Surgical schedule smoothing works, and few hospitals use it

Smoothing the elective surgery schedule adds inpatient capacity without new construction, and Cincinnati Children's published its results in 2009. Yet in 2020 the Institute for Healthcare Improvement wrote that "in most hospitals, surgeons electively schedule surgical cases unevenly throughout the week."

Hospitals tend to blame crowding on unpredictable emergency arrivals. When hospitals measure it, emergency demand turns out to be fairly steady through the week. The elective surgery schedule, which the hospital controls, swings widely by day of week. A 2024 study of 1.7 million adult admissions at New York hospitals in 2015 found patient volume 21% above average on Mondays and 32% below average on Fridays, and its authors trace that swing mainly to elective admissions and to when patients are discharged. Because the hospital creates that variation, it can remove it.

Cincinnati Children's raised inpatient occupancy from 76% to 91% after it smoothed its elective surgery schedule. Surgical volume grew about 7% a year. A 2012 presentation by Eugene Litvak puts the result at $137 million a year, plus more than $100 million saved by not building 75 new beds, and cites Frederic Ryckman of Cincinnati Children's as its source.

Command centers can also add capacity without new construction. Johns Hopkins built a capacity command center and reported bed-assignment times down about 30% and delays in moving patients out of the operating room down 70%. By 2021 it counted the equivalent of 16 beds of capacity it never had to build.

Why adoption stalls

The barrier has been political. Smoothing means reallocating operating-room block time, the hours reserved for each surgeon or group, and for surgeons that time brings status, income and autonomy. The fix asks surgeons to change their week so that a unit two floors away has a calmer Thursday. In 2020 the Institute for Healthcare Improvement wrote that hospital executives need the authority to rein in special interests, such as those of surgeons, ED physicians and hospitalists, for flow work across the hospital to succeed.

Smoothing is a fix where the method is known and the hard part is getting people to adopt it. What stands in the way is mostly people's habits and how hospitals are run. A tool that shows each stakeholder their own tradeoffs, simulates alternatives on the hospital's own data, and shows everyone how block time is divided can turn a political fight into a scheduling decision.

Questions for any capacity project

Before your organization adds beds or blames the ED, answer three questions. How does day-of-week variation in the elective schedule compare with emergency arrivals? Which units reach unsafe occupancy, on which weekdays, and how often? Who measures this today? If nobody does, start there. In the Cincinnati Children's account, the 75 beds the hospital did not have to build would have cost more than $100 million. Kent Applied's Throughput Diagnostic, which measures how full each unit runs from 90 days of your EHR timestamps, is $14,500.