Mis en Place: from the Kitchen to the Operating Room

The late Anthony Bourdain once said, “Mise en place is the religion of all good line cooks. Do not f *** with a line cook's ‘meez’ — meaning his setup, his carefully arranged supplies of sea salt, rough-cracked pepper, softened butter, cooking oil, wine, backup, and so on.”

Thomas Keller, whose restaurant, The French Laundry, was among the first U.S. culinary establishments to receive three Michelin stars and who is one of a select few chefs to win this distinction simultaneously at more than one restaurant famously stated, “Mise en place is the key to cooking. It’s about preparation. It’s the most important thing that you learn in a kitchen.”

A beautiful course from the French Laundry

The traditional French concept of mise en place, translated as "everything in its place”, represents an essential element of a high-performing kitchen. You will not find a Michelin star awarded to a restaurant whose kitchen does not rigidly subscribe to this principle. Mise en place is a core element of efficiency, quality assurance and is vital to a low-margin industry - cost-effectiveness.

So what does this have to do with the operating room?

Well…if chefs - from line cooks to Michelin three-star maestros embrace this concept - why can’t we get it right in an arguably more important environment: the operating room, where the stakes are much, much higher?

In today’s OR’s, even basic procedures have high levels of complexity. Advanced procedures can present overwhelming complexity. To continue with the culinary analogy, we aren’t boiling pasta in surgical/procedural healthcare; we routinely execute seven-course meals with wine pairings.

In the kitchen, one has a detailed recipe. In the operating room, we have a physician preference card, detailing all of the items - with quantities - needed for a given procedure. And yet, all too often one encounters a situation of “rien en place”, or “nothing in place”. Staff have low confidence in the accuracy of physician preference cards and so surgical case preparation careens between “just in case (we need it)”, fear, and “this is what I remember using last time we did this”, rather than data.

The result is low efficiency, frequent preoperative and intra-operative delays, increased stress, staff burnout, and increased risk for patient harm. From the perspective of supply chain, we see bloated/insufficient inventory, opened-not-used waste (from the kitchen - think a pound of butter opened and an ounce used), poor contract compliance, and “trunk stock” - representing a “dark pool” of high cost.

If any environment could benefit from the culinary sphere’s devotion to mise en place, one might think, it is the operating room.

So why hasn’t this happened?

Uh…it’s complicated. No, seriously; that’s it. The operating room environment is really, really, super complex.

So, it’s really, really, super challenging to track, forecast, and foster cost-effective stewardship of supply utilization by physicians and staff with accuracy and precision. It is impossible to do this manually with any degree of resilience.

Enter today’s buzz-worthy digital savior - AI. Specifically, machine learning (ML) - a subset of AI that enables systems to learn from data, identify patterns (novel opportunities), implement statistical methodologies to validate data integrity, and improve system performance over time.

One could argue that it is the only path forward for meaningful management of the data disaster that is the operating room.

ML can be applied to existing utilization data sets to smooth and bolster data integrity, facilitating accurate accounting of historical trends and permitting forecasting of future demand signals.

This allows for right-sizing of inventory, minimization of open-not-used waste, optimization of contract compliance, and elimination of trunk-stock. These operational improvements lower costs and tighten efficiency.

And…this is not future, but current state! This is happening. If you’re not using a tailored platform to analyze and optimize surgical/procedural supply utilization, your system is bleeding cash - day-by-day, month-by-month, year-by-year, to the tune of 7-to-8 figures for most medium-to-large IDN’s.

If that doesn’t work, you can always hire that angry, red-faced celebrity chef who is always yelling at everyone to come in and right your ship!