PV: So your first assumption was that this was due to influx of emergency patients?

EL: Absolutely. It was based on the common sense for two reasons: First, the volume is the highest among all admits, and second, it’s unpredictable by its nature. Elective admissions are smaller in terms of the volume, and their schedule is up to us. Unfortunately, our health care delivery is not always based on common sense.

PV: What did you find?

EL: It was impossible for Dr. Long and me to get the data from emergency departments. Nobody wanted to share the data with us. However, we were able to get the data from one operating room. Two transparencies were on the desk in front of us. One of them was bed occupancy, and the other was surgical volume. We found they were overlapping. They had about the same shape. So if you put it up to the window glass and overlap one over another to compare, we found that they practically coincided. That was for me a real aha moment: Emergency department admissions had very little to do with variability. Since then, for years I have talked to many hospital emergency department leaders asking, “Five Tuesdays from now, short of a bus crash or flu epidemic, could you predict approximately how many patients are going to be admitted to your emergency department?” The answer was always yes. Then I asked many operating room managers the same question: “Five weeks from now on Tuesday, how many surgeries are you going to perform?” Given that typically over 70 percent of all surgeries performed are elective, I was very surprised to find out that people cannot answer this question. That, to me, was clear evidence regarding the source of this variability. Of course, this was not just the surgical admissions. This is true for the other elective admissions, eg, cath lab.

PV: Do you find this to be true at most institutions?

EL: Practically everywhere. In dozens of hospitals where I asked this question, the answer was the same. It’s not just in the United States. It’s true in Europe, Canada, you name it. It looks like an international plot against health care cost and quality and the main driver of capacity problems.

PV: In response to this, there were three things that were implemented that we refer to as smoothing: separating out the emergency surgical flow from the elective surgical flow, smoothing the number of surgeries over the week, and also smoothing them to predict the number of ICU beds needed.