getting started.

Last year, this 1960s-era office tower was converted into a mixed-use development of Mr. Neumann’s design. There is a co-working space. On the ground floor are trendy restaurants including Westville, Fuku, Momofuku Milk Bar and a bar called the Mail Room.

And then there is a WeLive: a complex of about 200 fully furnished apartments rented out on a short-term basis. Tenants get the signature WeWork aesthetic of unpolished wood and wrought iron, as well as various perks. There are hot tubs on the terrace. There are arcade games and a pool table in the laundry room. There are a chef’s kitchen and a communal dining room. At a bar on a residential floor, a happy hour was brewing and free Tempranillo was flowing.

In the communal dining area, three brothers — Jordan, Jake and Jimmy DeCicco — were cooking for a half-dozen social media influencers, hoping to stir up enthusiasm for their protein-infused iced coffee company. Over rib-eye steaks and brussels sprouts, they talked about promoting the brand and breaking into new markets, passing out beers to anyone who walked by.

The brothers are all in: They live in WeLive, work in the adjacent WeWork space and exercise at WeWork’s nearby gym, Rise.

“It’s awesome,” Jake DeCicco said. “You just roll out of bed, go down the elevator and get to work.”

Had Mr. Neumann been there to share a beer, those words would have been music to his ears. He believes that creating a work and living environment where people mingle is in fact a world-changing innovation. Each WeWork has a “community manager” who keeps tabs on members, makes introductions and organizes social activities.

If more strangers are colliding by the grapefruit water, the thinking goes, they are more likely to meet up and invest in one another’s socially responsible start-ups, and then the world will be a better place.

“Once you choose to enter a WeWork, you choose to be part of something more ‘we’ than ‘me,’” Mr. Neumann said. “People start coming together. They’ll see each other in the elevator, they talk in the stairways. There’s a thousand other things they do.”
Elevators. Stairways. Hardly world-changing innovations. But WeWork takes extra steps to encourage fraternization. Like beer kegs that never run dry.

More than most companies, WeWork promotes the consumption of alcohol as an inherent virtue. Posters on the wall encourage people to have a drink. There are wine tastings at WeLive. Company parties feature top-shelf liquor. Mr. Neumann has a well-known penchant for tequila, and a well-stocked bar is prominent in his office.

On a recent Tuesday at 4:07 p.m., the community manager of a WeWork in Midtown Manhattan sent an email reading: “It’s time to get your creative juices flowing! Join us on the 5th floor to drink some wine & paint a beautiful picture.” Just after noon on Valentine’s Day, there was an invitation to share wine and cake in the common area.

Though alcohol is a social lubricant for some, it can be off-putting to many others. Many women have shared stories of feeling uncomfortable with what they described as a frat house culture at some WeWorks, prompting some to leave.

As WeWork has grown, minor scandals have rattled the company. In 2015, the company grew ensnared in a complicated legal dispute with a group of former janitors who tried to unionize at a subcontractor that WeWork used. The next year, WeWork drew scrutiny for its use of arbitration to settle workplace disputes, and for its firing of an employee who refused to adhere to a related policy.

But so far nothing — not alcohol, labor disputes, questions about the business fundamentals or bad publicity — has managed to alter the company’s trajectory.
“We’re a disrupter of the way people view the spaces they work in on a day-to-day basis,” said Mr. Dunlevie of Benchmark. “And we’re in the early days of taking advantage of that phenomenon.”

Teaching Tykes
In September, WeWork will open its most ambitious project to date: a kindergarten. It may also be the effort that tests whether WeWork is flying too close to the sun.
The creation of Mr. Neumann’s wife, Rebekah, 39, the school is known as WeGrow. When it opens, it promises a well-designed space with a curriculum that emphasizes socializing and entrepreneurship for 3-year-olds on up.

WeGrow fits neatly into Mr. Neumann’s expansive vision for creating a generation of empathetic social impact entrepreneurs. But the risk-reward calculus is different when starting a school.

WeGrow won’t scale as rapidly as WeWork has, so the financial upside is limited. Yet should something go wrong, the fallout could be devastating: It’s one thing to be responsible for the internet going out or paper running low at the communal printer. It’s another thing to take responsibility for the health and development of someone’s child.

Though Ms. Neumann has no background in education (on the website, she describes herself as “an avid student of life” and says her “superpower” is “intuition”), she has applied for accreditation from the state, has hired a team of career educators and is accepting applications for the coming school year. Tuition for toddlers: $36,000 a year.

“We all understand how complicated and regulated school is compared to the simpler business that we are already in,” Mr. Neumann said. “But we decided we’re going to go into education. If you really want to change the world, change kids when they’re 2.”
As he proselytized, Mr. Neumann was sitting on an enormous leather couch in his Chelsea office, which is bigger than many New York City apartments. It included a conference table, a video conferencing setup, several desks, a bar, spreads of food, a Peloton exercise bike, a climbing machine, a boxing bag hanging from the ceiling, a gong, an antechamber where assistants work and a private bathroom.

“It’s going to work,” Mr. Neumann continued. “Is it going to be perfect? Definitely not. Are we going to make mistakes? A hundred percent. Are we going to be comfortable admitting those mistakes? Definitely. It’s what we do here.”

Though such unbridled zeal can be abrasive to some, it could also be viewed as the mark of a peripatetic savant. Walter Isaacson, the biographer of Steve Jobs, Albert Einstein, Benjamin Franklin and Leonardo da Vinci, counts Mr. Neumann as a friend, and said he shared some of the attributes that had allowed those other titans to succeed.

“He has an instinctive feel for how millennials are going to want to have community work experiences without joining large corporations,” Mr. Isaacson said. “And like Steve Jobs and other great entrepreneurs, he knows how to connect the humanities with business and technology.”

‘Make a Life’
It can be tempting to dismiss WeWork as just another overvalued start-up that is high on its own rhetoric and flush with easy money from naïve investors. With little more than faddish interior design, free beer and an invitation to socialize with strangers, Mr. Neumann claims to have conjured up a whole new paradigm for white-collar workers — and for education — and vows that it can change the world.

It’s the kind of utopian prattle that can come off as dangerously out of touch at a moment when a backlash against big tech is brewing. But if any of these potential pitfalls concern Mr. Neumann, he doesn’t show it.
On a Wednesday night in January, Mr. Neumann strode onstage before a packed house at the Theater at Madison Square Garden, basked in spotlights. Wearing a black leather biker jacket and a T-shirt that read “High on We,” Mr. Neumann was playing host at his own extravagant party, a multiday celebration of WeWork and its extended community.

On this, the first night of festivities, Mr. Neumann would oversee a “Shark Tank”-like competition for socially responsible small businesses — ranging from a start-up that made customized prosthetics to a food-delivery service staffed by refugees — each vying for a $1 million prize.

Earlier, Mr. Neumann had rattled off the company’s achievements and outlined some of its more outsize ambitions. As the evening’s performer, the Grammy-winning rapper Macklemore, waited backstage, Mr. Neumann went on an impromptu riff about how people should “make a life, not just a living,” the company’s aspirational motto.

Mr. Neumann also stated that it was important to support social entrepreneurs. “Of course that makes a lot of sense, but who’s going to pay for that?” he said. “And we said, ‘Well, Masa might!’”

The line generated a laugh among the hundreds of knowing employees in the room — Mr. Son, whose nickname is Masa, was conveniently absent — but it was a tell from Mr. Neumann, a sly admission that at this point he is playing with house money.

Then, when the time came to choose a winner, Mr. Neumann made a surprise announcement: Instead of choosing one recipient, WeWork would give away $1 million each to two of the companies — Re:3D, a 3-D printing company, and Global Vision 2020, a nonprofit that provides prescription glasses to people in the developing world. And it would give another couple of million to the other half-dozen finalists.

Confetti fell from the rafters. The winners cried on stage. Mr. Neumann took it all in, beaming.

Even Macklemore was taken aback by all the money flying around. “I was just watching it, chugging a Red Bull,” he said shortly into his set, “and I immediately thought, ‘Damn, I should have got into technology.’”
Continue reading the main story

Cole Wilson for The New York Times
David Gelles is the Corner Office columnist and a business reporter. Follow him on Twitter @dgelles and LinkedIn.

A version of this article appears in print on February 18, 2018, on Page BU1 of the New York edition with the headline: First, Office Space; Then the World.

=================== PRIOR POST from January, 2015 ============
Co-Working

The field is going to explode.

The model for co-working is ROAM. GREAT business model – huge uptake. Place was packed.

They currently are in Alpharetta and Dunwoody, and are opening a Buckhead facility in Tower Place this summer. They have a mini-cafeteria, office space, mail handling, membership services, printing, etc.

Here is the download:

http://meetatroam.com

“Roam is the innovator’s workplace; a meeting and gathering experience for the new workforce. We are partnering for success by creating environments where people focus, collaborate, learn and socialize.”

“We are a Collective, a Local Community of Innovators, Pioneers and Visionaries.”

From a member: “Patrick also thinks that energy is Roam’s differentiator. “When you walk into Roam Dunwoody, it’s like you walk into a room full of vibrations,” he says. He loves interacting with the other members here and feeding off of that energy. “Every Roam member is passionate about whatever they do. They really want their business to make an impact.” The members as a whole are a forward-thinking group, open to new ideas and supportive of innovation, “

This entry was posted in Architecture, Well-Being – PersonaL and tagged Architecture, personal well-being, Serenbe on January 14, 2015.

Primary Care Best Practice

This post is about two important articles related to Primary Care Best Practice: One by Atul Gawande called “Big Med” and the other from Harvard Medical School about Physician Burnout.

As usual, Atul tells stories. His stories begin with his positive experience at the Cheesecake Factory and with his mother’s knee replacement surgery.

====================
Article by Atul Gawande Big Med and the Cheesecake Factory
====================
JCR NOTES

Article explores the potential for transferring some of the operational excellence of the Cheesecake Factory to aspects of health care.

He finds it tempting to look for 95% standardization and 5% customization.
He sees lessons in rolling out innovations through test kitchens and training that includes how to train others.
He sees heroes in doctors that push to articulate a standard of care, or technology, or equipment, or pharmaceutical.

====================
CREDIT: New Yorker Article by Atul Gawande “Big Med”

Annals of Health Care
August 13, 2012 Issue
Big Med
Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?

By Atul Gawande

Medicine has long resisted the productivity revolutions that transformed other industries. But the new chains aim to change this.Illustration by Harry Campbell

It was Saturday night, and I was at the local Cheesecake Factory with my two teen-age daughters and three of their friends. You may know the chain: a hundred and sixty restaurants with a catalogue-like menu that, when I did a count, listed three hundred and eight dinner items (including the forty-nine on the “Skinnylicious” menu), plus a hundred and twenty-four choices of beverage. It’s a linen-napkin-and-tablecloth sort of place, but with something for everyone. There’s wine and wasabi-crusted ahi tuna, but there’s also buffalo wings and Bud Light. The kids ordered mostly comfort food—pot stickers, mini crab cakes, teriyaki chicken, Hawaiian pizza, pasta carbonara. I got a beet salad with goat cheese, white-bean hummus and warm flatbread, and the miso salmon.

The place is huge, but it’s invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron, sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.
The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).

I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.
I’d come from the hospital that day. 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. 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.

It’s easy to mock places like the Cheesecake Factory—restaurants that have brought chain production to complicated sit-down meals. But the “casual dining sector,” as it is known, plays a central role in the ecosystem of eating, providing three-course, fork-and-knife restaurant meals that most people across the country couldn’t previously find or afford. The ideas start out in élite, upscale restaurants in major cities. You could think of them as research restaurants, akin to research hospitals. Some of their enthusiasms—miso salmon, Chianti-braised short ribs, flourless chocolate espresso cake—spread to other high-end restaurants. Then the casual-dining chains reëngineer them for affordable delivery to millions. Does health care need something like this?

Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth. Pizza Hut alone runs one in eight pizza restaurants in the country. The Cheesecake Factory’s major competitor, Darden, owns Olive Garden, LongHorn Steakhouse, Red Lobster, and the Capital Grille; it has more than two thousand restaurants across the country and employs more than a hundred and eighty thousand people. We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt.

Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based. But that’s changing. Hospitals and clinics have been forming into large conglomerates. And physicians—facing escalating demands to lower costs, adopt expensive information technology, and account for performance—have been flocking to join them. According to the Bureau of Labor Statistics, only a quarter of doctors are self-employed—an extraordinary turnabout from a decade ago, when a majority were independent. They’ve decided to become employees, and health systems have become chains.

I’m no exception. I am an employee of an academic, nonprofit health system called Partners HealthCare, which owns the Brigham and Women’s Hospital and the Massachusetts General Hospital, along with seven other hospitals, and is affiliated with dozens of clinics around eastern Massachusetts. Partners has sixty thousand employees, including six thousand doctors. Our competitors include CareGroup, a system of five regional hospitals, and a new for-profit chain called the Steward Health Care System.

Steward was launched in late 2010, when Cerberus—the multibillion-dollar private-investment firm—bought a group of six failing Catholic hospitals in the Boston area for nine hundred million dollars. Many people were shocked that the Catholic Church would allow a corporate takeover of its charity hospitals. But the hospitals, some of which were more than a century old, had been losing money and patients, and Cerberus is one of those firms which specialize in turning around distressed businesses.

Cerberus has owned controlling stakes in Chrysler and gmac Financing and currently has stakes in Albertsons grocery stories, one of Austria’s largest retail bank chains, and the Freedom Group, which it built into one of the biggest gun-and-ammunition manufacturers in the world. When it looked at the Catholic hospitals, it saw another opportunity to create profit through size and efficiency. In the past year, Steward bought four more Massachusetts hospitals and made an offer to buy six financially troubled hospitals in south Florida. It’s trying to create what some have called the Southwest Airlines of health care—a network of high-quality hospitals that would appeal to a more cost-conscious public.

Steward’s aggressive growth has made local doctors like me nervous. But many health systems, for-profit and not-for-profit, share its goal: large-scale, production-line medicine. The way medical care is organized is changing—because the way we pay for it is changing.
Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens. The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares.

Health-care reforms—public and private—have sought to reshape that system. This year, my employer’s new contracts with Medicare, BlueCross BlueShield, and others link financial reward to clinical performance. The more the hospital exceeds its cost-reduction and quality-improvement targets, the more money it can keep. If it misses the targets, it will lose tens of millions of dollars. This is a radical shift. Until now, hospitals and medical groups have mainly had a landlord-tenant relationship with doctors. They offered us space and facilities, but what we tenants did behind closed doors was our business. Now it’s their business, too.

The theory the country is about to test is that chains will make us better and more efficient. The question is how. To most of us who work in health care, throwing a bunch of administrators and accountants into the mix seems unlikely to help. Good medicine can’t be reduced to a recipe.

Then again neither can good food: every dish involves attention to detail and individual adjustments that require human judgment. Yet, some chains manage to achieve good, consistent results thousands of times a day across the entire country. I decided to get inside one and find out how they did it.

Dave Luz is the regional manager for the eight Cheesecake Factories in the Boston area. He oversees operations that bring in eighty million dollars in yearly revenue, about as much as a medium-sized hospital. Luz (rhymes with “fuzz”) is forty-seven, and had started out in his twenties waiting tables at a Cheesecake Factory restaurant in Los Angeles. He was writing screenplays, but couldn’t make a living at it. When he and his wife hit thirty and had their second child, they came back east to Boston to be closer to family. He decided to stick with the Cheesecake Factory. Luz rose steadily, and made a nice living. “I wanted to have some business skills,” he said—he started a film-production company on the side—“and there was no other place I knew where you could go in, know nothing, and learn top to bottom how to run a business.”

To show me how a Cheesecake Factory works, he 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.

I watched Mauricio Gaviria at the broiler station as the lunch crowd began coming in. Mauricio was twenty-nine years old and had worked there eight years. He’d got his start doing simple prep—chopping vegetables—and worked his way up to fry cook, the pasta station, and now the sauté and broiler stations. He bounced in place waiting for the pace to pick up. An order for a “hibachi” steak popped up. He tapped the screen to open the order: medium-rare, no special requests. A ten-minute timer began. He tonged a fat hanger steak soaking in teriyaki sauce onto the broiler and started a nest of sliced onions cooking beside it. While the meat was grilling, other orders arrived: a Kobe burger, a blue-cheese B.L.T. burger, three “old-fashioned” burgers, five veggie burgers, a “farmhouse” burger, and two Thai chicken wraps. Tap, tap, tap. He got each of them grilling.

I brought up the hibachi-steak recipe on the screen. There were instructions to season the steak, sauté the onions, grill some mushrooms, slice the meat, place it on the bed of onions, pile the mushrooms on top, garnish with parsley and sesame seeds, heap a stack of asparagus tempura next to it, shape a tower of mashed potatoes alongside, drop a pat of wasabi butter on top, and serve.

Two things struck me. First, the instructions were precise about the ingredients and the objectives (the steak slices were to be a quarter of an inch thick, the presentation just so), but not about how to get there. The cook has to decide how much to salt and baste, how to sequence the onions and mushrooms and meat so they’re done at the same time, how to swivel from grill to countertop and back, sprinkling a pinch of salt here, flipping a burger there, sending word to the fry cook for the asparagus tempura, all the while keeping an eye on the steak. In producing complicated food, there might be recipes, but there was also a substantial amount of what’s called “tacit knowledge”—knowledge that has not been reduced to instructions.

Second, Mauricio never looked at the instructions anyway. By the time I’d finished reading the steak recipe, he was done with the dish and had plated half a dozen others. “Do you use this recipe screen?” I asked.

“No. I have the recipes right here,” he said, pointing to his baseball-capped head.

He put the steak dish under warming lights, and tapped the screen to signal the servers for pickup. But before the dish was taken away, the kitchen manager stopped to look, and the system started to become clearer. He pulled a clean fork out and poked at the steak. Then he called to Mauricio and the two other cooks manning the grill station.

“Gentlemen,” he said, “this steak is perfect.” It was juicy and pink in the center, he said. “The grill marks are excellent.” The sesame seeds and garnish were ample without being excessive. “But the tower is too tight.” I could see what he meant. The mashed potatoes looked a bit like something a kid at the beach might have molded with a bucket. You don’t want the food to look manufactured, he explained. Mauricio fluffed up the potatoes with a fork.

I watched the kitchen manager for a while. At every Cheesecake Factory restaurant, a kitchen manager is stationed at the counter where the food comes off the line, and he rates the food on a scale of one to ten. A nine is near-perfect. An eight requires one or two corrections before going out to a guest. A seven needs three. A six is unacceptable and has to be redone. This inspection process seemed a tricky task. No one likes to be second-guessed. The kitchen manager prodded gently, being careful to praise as often as he corrected. (“Beautiful. Beautiful!” “The pattern of this pesto glaze is just right.”) But he didn’t hesitate to correct.

“We’re getting sloppy with the plating,” he told the pasta station. He was unhappy with how the fry cooks were slicing the avocado spring rolls. “Gentlemen, a half-inch border on this next time.” He tried to be a coach more than a policeman. “Is this three-quarters of an ounce of Parm-Romano?”

And that seemed to be the spirit in which the line cooks took him and the other managers. The managers had all risen through the ranks. This earned them a certain amount of respect. They in turn seemed respectful of the cooks’ skills and experience. Still, the oversight is tight, and this seemed crucial to the success of the enterprise.

The managers monitored the pace, too—scanning the screens for a station stacking up red flags, indicating orders past the target time, and deciding whether to give the cooks at the station a nudge or an extra pair of hands. They watched for waste—wasted food, wasted time, wasted effort. The formula was Business 101: Use the right amount of goods and labor to deliver what customers want and no more. Anything more is waste, and waste is lost profit.

I spoke to David Gordon, the company’s chief operating officer. He told me that the Cheesecake Factory has worked out a staff-to-customer ratio that keeps everyone busy but not so busy that there’s no slack in the system in the event of a sudden surge of customers. More difficult is the problem of wasted food. Although the company buys in bulk from regional suppliers, groceries are the biggest expense after labor, and the most unpredictable. Everything—the chicken, the beef, the lettuce, the eggs, and all the rest—has a shelf life. If a restaurant were to stock too much, it could end up throwing away hundreds of thousands of dollars’ worth of food. If a restaurant stocks too little, it will have to tell customers that their favorite dish is not available, and they may never come back. Groceries, Gordon said, can kill a restaurant.

The company’s target last year was at least 97.5-per-cent efficiency: the managers aimed at throwing away no more than 2.5 per cent of the groceries they bought, without running out. This seemed to me an absurd target. Achieving it would require knowing in advance almost exactly how many customers would be coming in and what they were going to want, then insuring that the cooks didn’t spill or toss or waste anything. Yet this is precisely what the organization has learned to do. The chain-restaurant industry has produced a field of computer analytics known as “guest forecasting.”

“We have forecasting models based on historical data—the trend of the past six weeks and also the trend of the previous year,” Gordon told me. “The predictability of the business has become astounding.” The company has even learned how to make adjustments for the weather or for scheduled events like playoff games that keep people at home.

A computer program known as Net Chef showed Luz that for this one restaurant food costs accounted for 28.73 per cent of expenses the previous week. It also showed exactly how many chicken breasts were ordered that week ($1,614 worth), the volume sold, the volume on hand, and how much of last week’s order had been wasted (three dollars’ worth). Chain production requires control, and they’d figured out how to achieve it on a mass scale.

As a doctor, I found such control alien—possibly from a hostile planet. We don’t have patient forecasting in my office, push-button waste monitoring, or such stringent, hour-by-hour oversight of the work we do, and we don’t want to. I asked Luz if he had ever thought about the contrast when he went to see a doctor. We were standing amid the bustle of the kitchen, and the look on his face shifted before he answered.
“I have,” he said. His mother was seventy-eight. She had early Alzheimer’s disease, and required a caretaker at home. Getting her adequate medical care was, he said, a constant battle.

Recently, she’d had a fall, apparently after fainting, and was taken to a local emergency room. The doctors ordered a series of tests and scans, and kept her overnight. They never figured out what the problem was. Luz understood that sometimes explanations prove elusive. But the clinicians didn’t seem to be following any coördinated plan of action. The emergency doctor told the family one plan, the admitting internist described another, and the consulting specialist a third. Thousands of dollars had been spent on tests, but nobody ever told Luz the results.

A nurse came at ten the next morning and said that his mother was being discharged. But his mother’s nurse was on break, and the discharge paperwork with her instructions and prescriptions hadn’t been done. So they waited. Then the next person they needed was at lunch. It was as if the clinicians were the customers, and the patients’ job was to serve them. “We didn’t get to go until 6 p.m., with a tired, disabled lady and a long drive home.” Even then she still had to be changed out of her hospital gown and dressed. Luz pressed the call button to ask for help. No answer. He went out to the ward desk.

The aide was on break, the secretary said. “Don’t you dress her yourself at home?” He explained that he didn’t, and made a fuss.

An aide was sent. She was short with him and rough in changing his mother’s clothes. “She was manhandling her,” Luz said. “I felt like, ‘Stop. I’m not one to complain. I respect what you do enormously. But if there were a video camera in here, you’d be on the evening news.’ I sent her out. I had to do everything myself. I’m stuffing my mom’s boob in her bra. It was unbelievable.”

His mother was given instructions to check with her doctor for the results of cultures taken during her stay, for a possible urinary-tract infection. But when Luz tried to follow up, he couldn’t get through to her doctor for days. “Doctors are busy,” he said. “I get it. But come on.” An office assistant finally told him that the results wouldn’t be ready for another week and that she was to see a neurologist. No explanations. No chance to ask questions.

The neurologist, after giving her a two-minute exam, suggested tests that had already been done and wrote a prescription that he admitted was of doubtful benefit. Luz’s family seemed to encounter this kind of disorganization, imprecision, and waste wherever his mother went for help.

“It is unbelievable to me that they would not manage this better,” Luz said. I asked him what he would do if he were the manager of a neurology unit or a cardiology clinic. “I don’t know anything about medicine,” he said. But when I pressed he thought for a moment, and said, “This is pretty obvious. I’m sure you already do it. But I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

This is not at all the normal way of doing things in medicine. (“You’re scaring me,” he said, when I told him.) But it’s exactly what the new health-care chains are now hoping to do on a mass scale. They want to create Cheesecake Factories for health care. The question is whether the medical counterparts to Mauricio at the broiler station—the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan. Fixing a nice piece of steak is hardly of the same complexity as diagnosing the cause of an elderly patient’s loss of consciousness. Doctors and patients have not had a positive experience with outsiders second-guessing decisions. How will they feel about managers trying to tell them what the “best practices” are?

In March, my mother underwent a total knee replacement, like at least six hundred thousand Americans each year. She’d had a partial knee replacement a decade ago, when arthritis had worn away part of the cartilage, and for a while this served her beautifully. The surgeon warned, however, that the results would be temporary, and about five years ago the pain returned.

She’s originally from Ahmadabad, India, and has spent three decades as a pediatrician, attending to the children of my small Ohio home town. She’s chatty. She can’t go through a grocery checkout line or get pulled over for speeding without learning people’s names and a little bit about them. But she didn’t talk about her mounting pain. I noticed, however, that she had developed a pronounced limp and had become unable to walk even moderate distances. When I asked her about it, she admitted that just getting out of bed in the morning was an ordeal. Her doctor showed me her X-rays. Her partial prosthesis had worn through the bone on the lower surface of her knee. It was time for a total knee replacement.
This past winter, she finally stopped putting it off, and asked me to find her a surgeon. I wanted her to be treated well, in both the technical and the human sense. I wanted a place where everyone and everything—from the clinic secretary to the physical therapists—worked together seamlessly.

My mother planned to come to Boston, where I live, for the surgery so she could stay with me during her recovery. (My father died last year.) Boston has three hospitals in the top rank of orthopedic surgery. But even a doctor doesn’t have much to go on when it comes to making a choice. A place may have a great reputation, but it’s hard to know about actual quality of care.

Unlike some countries, the United States doesn’t have a monitoring system that tracks joint-replacement statistics. Even within an institution, I found, surgeons take strikingly different approaches. They use different makes of artificial joints, different kinds of anesthesia, different regimens for post-surgical pain control and physical therapy.

In the absence of information, I went with my own hospital, the Brigham and Women’s Hospital. Our big-name orthopedic surgeons treat Olympians and professional athletes. Nine of them do knee replacements. Of most interest to me, however, was a surgeon who was not one of the famous names. He has no national recognition. But he has led what is now a decade-long experiment in standardizing joint-replacement surgery.

John Wright is a New Zealander in his late fifties. He’s a tower crane of a man, six feet four inches tall, and so bald he barely seems to have eyebrows. He’s informal in attire—I don’t think I’ve ever seen him in a tie, and he is as apt to do rounds in his zip-up anorak as in his white coat—but he exudes competence.

“Customization should be five per cent, not ninety-five per cent, of what we do,” he told me. A few years ago, he gathered a group of people from every specialty involved—surgery, anesthesia, nursing, physical therapy—to formulate a single default way of doing knee replacements. They examined every detail, arguing their way through their past experiences and whatever evidence they could find. Essentially, they did what Luz considered the obvious thing to do: they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit.

They came up with a plan for anesthesia based on research studies—including giving certain pain medications before the patient entered the operating room and using spinal anesthesia plus an injection of local anesthetic to block the main nerve to the knee. They settled on a postoperative regimen, too. The day after a knee replacement, most orthopedic surgeons have their patients use a continuous passive-motion machine, which flexes and extends the knee as they lie in bed. Large-scale studies, though, have suggested that the machines don’t do much good. Sure enough, when the members of Wright’s group examined their own patients, they found that the ones without the machine got out of bed sooner after surgery, used less pain medication, and had more range of motion at discharge. So Wright instructed the hospital to get rid of the machines, and to use the money this saved (ninety thousand dollars a year) to pay for more physical therapy, something that is proven to help patient mobility. Therapy, starting the day after surgery, would increase from once to twice a day, including weekends.

Even more startling, Wright had persuaded the surgeons to accept changes in the operation itself; there was now, for instance, a limit as to which prostheses they could use. Each of our nine knee-replacement surgeons had his preferred type and brand. Knee surgeons are as particular about their implants as professional tennis players are about their racquets. But the hardware is easily the biggest cost of the operation—the average retail price is around eight thousand dollars, and some cost twice that, with no solid evidence of real differences in results.

Knee implants were largely perfected a quarter century ago. By the nineteen-nineties, studies showed that, for some ninety-five per cent of patients, the implants worked magnificently a decade after surgery. Evidence from the Australian registry has shown that not a single new knee or hip prosthesis had a lower failure rate than that of the established prostheses. Indeed, thirty per cent of the new models were likelier to fail. Like others on staff, Wright has advised companies on implant design. He believes that innovation will lead to better implants. In the meantime, however, he has sought to limit the staff to the three lowest-cost knee implants.

These have been hard changes for many people to accept. Wright has tried to figure out how to persuade clinicians to follow the standardized plan. To prevent revolt, he learned, he had to let them deviate at times from the default option. Surgeons could still order a passive-motion machine or a preferred prosthesis. “But I didn’t make it easy,” Wright said. The surgeons had to enter the treatment orders in the computer themselves. To change or add an implant, a surgeon had to show that the performance was superior or the price at least as low.

I asked one of his orthopedic colleagues, a surgeon named John Ready, what he thought about Wright’s efforts. Ready was philosophical. He recognized that the changes were improvements, and liked most of them. But he wasn’t happy when Wright told him that his knee-implant manufacturer wasn’t matching the others’ prices and would have to be dropped.

“It’s not ideal to lose my prosthesis,” Ready said. “I could make the switch. The differences between manufacturers are minor. But there’d be a learning curve.” Each implant has its quirks—how you seat it, what tools you use. “It’s probably a ten-case learning curve for me.” Wright suggested that he explain the situation to the manufacturer’s sales rep. “I’m my rep’s livelihood,” Ready said. “He probably makes five hundred dollars a case from me.” Ready spoke to his rep. The price was dropped.

Wright has become the hospital’s kitchen manager—not always a pleasant role. He told me that about half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results. The surgeons now use a single manufacturer for seventy-five per cent of their implants, giving the hospital bargaining power that has helped slash its knee-implant costs by half. And the start-to-finish standardization has led to vastly better outcomes. The distance patients can walk two days after surgery has increased from fifty-three to eighty-five feet. Nine out of ten could stand, walk, and climb at least a few stairs independently by the time of discharge. The amount of narcotic pain medications they required fell by a third. They could also leave the hospital nearly a full day earlier on average (which saved some two thousand dollars per patient).

My mother was one of the beneficiaries. She had insisted to Dr. Wright that she would need a week in the hospital after the operation and three weeks in a rehabilitation center. That was what she’d required for her previous knee operation, and this one was more extensive.
“We’ll see,” he told her.

The morning after her operation, he came in and told her that he wanted her getting out of bed, standing up, and doing a specific set of exercises he showed her. “He’s pushy, if you want to say it that way,” she told me. The physical therapists and nurses were, too. They were a team, and that was no small matter. I counted sixty-three different people involved in her care. Nineteen were doctors, including the surgeon and chief resident who assisted him, the anesthesiologists, the radiologists who reviewed her imaging scans, and the junior residents who examined her twice a day and adjusted her fluids and medications. Twenty-three were nurses, including her operating-room nurses, her recovery-room nurse, and the many ward nurses on their eight-to-twelve-hour shifts. There were also at least five physical therapists; sixteen patient-care assistants, helping check her vital signs, bathe her, and get her to the bathroom; plus X-ray and EKG technologists, transport workers, nurse practitioners, and physician assistants. I didn’t even count the bioengineers who serviced the equipment used, the pharmacists who dispensed her medications, or the kitchen staff preparing her food while taking into account her dietary limitations. They all had to coördinate their contributions, and they did.

Three days after her operation, she was getting in and out of bed on her own. She was on virtually no narcotic medication. She was starting to climb stairs. Her knee pain was actually less than before her operation. She left the hospital for the rehabilitation center that afternoon.

The biggest complaint that people have about health care is that no one ever takes responsibility for the total experience of care, for the costs, and for the results. My mother experienced what happens in medicine when someone takes charge. Of course, John Wright isn’t alone in trying to design and implement this kind of systematic care, in joint surgery and beyond. The Virginia Mason Medical Center, in Seattle, has done it for knee surgery and cancer care; the Geisinger Health Center, in Pennsylvania, has done it for cardiac surgery and primary care; the University of Michigan Health System standardized how its doctors give blood transfusions to patients, reducing the need for transfusions by thirty-one per cent and expenses by two hundred thousand dollars a month. Yet, unless such programs are ramped up on a nationwide scale, they aren’t going to do much to improve health care for most people or reduce the explosive growth of health-care costs.

In medicine, good ideas still take an appallingly long time to trickle down. Recently, the American Academy of Neurology and the American Headache Society released new guidelines for migraine-headache-treatment. They recommended treating severe migraine sufferers—who have more than six attacks a month—with preventive medications and listed several drugs that markedly reduce the occurrence of attacks. The authors noted, however, that previous guidelines going back more than a decade had recommended such remedies, and doctors were still not providing them to more than two-thirds of patients. One study examined how long it took several major discoveries, such as the finding that the use of beta-blockers after a heart attack improves survival, to reach even half of Americans. The answer was, on average, more than fifteen years.

Scaling good ideas has been one of our deepest problems in medicine. Regulation has had its place, but it has proved no more likely to produce great medicine than food inspectors are to produce great food. During the era of managed care, insurance-company reviewers did hardly any better. We’ve been stuck. But do we have to be?

Every six months, the Cheesecake Factory puts out a new menu. This means that everyone who works in its restaurants expects to learn something new twice a year. The March, 2012, Cheesecake Factory menu included thirteen new items. The teaching process is now finely honed: from start to finish, rollout takes just seven weeks.

The ideas for a new dish, or for tweaking an old one, can come from anywhere. One of the Boston prep cooks told me about an idea he once had that ended up in a recipe. David Overton, the founder and C.E.O. of the Cheesecake Factory, spends much of his time sampling a range of cuisines and comes up with many dishes himself. All the ideas, however, go through half a dozen chefs in the company’s test kitchen, in Calabasas. They figure out how to make each recipe reproducible, appealing, and affordable. Then they teach the new recipe to the company’s regional managers and kitchen managers.

Dave Luz, the Boston regional manager, went to California for training this past January with his chief kitchen manager, Tom Schmidt, a chef with fifteen years’ experience. They attended lectures, watched videos, participated in workshops. It sounded like a surgical conference. Where I might be taught a new surgical technique, they were taught the steps involved in preparing a “Santorini farro salad.” But there was a crucial difference. The Cheesecake instructors also trained the attendees how to teach what they were learning. In medicine, we hardly ever think about how to implement what we’ve learned. We learn what we want to, when we want to.

On the first training day, the kitchen managers worked their way through thirteen stations, preparing each new dish, and their performances were evaluated. The following day, they had to teach their regional managers how to prepare each dish—Schmidt taught Luz—and this time the instructors assessed how well the kitchen managers had taught.
The managers returned home to replicate the training session for the general manager and the chief kitchen manager of every restaurant in their region. The training at the Boston Prudential Center restaurant took place on two mornings, before the lunch rush. The first day, the managers taught the kitchen staff the new menu items. There was a lot of poring over the recipes and videos and fussing over the details. The second day, the cooks made the new dishes for the servers. This gave the cooks some practice preparing the food at speed, while allowing the servers to learn the new menu items. The dishes would go live in two weeks. I asked a couple of the line cooks how long it took them to learn to make the new food.

“I know it already,” one said.
“I make it two times, and that’s all I need,” the other said.
Come on, I said. How long before they had it down pat?
“One day,” they insisted. “It’s easy.”

I asked Schmidt how much time he thought the cooks required to master the recipes. They thought a day, I told him. He grinned. “More like a month,” he said.

Even a month would be enviable in medicine, where innovations commonly spread at a glacial pace. The new health-care chains, though, are betting that they can change that, in much the same way that other chains have.
Armin Ernst is responsible for intensive-care-unit operations in Steward’s ten hospitals. The I.C.U.s he oversees serve some eight thousand patients a year. In another era, an I.C.U. manager would have been a facilities expert. He would have spent his time making sure that the equipment, electronics, pharmacy resources, and nurse staffing were up to snuff. He would have regarded the I.C.U. as the doctors’ workshop, and he would have wanted to give them the best possible conditions to do their work as they saw fit.
Ernst, though, is a doctor—a new kind of doctor, whose goal is to help disseminate good ideas. He doesn’t see the I.C.U. as a doctors’ workshop. He sees it as the temporary home of the sickest, most fragile people in the country. Nowhere in health care do we expend more resources. Although fewer than one in four thousand Americans are in intensive care at any given time, they account for four per cent of national health-care costs. Ernst believes that his job is to make sure that everyone is collaborating to provide the most effective and least wasteful care possible.

He looked like a regular doctor to me. Ernst is fifty years old, a native German who received his medical degree at the University of Heidelberg before training in pulmonary and critical-care medicine in the United States. He wears a white hospital coat and talks about drips and ventilator settings, like any other critical-care specialist. But he doesn’t deal with patients: he deals with the people who deal with patients.

Ernst says he’s not telling clinicians what to do. Instead, he’s trying to get clinicians to agree on precise standards of care, and then make sure that they follow through on them. (The word “consensus” comes up a lot.) What I didn’t understand was how he could enforce such standards in ten hospitals across three thousand square miles.

Late one Friday evening, I joined an intensive-care-unit team on night duty. But this team was nowhere near a hospital. We were in a drab one-story building behind a meat-trucking facility outside of Boston, in a back section that Ernst called his I.C.U. command center. It was outfitted with millions of dollars’ worth of technology. Banks of computer screens carried a live feed of cardiac-monitor readings, radiology-imaging scans, and laboratory results from I.C.U. patients throughout Steward’s hospitals. Software monitored the stream and produced yellow and red alerts when it detected patterns that raised concerns. Doctors and nurses manned consoles where they could toggle on high-definition video cameras that allowed them to zoom into any I.C.U. room and talk directly to the staff on the scene or to the patients themselves.

The command center was just a few months old. The team had gone live in only four of the ten hospitals. But in the next several months Ernst’s “tele-I.C.U.” team will have the ability to monitor the care for every patient in every I.C.U. bed in the Steward health-care system.
A doctor, two nurses, and an administrative assistant were on duty in the command center each night I visited. Christina Monti was one of the nurses. A pixie-like thirty-year-old with nine years’ experience as a cardiac intensive-care nurse, she was covering Holy Family Hospital, on the New Hampshire border, and St. Elizabeth’s Medical Center, in Boston’s Brighton neighborhood. When I sat down with her, she was making her rounds, virtually.

First, she checked on the patients she had marked as most critical. She reviewed their most recent laboratory results, clinical notes, and medication changes in the electronic record. Then she made a “visit,” flicking on the two-way camera and audio system. If the patients were able to interact, she would say hello to them in their beds. She asked the staff members whether she could do anything for them. The tele-I.C.U. team provided the staff with extra eyes and ears when needed. If a crashing patient diverts the staff’s attention, the members of the remote team can keep an eye on the other patients. They can handle computer paperwork if a nurse falls behind; they can look up needed clinical information. The hospital staff have an OnStar-like button in every room that they can push to summon the tele-I.C.U. team.

Monti also ran through a series of checks for each patient. She had a reference list of the standards that Ernst had negotiated with the people running the I.C.U.s, and she looked to see if they were being followed. The standards covered basics, from hand hygiene to measures for stomach-ulcer prevention. In every room with a patient on a respirator, for instance, Monti made sure the nurse had propped the head of the bed up at least thirty degrees, which makes pneumonia less likely. She made sure the breathing tube in the patient’s mouth was secure, to reduce the risk of the tube’s falling out or becoming disconnected. She zoomed in on the medication pumps to check that the drips were dosed properly. She was not looking for bad nurses or bad doctors. She was looking for the kinds of misses that even excellent nurses and doctors can make under pressure.
The concept of the remote I.C.U. started with an effort to let specialists in critical-care medicine, who are in short supply, cover not just one but several community hospitals. Two hundred and fifty hospitals from Alaska to Virginia have installed a version of the tele-I.C.U. It produced significant improvements in outcomes and costs—and, some discovered, a means of driving better practices even in hospitals that had specialists on hand.
After five minutes of observation, however, I realized that the remote I.C.U. team wasn’t exactly in command; it was in negotiation. I observed Monti perform a video check on a middle-aged man who had just come out of heart surgery. A soft chime let the people in the room know she was dropping in. The man was unconscious, supported by a respirator and intravenous drips. At his bedside was a nurse hanging a bag of fluid. She seemed to stiffen at the chime’s sound.

“Hi,” Monti said to her. “I’m Chris. Just making my evening rounds. How are you?” The bedside nurse gave the screen only a sidelong glance.
Ernst wasn’t oblivious of the issue. He had taken pains to introduce the command center’s team, spending weeks visiting the units and bringing doctors and nurses out to tour the tele-I.C.U. before a camera was ever turned on. But there was no escaping the fact that these were strangers peering over the staff’s shoulders. The bedside nurse’s chilliness wasn’t hard to understand.

In a single hour, however, Monti had caught a number of problems. She noticed, for example, that a patient’s breathing tube had come loose. Another patient wasn’t getting recommended medication to prevent potentially fatal blood clots. Red alerts flashed on the screen—a patient with an abnormal potassium level that could cause heart-rhythm problems, another with a sudden leap in heart rate.

Monti made sure that the team wasn’t already on the case and that the alerts weren’t false alarms. Checking the computer, she figured out that a doctor had already ordered a potassium infusion for the woman with the low level. Flipping on a camera, she saw that the patient with the high heart rate was just experiencing the stress of being helped out of bed for the first time after surgery. But the unsecured breathing tube and the forgotten blood-clot medication proved to be oversights. Monti raised the concerns with the bedside staff.

Sometimes they resist. “You have got to be careful from patient to patient,” Gerard Hayes, the tele-I.C.U. doctor on duty, explained. “Pushing hard on one has ramifications for how it goes with a lot of patients. You don’t want to sour whole teams on the tele-I.C.U.” Across the country, several hospitals have decommissioned their systems. Clinicians have been known to place a gown over the camera, or even rip the camera out of the wall. Remote monitoring will never be the same as being at the bedside. One nurse called the command center to ask the team not to turn on the video system in her patient’s room: he was delirious and confused, and the sudden appearance of someone talking to him from the television would freak him out.
Still, you could see signs of change. I watched Hayes make his virtual rounds through the I.C.U. at St. Anne’s Hospital, in Fall River, near the Rhode Island border. He didn’t yet know all the members of the hospital staff—this was only his second night in the command center, and when he sees patients in person it’s at a hospital sixty miles north. So, in his dealings with the on-site clinicians, he was feeling his way.

Checking on one patient, he found a few problems. Mr. Karlage, as I’ll call him, was in his mid-fifties, an alcoholic smoker with cirrhosis of the liver, severe emphysema, terrible nutrition, and now a pneumonia that had put him into respiratory failure. The I.C.U. team injected him with antibiotics and sedatives, put a breathing tube down his throat, and forced pure oxygen into his lungs. Over a few hours, he stabilized, and the I.C.U. doctor was able to turn his attention to other patients.

But stabilizing a sick patient is like putting out a house fire. There can be smoldering embers just waiting to reignite. Hayes spotted a few. The ventilator remained set to push breaths at near-maximum pressure, and, given the patient’s severe emphysema, this risked causing a blowout. The oxygen concentration was still cranked up to a hundred per cent, which, over time, can damage the lungs. The team had also started several broad-spectrum antibiotics all at once, and this regimen had to be dialled back if they were to avoid breeding resistant bacteria.

Hayes had to notify the unit doctor. An earlier interaction, however, had not been promising. During a video check on a patient, Hayes had introduced himself and mentioned an issue he’d noticed. The unit doctor stared at him with folded arms, mouth shut tight. Hayes was a former Navy flight surgeon with twenty years’ experience as an I.C.U. doctor and looked to have at least a decade on the St. Anne’s doctor. But the doctor was no greenhorn, either, and gave him the brushoff: “The morning team can deal with that.” Now Hayes needed to call him about Mr. Karlage. He decided to do it by phone.

“Sounds like you’re having a busy night,” Hayes began when he reached the doctor. “Mr. Karlage is really turning around, huh?” Hayes praised the doctor’s work. Then he brought up his three issues, explaining what he thought could be done and why. He spoke like a consultant brought in to help. This went over better. The doctor seemed to accept Hayes’s suggestions.

Unlike a mere consultant, however, Hayes took a few extra steps to make sure his suggestions were carried out. He spoke to the nurse and the respiratory therapist by video and explained the changes needed. To carry out the plan, they needed written orders from the unit doctor. Hayes told them to call him back if they didn’t get the orders soon.

Half an hour later, Hayes called Mr. Karlage’s nurse again. She hadn’t received the orders. For all the millions of dollars of technology spent on the I.C.U. command center, this is where the plug meets the socket. The fundamental question in medicine is: Who is in charge? With the opening of the command center, Steward was trying to change the answer—it gave the remote doctors the authority to issue orders as well. The idea was that they could help when a unit doctor got too busy and fell behind, and that’s what Hayes chose to believe had happened. He entered the orders into the computer. In a conflict, however, the on-site physician has the final say. So Hayes texted the St. Anne’s doctor, informing him of the changes and asking if he’d let him know if he disagreed.

Hayes received no reply. No “thanks” or “got it” or “O.K.” After midnight, though, the unit doctor pressed the video call button and his face flashed onto Hayes’s screen. Hayes braced for a confrontation. Instead, the doctor said, “So I’ve got this other patient and I wanted to get your opinion.”
Hayes suppressed a smile. “Sure,” he said.

When he signed off, he seemed ready to high-five someone. “He called us,” he marvelled. The command center was gaining credibility.
Armin Ernst has big plans for the command center—a rollout of full-scale treatment protocols for patients with severe sepsis, acute respiratory-distress syndrome, and other conditions; strategies to reduce unnecessary costs; perhaps even computer forecasting of patient volume someday. Steward is already extending the command-center concept to in-patient psychiatry. Emergency rooms and surgery may be next. Other health systems are pursuing similar models. The command-center concept provides the possibility of, well, command.

Today, some ninety “super-regional” health-care systems have formed across the country—large, growing chains of clinics, hospitals, and home-care agencies. Most are not-for-profit. Financial analysts expect the successful ones to drive independent medical centers out of existence in much of the country—either by buying them up or by drawing away their patients with better quality and cost control. Some small clinics and stand-alone hospitals will undoubtedly remain successful, perhaps catering to the luxury end of health care the way gourmet restaurants do for food. But analysts expect that most of us will gravitate to the big systems, just as we have moved away from small pharmacies to CVS and Walmart.
Already, there have been startling changes. Cleveland Clinic, for example, opened nine regional hospitals in northeast Ohio, as well as health centers in southern Florida, Toronto, and Las Vegas, and is now going international, with a three-hundred-and-sixty-four-bed hospital in Abu Dhabi scheduled to open next year. It reached an agreement with Lowe’s, the home-improvement chain, guaranteeing a fixed price for cardiac surgery for the company’s employees and dependents. The prospect of getting better care for a lower price persuaded Lowe’s to cover all out-of-pocket costs for its insured workers to go to Cleveland, including co-payments, airfare, transportation, and lodging. Three other companies, including Kohl’s department stores, have made similar deals, and a dozen more, including Boeing, are in negotiations.

Big Medicine is on the way.
Reinventing medical care could produce hundreds of innovations. Some may be as simple as giving patients greater e-mail and online support from their clinicians, which would enable timelier advice and reduce the need for emergency-room visits. Others might involve smartphone apps for coaching the chronically ill in the management of their disease, new methods for getting advice from specialists, sophisticated systems for tracking outcomes and costs, and instant delivery to medical teams of up-to-date care protocols. Innovations could take a system that requires sixty-three clinicians for a knee replacement and knock the number down by half or more. But most significant will be the changes that finally put people like John Wright and Armin Ernst in charge of making care coherent, coördinated, and affordable. Essentially, we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring.

Yet it seems strange to pin our hopes on chains. We have no guarantee that Big Medicine will serve the social good. Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health-care systems that pursued size and market power were better at raising prices than at lowering them.
A new generation of medical leaders and institutions professes to have a different aim. But a lesson of the past century is that government can influence the behavior of big corporations, by requiring transparency about their performance and costs, and by enacting rules and limitations to protect the ordinary citizen. The federal government has broken up monopolies like Standard Oil and A.T. & T.; in some parts of the country, similar concerns could develop in health care.

Mixed feelings about the transformation are unavoidable. There’s not just the worry about what Big Medicine will do; there’s also the worry about how society and government will respond. For the changes to live up to our hopes—lower costs and better care for everyone—liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight.

The vast savings of Big Medicine could be widely shared—or reserved for a few. The clinicians who are trying to reinvent medicine aren’t doing it to make hedge-fund managers and bondholders richer; they want to see that everyone benefits from the savings their work generates—and that won’t be automatic.

Our new models come from industries that have learned to increase the capabilities and efficiency of the human beings who work for them. Yet the same industries have also tended to devalue those employees. The frontline worker, whether he is making cars, solar panels, or wasabi-crusted ahi tuna, now generates unprecedented value but receives little of the wealth he is creating. Can we avoid this as we revolutionize health care?

Those of us who work in the health-care chains will have to contend with new protocols and technology rollouts every six months, supervisors and project managers, and detailed metrics on our performance. Patients won’t just look for the best specialist anymore; they’ll look for the best system. Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more. We’ll also have to figure out how to reward people for taking the time and expense to teach the next generations of clinicians. All this will be an enormous upheaval, but it’s long overdue, and many people recognize that. When I asked Christina Monti, the Steward tele-I.C.U. nurse, why she wanted to work in a remote facility tangling with staffers who mostly regarded her with indifference or hostility, she told me, “Because I wanted to be part of the change.”

And we are seeing glimpses of this change. In my mother’s rehabilitation center, miles away from where her surgery was done, the physical therapists adhered to the exercise protocols that Dr. Wright’s knee factory had developed. He didn’t have a video command center, so he came out every other day to check on all the patients and make sure that the staff was following the program. My mother was sure she’d need a month in rehab, but she left in just a week, incurring a fraction of the costs she would have otherwise. She walked out the door using a cane. On her first day at home with me, she climbed two flights of stairs and walked around the block for exercise.

The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be. ♦

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Article on Physician Burnout and Best Practice
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JCR Notes:

A primary care physician’s work includes vaccinations, screenings, chronic disease prevention and treatment, relationship building, family planning, behavioral health, counseling, and other vital but time-consuming work.

To be in full compliance with the U.S. Preventive Services Task Force recommendations, primary care physicians with average-sized patient populations need to dedicate 7.4 hours per day to preventative care alone. Taken in conjunction with the other primary care services, namely acute and chronic care, the estimated total working hours per primary care physician comes to 21.7 hours per day, or 108.5 hours per week.

“Complete Care” across 8500 physicians and 4.4 million members at SCPMG has four elements:

1. Share accountability:
share accountability for preventative and chronic care services (e.g., treating people with hypertension or women in need of a mammogram) with high-volume specialties.

2. Delegation:
One fundamental move was to transfer tasks from physicians — not just those in primary care — to non-physicians

3. Information technology
“Outreach team” manages information technologies that allowed patients to schedule visits from mobile apps, access online personalized health care plans (e.g., customized weight-loss calendars and healthy recipes), and manage complex schedules (e.g., the steps prior to a kidney transplant).

4. Standardized Care Process (see Atul Gawande Big Med)
“Proactive Office Encounter” (POE), ensures consistent evidence-based care at every encounter across the organization. At its core, the POE is an agreement of process and delegation of tasks between physicians and their administrative supports.

Glossary:
Medical assistants (MAs)
Licensed vocational nurses (LVNs)

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CREDIT HBR Case Study on SCPMG Primary Care Best Practice

How One California Medical Group Is Decreasing Physician Burnout
Sophia Arabadjis
Erin E. Sullivan
JUNE 07, 2017

Physician burnout is a growing problem for all health care systems in the United States. Burned-out physicians deliver lower quality care, reduce their hours, or stop practicing, reducing access to care around the country. Primary care physicians are particularly vulnerable: They have some of the highest burnout rates of any medical discipline.

As part of our work researching high-performing primary care systems, we discovered a system-wide approach launched by Southern California Permanente Medical Group (SCPMG) in 2004 that unburdens primary care physicians. We believe the program — Complete Care — may be a viable model for other institutions looking to decrease burnout or increase physician satisfaction. (While burnout can easily be measured, institutions often don’t publicly report their own rates and the associated turnover they experience. Consequently, we used physician satisfaction as a proxy for burnout in our research.)

In most health care systems, primary care physicians are the first stop for patients needing care. As a result, their patients’ needs — and their own tasks — vary immensely. A primary care physician’s work includes vaccinations, screenings, chronic disease prevention and treatment, relationship building, family planning, behavioral health, counseling, and other vital but time-consuming work.

Some studies have examined just how much time a primary care physician needs to do all of these tasks and the results are staggering. To be in full compliance with the U.S. Preventive Services Task Force recommendations, primary care physicians with average-sized patient populations need to dedicate 7.4 hours per day to preventative care alone. Taken in conjunction with the other primary care services, namely acute and chronic care, the estimated total working hours per primary care physician comes to 21.7 hours per day, or 108.5 hours per week. Given such workloads, the high burnout rate is hardly surprising.

While designed with the intent to improve quality of care, SCPMG’s Complete Care program also alleviates some of the identified drivers of physician burnout by following a systematic approach to care delivery. Comprised of 8,500 physicians, SCPMG consistently provides the highest quality care to the region’s 4.4 million plan members. And a recent study of SCPMG physician satisfaction suggests that regardless of discipline, physicians feel high levels of satisfaction in three key areas: their compensation, their perceived ability to deliver high-quality care, and their day-to-day professional lives.

Complete Care has four core elements:

Share Accountability with Specialists
A few years ago, SCPMG’s regional medical director of quality and clinical analysis noticed a plateauing effect in some preventative screenings where screenings rates failed to increase after a certain percentage. He asked his team to analyze how certain patient populations — for example, women in need of a mammogram — accessed the health care system. As approximately one in eight women will develop invasive breast cancer over the course of their lifetimes, a failure to receive the recommended preventative screening could have serious health repercussions.
What the team found was startling: Over the course of a year, nearly two-thirds of women clinically eligible for a mammogram never set foot in their primary care physician’s office. Instead they showed up in specialty care or urgent care.

While this discovery spurred more research into patient access, the outcome remained the same: To achieve better rates of preventative and chronic care compliance, specialists had to be brought into the fold.
SCPMG slowly started to share accountability for preventative and chronic care services (e.g., treating people with hypertension or women in need of a mammogram) with high-volume specialties. In order to bring the specialists on board, SCPMG identified and enlisted physician champions across the medical group to promote the program throughout the region; carefully timed the rollouts of different elements of the program pieces so increased demands wouldn’t overwhelm specialists; and crafted incentive programs whose payout was tied to their performance of preventative and chronic-care activities.

This reallocation of traditional primary care responsibilities has allowed SCPMG to achieve a high level of care integration and challenge traditional notions of roles and systems. Its specialists now have to respond to patients’ needs outside their immediate expertise: For example, a podiatrist will inquire whether a diabetic patient has had his or her regular eye examination, and an emergency room doctor will stitch up a cut and give immunizations in the same visit. And the whole system, not just primary care, is responsible for quality metrics related to prevention and chronic care (e.g., the percentage of eligible patients who received a mammogram).

In addition, SCPMG revamped the way it provided care to match how patients accessed and used their system. For example, it began promoting the idea of the comprehensive visit, where patients could see their primary care provider, get blood drawn, and pick up prescribed medications in the same building.

Ultimately, the burden on primary care physicians started to ease. Even more important, SCPMG estimates that Complete Care has saved over 17,000 lives.

Delegate Responsibility
“Right work, right people,” a guiding principle, helped shape the revamping of the organization’s infrastructure. One fundamental move was to transfer tasks from physicians — not just those in primary care — to non-physicians so physicians could spend their time doing tasks only they could do and everyone was working at the top of his or her license. For example, embedded nurse managers of diabetic patients help coordinate care visits, regularly communicate directly with patients about meeting their health goals (such as weekly calls about lower HbA1c levels), and track metrics on diabetic populations across the entire organization. At the same time, dedicated prescribing nurse practitioners work closely with physicians to monitor medication use, which in the case of blood thinners, is very time intensive and requires careful titration.

Leverage Technology

SCPMG invested in information technologies that allowed patients to schedule visits from mobile apps, access online personalized health care plans (e.g., customized weight-loss calendars and healthy recipes), and manage complex schedules (e.g., the steps prior to a kidney transplant). It also established a small outreach team (about four people) that uses large automated registries of patients to mail seasonal reminders (e.g., “it’s time for your flu vaccine shot”) and alerts about routine checkups (e.g., “you are due for a mammogram”) and handle other duties (e.g., coordinating mail-order, at-home fecal tests for colon cancer). In addition, the outreach team manages automated calls and e-mail reminders for the regions 4.4 million members.

Thanks to this reorganization of responsibilities and use of new technology, traditional primary care tasks such as monitoring blood thinners, managing diabetic care, and tracking patients eligibility for cancer screenings have been transferred to other people and processes within the SCPMG system.

Standardize Care Processes
The final element of Complete Care is the kind of process standardization advocated by Atul Gawande’s in his New Yorker article “Big Med.” Standardizing processes — and in particular, workflows — removes duplicative work, strengthens working relationships, and results in higher-functioning teams, reliable routines and higher-quality outcomes. In primary care, standardized workflows help create consistent communications between providers and staff and providers and patients, which allows physicians to spend more time during visits on patients’ pressing needs.
One such process, the “Proactive Office Encounter” (POE), ensures consistent evidence-based care at every encounter across the organization. At its core, the POE is an agreement of process and delegation of tasks between physicians and their administrative supports. It was originally developed to improve communications between support staff and physicians after SCPMG’s electronic medical record was introduced.
Medical assistants (MAs) and licensed vocational nurses (LVNs) are key players. A series of checklists embedded into the medical record guide their work both before and after the visit. These checklists contain symptoms, actions, and questions that are timely and specific to each patient based on age, disease status, and reason for his or her visit. Prior to the visit, MAs or LVNs contact patients with pre-visit instructions or to schedule necessary lab work. During the visit, they use the same checklists to follow up pre-visit instructions, take vitals, conduct medication reconciliation and prep the patient for the provider.

Pop-ups within the medical record indicate a patient’s eligibility for a new screening or regular test based on new literature, prompting the MAs or LVNs to ask patients for additional information. During the visit, physicians have access to the same checklists and data collected by the MAs or LVNs. This enables them to review the work quickly and efficiently and follow up on any flagged issues. After the visit with the physician, patients see an MA or LVN again and receive a summary of topics discussed with the provider and specific instructions or health education resources.

Contemporary physicians face many challenges: an aging population, rising rates of chronic conditions, workforce shortages, technological uncertainty, changing governmental policies, and greater disparities in health outcomes across populations. All of this, it could be argued, disproportionately affect primary care specialties. These factors promise to increase physician burnout unless something is done by health care organizations to ease their burden. SCPMG’s Complete Care initiative offers a viable blueprint to do just that.

Sophia Arabadjis is a researcher and case writer at the Harvard Medical School Center for Primary Care and a research assistant at the University of Colorado. She has investigated health systems in Europe and the United States.

Erin E. Sullivan is the research director of the Harvard Medical School Center for Primary Care. Her research focuses on high-performing primary care systems.

UHVDC and China

Credit: Economist Article about UHVDC and China

A greener grid
China’s embrace of a new electricity-transmission technology holds lessons for others
The case for high-voltage direct-current connectors
Jan 14th 2017

YOU cannot negotiate with nature. From the offshore wind farms of the North Sea to the solar panels glittering in the Atacama desert, renewable energy is often generated in places far from the cities and industrial centres that consume it. To boost renewables and drive down carbon-dioxide emissions, a way must be found to send energy over long distances efficiently.

The technology already exists (see article). Most electricity is transmitted today as alternating current (AC), which works well over short and medium distances. But transmission over long distances requires very high voltages, which can be tricky for AC systems. Ultra-high-voltage direct-current (UHVDC) connectors are better suited to such spans. These high-capacity links not only make the grid greener, but also make it more stable by balancing supply. The same UHVDC links that send power from distant hydroelectric plants, say, can be run in reverse when their output is not needed, pumping water back above the turbines.

Boosters of UHVDC lines envisage a supergrid capable of moving energy around the planet. That is wildly premature. But one country has grasped the potential of these high-capacity links. State Grid, China’s state-owned electricity utility, is halfway through a plan to spend $88bn on UHVDC lines between 2009 and 2020. It wants 23 lines in operation by 2030.

That China has gone furthest in this direction is no surprise. From railways to cities, China’s appetite for big infrastructure projects is legendary (see article). China’s deepest wells of renewable energy are remote—think of the sun-baked Gobi desert, the windswept plains of Xinjiang and the mountain ranges of Tibet where rivers drop precipitously. Concerns over pollution give the government an additional incentive to locate coal-fired plants away from population centres. But its embrace of the technology holds two big lessons for others. The first is a demonstration effect. China shows that UHVDC lines can be built on a massive scale. The largest, already under construction, will have the capacity to power Greater London almost three times over, and will span more than 3,000km.

The second lesson concerns the co-ordination problems that come with long-distance transmission. UHVDCs are as much about balancing interests as grids. The costs of construction are hefty. Utilities that already sell electricity at high prices are unlikely to welcome competition from suppliers of renewable energy; consumers in renewables-rich areas who buy electricity at low prices may balk at the idea of paying more because power is being exported elsewhere. Reconciling such interests is easier the fewer the utilities involved—and in China, State Grid has a monopoly.

That suggests it will be simpler for some countries than others to follow China’s lead. Developing economies that lack an established electricity infrastructure have an advantage. Solar farms on Africa’s plains and hydroplants on its powerful rivers can use UHVDC lines to get energy to growing cities. India has two lines on the drawing-board, and should have more.

Things are more complicated in the rich world. Europe’s utilities work pretty well together but a cross-border UHVDC grid will require a harmonised regulatory framework. America is the biggest anomaly. It is a continental-sized economy with the wherewithal to finance UHVDCs. It is also horribly fragmented. There are 3,000 utilities, each focused on supplying power to its own customers. Consumers a few states away are not a priority, no matter how much sense it might make to send them electricity. A scheme to connect the three regional grids in America is stuck. The only way that America will create a green national grid will be if the federal government throws its weight behind it.

Live wire
Building a UHVDC network does not solve every energy problem. Security of supply remains an issue, even within national borders: any attacker who wants to disrupt the electricity supply to China’s east coast will soon have a 3,000km-long cable to strike. Other routes to a cleaner grid are possible, such as distributed solar power and battery storage. But to bring about a zero-carbon grid, UHVDC lines will play a role. China has its foot on the gas. Others should follow.
This article appeared in the Leaders section of the print edition under the headline “A greener grid”

Dubai and Well-Being

Dubai: Dubai Healthcare City , a health and wellness destination, today announced the launch of the world’s largest wellness concept in its Phase 2 expansion in Al Jadaf Dubai.

World’s Largest Wellness Village

Jan 25 2016

World’s largest wellness village to launch in Dubai Healthcare City Phase 2

Dubai: Dubai Healthcare City , a health and wellness destination, today announced the launch of the world’s largest wellness concept in its Phase 2 expansion in Al Jadaf Dubai.

Strategically located on the waterfront, the WorldCare Wellness Village will occupy an area equivalent to roughly the size of 16 football fields, and is estimated to be significantly larger in scale and offerings to current wellness properties in Europe and the US.

Tapping into the growing demand of people looking for evidence-based and holistic care, the wellness concept is driven by US-based WorldCare International and developed by the Dubai-based MAG Group. WorldCare is renowned for its online medical consultation service that digitally connects millions of members worldwide with over 20,000 specialists at world-class medical centers.
MR_Story

The Wellness Village concept contributes to the vision of Dubai Healthcare City to become an internationally recognized location of choice for quality healthcare and wellness services. With DHCC ‘s Phase 2 expansion, over land area of 22 million square feet, the free zone will drive the global trend of preventative healthcare taking into account local and regional healthcare demands and demographic changes.

Increasing access to preventative care is important to improve wellbeing and lower healthcare expenditure in the long term, said Her Excellency Dr Raja Al Gurg, Vice-Chairperson and Executive Director of Dubai Healthcare City Authority.
IN_READ

“By enabling access to wellness services, we are strengthening the health system and bringing patient centered care to the forefront. We are confident that Phase 2 will drive wellness tourism together with medical tourism, boosting Dubai’s diversified economy. It will bring together unique wellness concepts and specialized services such as rehabilitation, counseling, sports medicine and elderly care for both residents and visitors.”

The WorldCare Wellness Village will be anchored by a 100,000 square feet Wellness Center that will focus on prevention and management of diseases such as obesity, hypertension, diabetes and other physical conditions.

The Center will provide diagnosis and treatment plans, offering comprehensive two-to-six week medical programs built around patient education and lifestyle change. More than 100 healthcare and allied professionals are expected to work at the Center.
Nasser Menhall, Chief Executive Officer and co-founder of WorldCare International, said “We are proud to bring to Dubai a diversified wellness capability that will aggregate leading technologies and best practices in wellness programs in an unprecedented manner. Benefiting from economies of scale and our broad medical network, we hope to deliver a unique package of services that will raise the bar and set high standards.”

The Wellness Village, occupying 810,000 square feet of built up area (gross floor area /GFA) on a 900,000 square feet plot, is also conceptualized to include customized living spaces such as residential villas and apartments, as well as rental units to support long-term stay for both for local and foreign patients.

The eco-friendly living spaces will be designed to serve wellness and rehabilitation needs through features such as therapy zero-gravity pools, personalized spas, and rigorous exercise and diet facilities.

Bader Saeed Hareb, Chief Executive Officer (CEO), Investment Sector, Dubai Healthcare City , said, “We welcome our new wellness partner WorldCare who brings international systems and healthcare expertise that will strengthen what we already offer within the free zone. Unique concepts like WorldCare are a step in the right direction to ensure long-term sustainability and to develop a health and wellness destination that improves quality of life and sense of community.”

Hareb added, “As projects take shape, there will be a significant impact on the overall health of our communities, giving impetus to more opportunities to develop unique wellness concepts.”
-Ends-

About Dubai Healthcare City ( DHCC )
Dubai Healthcare City ( DHCC ) is a free zone committed to creating a health and wellness destination.

Since its launch in 2002 by His Highness Sheikh Mohammed Bin Rashid Al Maktoum, Vice-President and Prime Minister of the UAE and Ruler of Dubai, the free zone has worked towards its vision to become an internationally recognized location of choice for quality healthcare and an integrated center of excellence for clinical and wellness services, medical education and research.

Located in the heart of Dubai, the world’s largest healthcare free zone comprises two phases. Phase 1, dedicated to healthcare and medical education, occupies 4.1 million square feet in Oud Metha, and Phase 2, which is dedicated to wellness, occupies 22 million square feet in Al Jadaf, overlooking the historic Dubai Creek.

The free zone is governed by the Dubai Healthcare City Authority (DHCA) and regulated by the independent regulatory body, Dubai Healthcare City Authority – Regulation (DHCR), whose quality standards are accredited by the International Society for Quality in Healthcare (ISQua).

DHCC has close to 160 clinical partners including hospitals, outpatient medical centers and diagnostic laboratories across 150 plus specialties with licensed professionals from almost 90 countries, strengthening its medical tourism portfolio. Representing its network of support partners, close to 200 retail and non-clinical facilities serve the free zone.

DHCC is also home to academic institution the Mohammed Bin Rashid University of Medicine and Health Sciences, part of the Mohammed Bin Rashid Academic Medical Center. The free zone’s integrated environment provides leverage for potential partners to set up operations to promote health and wellness.
To learn more, log on to www.dhcc.ae.

About WorldCare International, Inc.
WorldCare’s mission is to improve the quality of health care worldwide by maximizing timely, efficient and strategic access to the best in health care. For over 20 years, WorldCare has empowered members and physicians with the clinical information and resources needed to make more informed medical decisions. WorldCare’s online medical second opinion service does this by digitally connecting millions of members worldwide with specialists at world-class medical centers within the WorldCare Consortium®. These teams of specialists and sub-specialists, with the experience that best matches each member’s needs, review the member’s medical records and diagnostics, confirm the diagnosis, recommend optimal treatments and empower members and their treating physicians with the information and resources needed to make informed medical decisions. WorldCare’s services are available through health plans, employers or insurers. 


For media enquiries, please contact:
Dubai Healthcare City
Carolina D’Souza / Awad Al Atatra
PR & Communications Department
+971 4 391 1999 / +971 4 375 6264
media@dhcc.ae

Africa Grid lags economic growth

New York Times reports…and here is the essence:

Nigeria’s leaders have promised a stable power supply since the end of military rule in 1999, spending about $20 billion and dismantling the state National Electric Power Authority, better known as N.E.P.A. — and widely derided as “Never Expect Power Always.”

Yet the country’s power generating capacity has remained virtually unchanged, about six gigawatts for a country of 170 million. The United States, with 310 million people, has a capacity of more than 1,000 gigawatts

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Here is what keeps hope alive:

Post on Elon Musk and his powerwall factory

Note Musk is in record that his real vision is to sell battery factories….like the factory he is building in Nevada.

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For Many in Africa, Lack of Electricity Is Barrier to Growth

JULY 1, 2015

JOHANNESBURG — In the darkened and chilly parking lot of a mall, a suburban family huddling around a shopping cart shared a snack on a Friday evening out. After finding their favorite restaurant closed because of a blackout, Buhle Ngwenya, with her two sons and two nephews, settled for meat pies from one of the few stores open in the mall.

“It’s like death, this load shedding,” Ms. Ngwenya, 45, said, referring to the blackouts imposed by South Africa’s state utility to prevent a collapse of the national electricity grid.

With winter here in South Africa, the worst blackouts in years are plunging residents into darkness in poor townships and wealthy suburbs alike. The cutoffs have dampened South Africa’s economy, Africa’s second biggest, and are expected to continue for another two to three years.

Despite a decade of strong economic expansion, sub-Saharan Africa is still far behind in its ability to generate something fundamental to its future — electricity — hampering growth and frustrating its ambitions to catch up with the rest of the world.

All of sub-Saharan Africa’s power generating capacity amounts to less than South Korea’s, and a quarter of it is unproductive at any given moment because of the continent’s aging infrastructure. The World Bank estimates that blackouts alone cut down the gross domestic products of sub-Saharan countries by 2.1 percent.

The crippling effect on sub-Saharan Africa was recently on display in Nigeria, which overtook South Africa as the continent’s biggest economy last year.

Nigeria’s electrical grid churns out so little power that the country mostly runs on private generators. So when a fuel shortage struck this spring, a national crisis quickly followed, disrupting cellphone service, temporarily closing bank branches and grounding airplanes.

The power shortages and blackouts have cast a harsh light on elected officials, causing rising anger among voters for whom reliable electricity was supposed to be a dividend of democracy and economic growth.

Experts say that the appointment of politically connected officials with little industry expertise at the South African state utility, Eskom, has led to mismanagement just as it has at other state-owned enterprises.

“It’s not only a symbol of failure when the lights go off,” said Anton Eberhard, an energy expert and a professor of management at the University of Cape Town. “It’s experienced directly by people. If you’re about to cook or if your child is studying for an exam the next day and your lights go off, people feel this very directly. There is a very concrete and dramatic expression of failure.”

The demand for power in Africa has become a major international issue. China has taken the lead in financing many power projects across the continent — mostly hydroelectric dams, but also solar power plants and wind farms. Private companies from Asia, the United States and Europe are also supplying power to an increasing number of countries.

China has taken the lead in financing many power projects across the continent, and independent power producers are now supplying some countries with electricity.

President Obama, in a visit to Africa two years ago, highlighted the importance of improving the continent’s power supply with a $7 billion initiative called Power Africa. The American government, partly through entities like the Millennium Challenge Corporation, is focusing on improving the electricity infrastructure in several countries, including Ghana, Malawi and Tanzania.

But investments and changes in the electricity sector on the continent have yet to yield significant gains, and experts predict that it will take decades before sub-Saharan Africa enjoys universal access to electricity.

In his inaugural address last month, Nigeria’s new president, Muhammadu Buhari, said that his nation’s attempts to overhaul its electricity sector “have only brought darkness, frustration, misery and resignation among Nigerians.” He singled out unreliable power service as the biggest drag on his country’s economy.

Nigeria’s leaders have promised a stable power supply since the end of military rule in 1999, spending about $20 billion and dismantling the state National Electric Power Authority, better known as N.E.P.A. — and widely derided as “Never Expect Power Always.”

Yet the country’s power generating capacity has remained virtually unchanged, about six gigawatts for a country of 170 million. The United States, with 310 million people, has a capacity of more than 1,000 gigawatts.

“Most companies don’t have four hours of power a day from the national grid,” said Akpan Ekpo, the director general of the West African Institute for Financial and Economic Management in Lagos, Nigeria’s commercial capital. “If they do, they’re lucky.”

Most of the $20 billion spent to overhaul the power sector is believed to have gone into the pockets of corrupt officials, Mr. Ekpo said.

“With the advent of democracy, we were promised constant power, or at least improved power,” he added. “But much to our surprise, things have only gotten worse. In some middle-class parts of Lagos, people are lucky if they now get 30 minutes of power a day.”

Yet the country’s power generating capacity has remained virtually unchanged, about six gigawatts for a country of 170 million. The United States, with 310 million people, has a capacity of more than 1,000 gigawatts.
“Most companies don’t have four hours of power a day from the national grid,” said Akpan Ekpo, the director general of the West African Institute for Financial and Economic Management in Lagos, Nigeria’s commercial capital. “If they do, they’re lucky.”
Most of the $20 billion spent to overhaul the power sector is believed to have gone into the pockets of corrupt officials, Mr. Ekpo said.
“With the advent of democracy, we were promised constant power, or at least improved power,” he added. “But much to our surprise, things have only gotten worse. In some middle-class parts of Lagos, people are lucky if they now get 30 minutes of power a day.”
South Africa’s recent history of electrification is more complicated, and it has been the subject of fierce debate as the current blackout crisis has dragged on for several months.
In the last years of apartheid, before a democratic government was elected in 1994, electricity reached only a third of South African households, few of them black.
Under the African National Congress — whose leaders have governed ever since, often promising free electricity and other services as part of the nation’s new democracy — 85 percent of households now have electricity, a remarkable accomplishment by any standard.
President Jacob Zuma has forcefully rejected any blame for the energy crisis. The strain on the grid, he said, resulted from the burden of bringing light to millions of black households without power under white-minority rule.
“It is a problem of apartheid, which we are resolving,” he said this year.
But energy experts say that these households, many of them low-income, consume little electricity. Instead, they said, the shortages result from frequent breakdowns at aging plants and, most critically, the delayed construction of two new facilities.
As far back as 1998, a government report warned that without new capacity, the country would face serious power shortages by 2007. A year later, in 2008, South Africa suffered its first rolling blackouts.
South Africa, which has the continent’s only nuclear power plant, has around half of sub-Saharan Africa’s power generating capacity, roughly 44 gigawatts. Still, the power cuts contributed to a recent drop in economic growth and a spike in unemployment to 26.4 percent, the worst level in a dozen years.
The rolling blackouts have affected everyone from giant gold mining companies and manufacturers to small businesses and individuals.
South Africans are now buying up generators, rechargeable lights and gas burners. They plan their days and evenings around scheduled blackouts by the utility. Dominating South Africa’s list of popular app downloads are ones that alert smartphone users to the impending start of a cutoff in their neighborhood or the risk of one as load shedding across the nation increases from Stage 1 to Stage 2 or Stage 3.
To Ms. Ngwenya, who was sharing meat pies with her family in the parking lot, load shedding was not only about electricity. She blamed the African National Congress, the party that liberated South Africa and has steered its course ever since.
“I always supported the A.N.C.,” said Ms. Ngwenya, who grew up in Soweto, a black township outside Johannesburg, but now lives in a wealthy suburb. “However, when it comes to load shedding, I don’t know. It’s not normal coming to a mall and carrying a torch like this man here,” she said, pointing to another consumer shrouded in darkness.
“For me, this is the biggest failure of the A.N.C.,” she added. “We even have a name for it, load shedding. Why don’t they say blackout once and for all?”
In Sandton, a Johannesburg suburb with gated communities and sumptuous malls, Junior Nji, 38, walked out of a well-lit Woolworth’s in an otherwise dark mall. His wife had just sent him a text message with the news that their neighborhood had gone dark and not to bother getting groceries.
“Load shedding boo,” she had written him, using a term of endearment. “This can’t be life.”
That morning, Mr. Nji said, he had finally decided to buy a diesel generator for his house, and workers had come to prepare for the installation. But Mr. Nji, an architect, was holding off on plans to move to a bigger office because of the extra costs of equipping it with a generator. He had been planning, he said, to hire an additional architect and a draftsman.
He texted his wife: “Then let’s go out somewhere. That Chinese restaurant might just be O.K.”

Michael Brill and Bosti

Phil Tabb recently recommended Michael Brill as a source for inspiration. He likened him to Christopher Alexander – in the way that he pursued design principles.

Here is a short write-up about Michael Brill and Bosti:

MICHAEL BRILL
Michael Brill was President of BOSTI Associates for 30 years, and for 15 of those was also a Professor of Architecture at the State University of New York at Buffalo. His career successfully combined the rigorous research and design emphases of his academic background with business-based, innovative workplace solutions to organizational problems.

He led all of BOSTI’s analyses, providing major intellectual content and direction, and developed innovative recommendations solutions. Publishing more than 50 papers, articles, monographs and book sections on this work, he also authored a much consulted two-volume work, Using Office Design to Increase Productivity. Two of his other workplace publications are widely distributed and were translated into other languages: “The Office as a Tool”, and “New Offices, No Offices, Now Offices … Wild Times in the World of Office Work”. He wrote an eclectic monthly column for Interiors Magazine from 1996-1998.

He won many awards for his design-research, including the Star Award for outstanding leadership to the interior design profession from IIDA in 1999, and “distinguished author of the year” from IFMA in 1990. His projects have won 7 national awards from various design magazines. He gave hundreds of keynote speeches and lectures, and his and BOSTI’s work has been featured in the business and popular press, and in major international architectural and interior design books and journals.

Co-Working

The field is going to explode.

The model for co-working is ROAM. GREAT business model – huge uptake. Place was packed.

They currently are in Alpharetta and Dunwoody, and are opening a Buckhead facility in Tower Place this summer. They have a mini-cafeteria, office space, mail handling, membership services, printing, etc.

Here is the download:

http://meetatroam.com

“Roam is the innovator’s workplace; a meeting and gathering experience for the new workforce. We are partnering for success by creating environments where people focus, collaborate, learn and socialize.”

“We are a Collective, a Local Community of Innovators, Pioneers and Visionaries.”

From a member: “Patrick also thinks that energy is Roam’s differentiator. “When you walk into Roam Dunwoody, it’s like you walk into a room full of vibrations,” he says. He loves interacting with the other members here and feeding off of that energy. “Every Roam member is passionate about whatever they do. They really want their business to make an impact.” The members as a whole are a forward-thinking group, open to new ideas and supportive of innovation, “

Fab Labs

Another great idea from Clay Johnson: let’s create the first “Fab Lab” in Atlanta – at Serenbe.

“Fab” is short for “fabrication” – and a Fab Lab is part of a global network of Fab Labs, initiated by the MIT Center of Bits and Atoms to encourage fabrication by lay people.

The idea is that making things with tools, particular things that are a part of the emerging digital economy, is much easier and much more fun than people think. Participants can learn a lot, and create a lot.

Reference: www.fabfoundation.org

Serenbe needs a Fab Lab!

A very rough guess was made to answer the question: what would it cost to make this happen? Clay’s best guess is $100K.

Where would the Fab Lab be housed? Not clear at this time, but surely we can find a great place.

The section below of the WWW.Fabfoundation.org website makes it clear that there are four criteria, all of which we can meet:

1. Must be open to the public
2. Must subscribe to the FabLab charter
3. Must have a common set of tools and processes*
4. Must participate in the global network (there is a Fab Lab academy, and annual global summit, etc)

* a laser cutter for 2D/3D design and fabrication, a high precision milling machine for making circuits and molds for casting, a vinyl cutter for making flexible circuits and crafts, and a fairly sophisticated electronics workbench for prototyping circuits and programming micro controllers. Optional: large wood routing machine for furniture and housing applications and 3D printers.

From the Website
Who/What qualifies as a Fab Lab?
The four qualities and requirements listed below altogether create an enabling environment that we call a Fab Lab. If your lab effort meets all these criteria, “Welcome!” If you feel you are in synchrony with the Fab Lab form and spirit, please use our logo in your fundraising efforts, and keep us informed of your progress. Please register your lab effort or new fab lab on the world map here. Here are the criteria we currently use for defining a Fab Lab:

First and foremost, public access to the Fab Lab is essential. A Fab Lab is about democratizing access to the tools for personal expression and invention. So a Fab Lab must be open to the public for free or in-kind service/barter at least part of the time each week, that’s essential.

Fab Labs support and subscribe to the Fab Lab charter: http://fab.cba.mit.edu/about/charter/

Fab Labs have to share a common set of tools and processes. A prototyping facility is not the equivalent of a Fab Lab. A 3D printer is not a Fab Lab. The idea is that all the labs can share knowledge, designs, and collaborate across international borders. If I make something here in Boston and send you the files and documentation, you should be able to reproduce it there, fairly painlessly. If I walk into a Fab Lab in Russia, I should be able to do the same things that I can do in Nairobi, Cape Town, Delhi, Amsterdam or Boston Fab Labs. The critical machines and materials are identified in this list: http://fab.cba.mit.edu/about/fab/inv.html and there’s a list of open source software and freeware that we use online as well (embedded in Fab Academy modules here: http://academy.cba.mit.edu/classes/ ) But essentially it’s the processes and the codes and the capabilities that are important. So you want a laser cutter for 2D/3D design and fabrication, a high precision milling machine for making circuits and molds for casting, a vinyl cutter for making flexible circuits and crafts, a fairly sophisticated electronics workbench for prototyping circuits and programming microcontrollers, and if you can possibly find the funds, you’ll want the large wood routing machine for furniture and housing applications. We are also testing fairly inexpensive, but robust and with fair resolution 3D printers—the most current favorite is listed in the inventory.

Fab Labs must participate in the larger, global Fab Lab network, that is, you can’t isolate yourself. This is about being part of a global, knowledge-sharing community. The public videoconference is one way to do connect. Attending the annual Fab Lab meeting is another. FAB10 is in Barcelona this year, July 2-8. Collaborating and partnering with other labs in the network on workshops, challenges or projects is another way. Participating in Fab Academy is yet another way.