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A lot of facilities run on a McDonalds type thinking when they should be looking at how In-N-Out is able to deliver a very similar product that is both dramatic

A lot of facilities run on a McDonalds type thinking when they should be looking at how In-N-Out is able to deliver a very similar product that is both dramatically better and either the same price or even cheaper. In-N-Out staff is well compensated, customers rate the institution as one of the most beloved in american life. McDonalds achieves neither of those things. What makes In-N-Out different? The difference is competence in operations. A lot of healthcare today delivers an inferior product at an inferior price, it doesn't have to be that way. A lot of people think that quality is only possible at an increased "price". A change in thinking is what is needed to achieve a change in quality (result/price). Responding to the request below for a specific example. Hand washing, you wash your hands when medically appropriate to prevent facility acquired infections. If you don't you are progressively warned ultimately leading to termination and/or loss of license. If instituted nationally this alone would save at least 5,000 lives a year. Good luck getting it instituted at most facilities. A different example, diesel fuel and generator maintenance is a meaningful part of medical facility physical plant. A shocking number of facilities place procurement responsibility and oversight of this in the hands of a doctor who also has medical responsibilities. The results are as financially and operationally disasterous as you would expect. Data centers have similar requirements. Who do you think pays more and operates better? Formularies are a sort of default medication lookup table. Most organizations have one that was created decades ago by people who aren't with the organization anymore. Review and revise them with someone who understands both the medical/pharmacological aspects of the drugs involved as well as their costs. Win for doctors, win for patients, win for insurers, almost no one does this. They have some clueless administrator carry forward last years formulary with minor changes or alternatively have a medical professional with absolutely no idea what costs are involved do it.

deadmutex 3y ago
Can you please add more details/examples? The current responses seem to be a bit broad/vague to follow. E.g. what are your recommendations? pay staff more? i.e. increase doctor pay?
ako 3y ago
I'm from Europe, have never heard of In-N-Out before, don't know how they work, nor the quality they provide...
- vinay427 3y ago
  Respectfully, I’m not sure what you are asking for. In-N-Out is only in a small fraction of the US so most people from the US wouldn’t know much about it either. I believe that’s why the GP comment provided a little more context which was more or less sufficient for me to understand the comparison.
  - ako 3y ago
    Initially the In-N-Out example was made without explaining what it is, and even with the added context i think it doesn't really explain how In-N-Out differs from McDonalds. Their operations are better, what does that mean, how does that impact customers, how does that impact cost, etc.
    - bogwog 3y ago
      If you ever go to one, you'll understand. They're like the Rolls-Royce of fast food burgers.
      - philwelch 3y ago
        I’ve been. It’s nothing special.
      - Nexxius 3y ago
        I wouldn't say Rolls-Royce, more like Lexus. Fuddruckers would be closer to Rolls quality as they actually allow for something other than well-done, preformed, meat pucks.
  - bombcar 3y ago
    In-n-Out has saturated the southwestern coast, which is a pretty significant fraction of the United States. The key is they have an absolute ton of employees in the restaurant (a busy McDonald’s might have four or five, In-n-out can have double or triple that. I’ve seen other fast food with two employees, never an In-n-Out) and they work exceptionally hard on specific tasks. They also only deploy in areas where they’ve determined they’ll be able to keep the store busy enough.
msteffen 3y ago
Some of these suggestions seem like non-trivial management problems, though, I think? Diesel fuel and generator maintenance: how do you hire for that? Does that position require experience? In what? Where do you post that job ad to get qualified candidates? If you hire wrong, it seems like the results could be worse than foisting the task on a doctor, no? Revising formularies: how many doctors at a hospital have the right expertise for that? Who cares for their patients while the formulary work is happening? Can you hire someone temporary to come do it so it doesn’t disrupt operations, and how expensive is that person and how good is the result? I’m a software person, not a doctor, but I _can_ see how these choices would be made if the alternative seemed riskier to someone inexperienced at hiring for hospitals.
- pjc50 3y ago
  > Some of these suggestions seem like non-trivial management problems, though, I think? Yes, that's the discipline called "operations". Crucially it's a separate set of skills from anything one might learn in medical school.
- CommieBobDole 3y ago
  >Diesel fuel and generator maintenance: how do you hire for that? This is typically part of the job of a facilities manager, someone who is in charge of maintaining the physical structure and amenities of a building or complex of buildings. You hire for it the same way you hire for everything else; you find someone in the category that you want, who has apparent success doing something similar to what you're doing.
Naijoko 3y ago
"Responding to the request below for a specific example. Hand washing, you wash your hands when medically appropriate to prevent facility acquired infections. If you don't you are progressively warned ultimately leading to termination and/or loss of license. If instituted nationally this alone would save at least 5,000 lives a year. Good luck getting it instituted at most facilities." Sad thing is most staff in hospital doesnt wash hands. Reality is it would cost so much time. Handwashing is like a minute and staff has to go in an out of rooms where hand washing is needed so many times an hour it would slow everything down. And then trying to fire staff about this is not real because this would kick out half of it and it isnt replaceble. The problem is more why has staff to get in and out of stations so frequently. And multiresitence bacteria.
- kurthr 3y ago
  I'm always terrified to see surgical caps and such on doctors in a hospital cafeteria. Also a nurse or surgeon wearing scrubs on public transit. Whether they're coming into work and carrying unknown filth into the facility, or leaving with deadly resistant hospital pathogens on high density transport... they're both terrible. Unless you're outpatient, don't wear scrubs to/from work. Don't be Dr Oz wearing your status on your shirt sleave for giggles while risking patients and public.
- naasking 3y ago
  > Handwashing is like a minute and staff has to go in an out of rooms where hand washing is needed so many times an hour it would slow everything down. Sounds like the workflow is poorly designed then. Use gloves instead of hand washing.
- duffpkg 3y ago
  Specifically with handwashing which is a problem I have been very successful at solving, time is not the main factor. It is wear and tear on the hands and this comes down to the soap used and water quality, really. If you get those too things right people mostly find it no problem to wash their hands when appropriate. Also for non-medical people this is not washing your hands before surgery washing, this is routine washing between patients, bathrooms, and duties. Regarding gloves, gloves don't solve disease transmission from dirty hands. You need both hand washing and gloves.
joenot443 3y ago
McDonald’s menu is enormous, much larger than In n Out. If you’ve ever worked in the quick service food industry (it sounds like you haven’t), you’d know this considerably affects how every facet of the restaurant functions. I also completely disagree that In n Out is “dramatically better” and I’d be very surprised if that was the resounding opinion across Americans. It is fine, but again, it serves a different purpose, so making such broad apples-to-apples comparisons seems a little short sighted. “Competence in operations” is a nice sound bite but without some real examples related to restaurant management I’m just not convinced. I ensure you that it has indeed come up in a McDonald’s boardroom that raising their wages would result in more competitive hiring, that is not a novel observation. I did three years at McDonald’s and another several at other restaurants; admittedly it doesn’t sound like this comment was made from a place of experience, more a place of convenient idealism.
- addicted 3y ago
  In-n-Out tastes basically like McDonalds. I don’t understand the people who rave about it. There’s very little difference other than the fact that they have a “secret” menu with their own coded language.
  - nijuashi 3y ago
    You should eat more junk food ;) I’ve been to both good and bad McDonalds. Burgers and fries from well-run ones can taste very good. In-n-Out has better consistency, and it’s on par with the quality of well-run McDonalds. It’s probably due to the fact that In-n-out has fewer items? I don’t know.
    - selestify 3y ago
      Huh. I like the slightly toasted bun and the generous amount of veggies they put in the Inn n Out burger. I’m not aware of a similar looking or tasting burger on the McDonald’s menu.
- a2tech 3y ago
  Also don’t forget scale—-in/out might have ‘dozens’ of restaurants but McDonald’s has ‘thousands’. They also have software that was developed entirely in house that is unbelievably optimized. Weird, but usable. They are a company that fully understands the problem space they operate in. Hospitals should be doing everything they can to run like them but no one likes to hear that.
astura 3y ago
> customers rate the institution as one of the most beloved in american life. That's a bit overstated, the majority of Americans haven't been to an In-and-Out, ever, because they are a mostly-California chain. They're only available in a very small handful of states. In-and-Out can probably run so efficiently because their menu is extremely tiny.
usrusr 3y ago
That diesel maintenance example gets even more interesting when read through the lense of the ongoing Boeing threads: there, consensus is that the root problem is authority erosion for the core discipline: in old Boeing, engineering was a requirement for responsibility, but that is gone. In hospitals, the core discipline still holds on, but the blanket implicitness (or is it already a struggle? "we can't give up the diesel!"?) leads to terrible outcomes as well. Extremes rarely end well.

deadmutex 3y ago

Can you please add more details/examples? The current responses seem to be a bit broad/vague to follow. E.g. what are your recommendations? pay staff more? i.e. increase doctor pay?

ako 3y ago

I'm from Europe, have never heard of In-N-Out before, don't know how they work, nor the quality they provide...

vinay427 3y ago
Respectfully, I’m not sure what you are asking for. In-N-Out is only in a small fraction of the US so most people from the US wouldn’t know much about it either. I believe that’s why the GP comment provided a little more context which was more or less sufficient for me to understand the comparison.
- ako 3y ago
  Initially the In-N-Out example was made without explaining what it is, and even with the added context i think it doesn't really explain how In-N-Out differs from McDonalds. Their operations are better, what does that mean, how does that impact customers, how does that impact cost, etc.
  - bogwog 3y ago
    If you ever go to one, you'll understand. They're like the Rolls-Royce of fast food burgers.
    - philwelch 3y ago
      I’ve been. It’s nothing special.
    - Nexxius 3y ago
      I wouldn't say Rolls-Royce, more like Lexus. Fuddruckers would be closer to Rolls quality as they actually allow for something other than well-done, preformed, meat pucks.
- bombcar 3y ago
  In-n-Out has saturated the southwestern coast, which is a pretty significant fraction of the United States. The key is they have an absolute ton of employees in the restaurant (a busy McDonald’s might have four or five, In-n-out can have double or triple that. I’ve seen other fast food with two employees, never an In-n-Out) and they work exceptionally hard on specific tasks. They also only deploy in areas where they’ve determined they’ll be able to keep the store busy enough.

msteffen 3y ago

Some of these suggestions seem like non-trivial management problems, though, I think? Diesel fuel and generator maintenance: how do you hire for that? Does that position require experience? In what? Where do you post that job ad to get qualified candidates? If you hire wrong, it seems like the results could be worse than foisting the task on a doctor, no? Revising formularies: how many doctors at a hospital have the right expertise for that? Who cares for their patients while the formulary work is happening? Can you hire someone temporary to come do it so it doesn’t disrupt operations, and how expensive is that person and how good is the result? I’m a software person, not a doctor, but I _can_ see how these choices would be made if the alternative seemed riskier to someone inexperienced at hiring for hospitals.

pjc50 3y ago
> Some of these suggestions seem like non-trivial management problems, though, I think? Yes, that's the discipline called "operations". Crucially it's a separate set of skills from anything one might learn in medical school.
CommieBobDole 3y ago
>Diesel fuel and generator maintenance: how do you hire for that? This is typically part of the job of a facilities manager, someone who is in charge of maintaining the physical structure and amenities of a building or complex of buildings. You hire for it the same way you hire for everything else; you find someone in the category that you want, who has apparent success doing something similar to what you're doing.

Naijoko 3y ago

"Responding to the request below for a specific example. Hand washing, you wash your hands when medically appropriate to prevent facility acquired infections. If you don't you are progressively warned ultimately leading to termination and/or loss of license. If instituted nationally this alone would save at least 5,000 lives a year. Good luck getting it instituted at most facilities." Sad thing is most staff in hospital doesnt wash hands. Reality is it would cost so much time. Handwashing is like a minute and staff has to go in an out of rooms where hand washing is needed so many times an hour it would slow everything down. And then trying to fire staff about this is not real because this would kick out half of it and it isnt replaceble. The problem is more why has staff to get in and out of stations so frequently. And multiresitence bacteria.

kurthr 3y ago
I'm always terrified to see surgical caps and such on doctors in a hospital cafeteria. Also a nurse or surgeon wearing scrubs on public transit. Whether they're coming into work and carrying unknown filth into the facility, or leaving with deadly resistant hospital pathogens on high density transport... they're both terrible. Unless you're outpatient, don't wear scrubs to/from work. Don't be Dr Oz wearing your status on your shirt sleave for giggles while risking patients and public.
naasking 3y ago
> Handwashing is like a minute and staff has to go in an out of rooms where hand washing is needed so many times an hour it would slow everything down. Sounds like the workflow is poorly designed then. Use gloves instead of hand washing.
duffpkg 3y ago
Specifically with handwashing which is a problem I have been very successful at solving, time is not the main factor. It is wear and tear on the hands and this comes down to the soap used and water quality, really. If you get those too things right people mostly find it no problem to wash their hands when appropriate. Also for non-medical people this is not washing your hands before surgery washing, this is routine washing between patients, bathrooms, and duties. Regarding gloves, gloves don't solve disease transmission from dirty hands. You need both hand washing and gloves.

joenot443 3y ago

McDonald’s menu is enormous, much larger than In n Out. If you’ve ever worked in the quick service food industry (it sounds like you haven’t), you’d know this considerably affects how every facet of the restaurant functions. I also completely disagree that In n Out is “dramatically better” and I’d be very surprised if that was the resounding opinion across Americans. It is fine, but again, it serves a different purpose, so making such broad apples-to-apples comparisons seems a little short sighted. “Competence in operations” is a nice sound bite but without some real examples related to restaurant management I’m just not convinced. I ensure you that it has indeed come up in a McDonald’s boardroom that raising their wages would result in more competitive hiring, that is not a novel observation. I did three years at McDonald’s and another several at other restaurants; admittedly it doesn’t sound like this comment was made from a place of experience, more a place of convenient idealism.

addicted 3y ago
In-n-Out tastes basically like McDonalds. I don’t understand the people who rave about it. There’s very little difference other than the fact that they have a “secret” menu with their own coded language.
- nijuashi 3y ago
  You should eat more junk food ;) I’ve been to both good and bad McDonalds. Burgers and fries from well-run ones can taste very good. In-n-Out has better consistency, and it’s on par with the quality of well-run McDonalds. It’s probably due to the fact that In-n-out has fewer items? I don’t know.
  - selestify 3y ago
    Huh. I like the slightly toasted bun and the generous amount of veggies they put in the Inn n Out burger. I’m not aware of a similar looking or tasting burger on the McDonald’s menu.
a2tech 3y ago
Also don’t forget scale—-in/out might have ‘dozens’ of restaurants but McDonald’s has ‘thousands’. They also have software that was developed entirely in house that is unbelievably optimized. Weird, but usable. They are a company that fully understands the problem space they operate in. Hospitals should be doing everything they can to run like them but no one likes to hear that.

astura 3y ago

> customers rate the institution as one of the most beloved in american life. That's a bit overstated, the majority of Americans haven't been to an In-and-Out, ever, because they are a mostly-California chain. They're only available in a very small handful of states. In-and-Out can probably run so efficiently because their menu is extremely tiny.

usrusr 3y ago

That diesel maintenance example gets even more interesting when read through the lense of the ongoing Boeing threads: there, consensus is that the root problem is authority erosion for the core discipline: in old Boeing, engineering was a requirement for responsibility, but that is gone. In hospitals, the core discipline still holds on, but the blanket implicitness (or is it already a struggle? "we can't give up the diesel!"?) leads to terrible outcomes as well. Extremes rarely end well.