EL: That is absolutely correct. Moreover, I would say that’s not an intervention. That is the intervention. We have only two options. The first option is to provide excessive resources to staff at the peak level, which no hospital in the world has resources to do. The other choice is to staff below the peak level, a pivotal way of staffing hospital wards today. Typically, we staff them at the average level that has been documented historically from the last year. About 10 years ago, we received a grant from the Robert Wood Johnson Foundation to study two community and two academic hospitals, and we found that ward bed occupancies changed every hour, if not every half hour. There is absolutely no way that one may have a pool of nurses dynamic enough to address heavy peak volumes because nurses do not live in the hallway to address every hour or half-hour change in the census.

PV: In the places where you helped to implement smoothing of the elective schedule, what was the end result?

EL: The end result was huge, both financial and quality wise at every hospital. Cincinnati Children’s is probably one of the most impressive examples. When we started working with them on smoothing, their census was at the 76 percent level. In order to address peaks, they planned to build a new tower for $100 million in capital costs. Each bed in the United States, in terms of the capital cost, varies from $1.5 million to $3 million in capital cost alone. Plus, the annual operational cost per bed is at least half a million dollars. At the end of our smoothing project, they abandoned their plan to build the new tower. The average census reached 91 percent, a 15 percent increase. Their surgical volume increased dramatically without capacity issues because when we cut off the peak, we filled up the valley. It’s not just the peaks that create quality consequences; when we have those valleys, that’s a waste of our resources. Their surgical volume dramatically increased, and according to their report, their margin improved by over $100 million a year. It’s not just $100 million in avoided capital cost; it’s an additional over $100 million a year margin improvement and quality improvement.

PV: I understand that hospitals had had significant problems with boarding in the emergency department that also disappeared as soon as they smoothed their capacity.