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Imagine seeing a patient who drinks excessively, eats only foods high in saturated and trans fats, never exercises, and ignores prescribed medications — yet constantly complains that he doesn’t feel well. The advice would be obvious: change those behaviors.
In many ways, U.S. health care delivery resembles this person. For decades, we have documented systemic problems, like unsafe staffing ratios, medical errors, clinician burnout, and rising costs. Yet we continue to operate hospitals in ways that predictably produce these outcomes.
More than 25 years ago, researchers proposed a practical solution to one of the core operational problems — highly variable patient demand. The intervention, known as smoothing elective hospital admissions, simply distributes scheduled admissions, mostly surgical, more evenly rather than concentrating them early in the week.
The logic is straightforward. Emergency admissions occur randomly. Elective admissions are scheduled. When hospitals cluster large numbers of elective cases on certain days — most commonly Monday and Tuesday, to spare doctors from coming in on the weekend to check on their patients — they create artificial surges in patient demand. Those surges overwhelm inpatient units, intensive care beds, and operating rooms. The consequences ripple throughout the hospital.
Every hospital that has implemented smoothing elective admissions has reported dramatic improvements. (It is impossible to find out how many hospitals have implemented it, but it is definitely the minority.) These include major reductions in emergency department (ED) boarding, which is one of the most persistent and dangerous problems in American health care. This intervention has been widely credited among the most effective operational strategies to reduce ED boarding.
The benefits extend far beyond the emergency department. Hospitals implementing this approach have reported safer patient-to-nurse ratios, fewer medical errors, lower mortality, fewer readmissions, and faster access to surgeries. Clinicians also report significantly improved working environments.
The financial implications are equally striking. Hospitals that implemented smoothing elective admissions have reported millions of dollars in additional annual revenue. Cincinnati Children’s additional revenue exceeded $100 million. That’s primarily because operating rooms — the financial lifeblood of hospitals — can run more consistently, safely, and efficiently. Surgical case volume increases as operating rooms are less frequently underutilized due to postsurgical inpatient bed shortages that force case postponement. Surgeon, anesthesiologist, and nurse working environments improve, along with satisfaction. Why should children in Cincinnati have a better access to care than the others?
At one hospital, surgical volume increased by 7% annually for three consecutive years after implementing this approach.
Surgeons themselves turn out to be among the biggest beneficiaries. Contrary to the myth that smoothing elective admissions would disrupt surgical practices, the evidence shows the opposite. Surgeons gain more reliable and timely access to operating rooms. Their overtime declines significantly. Their patients are more likely to receive postoperative placement in preferred beds rather than being held in recovery areas. Urgent and emergent cases reach the operating room faster — an important lifesaving factor. And the ability to operate with stable, highly efficient teams of anesthesiologists and nurses improves.
Operating room nurses benefit as well. One hospital reported a 41% reduction in OR nurse turnover in a single year after adopting the approach.
These operational improvements translate into substantial national economic impact. The aggregate effect of smoothing elective admissions has been estimated to reduce overall U.S. health care spending by more than $200 billion annually — more than twice the savings projected from the widely discussed “Big Beautiful Bill,” and achieved without cutting Medicaid benefits.
Such savings could also have major implications for federal programs. According to projections from the 2025 Trustees Report, the Medicare Hospital Insurance (Part A) trust fund is expected to become insolvent by 2033. Reducing systemwide hospital waste at the scale demonstrated by this intervention could significantly prolong Medicare’s solvency.
The human impact would be even more important. When hospitals operate under extreme and unpredictable demand spikes, patient safety deteriorates. Intensive care units and wards struggle to maintain safe staffing levels. Emergency departments hold admitted patients for hours or days waiting for inpatient beds, surgeries are delayed, medical errors increase.
Hospitals that smooth elective admissions report meaningful reductions in mortality. For example, the Ottawa Hospital reported that in a single year the intervention was associated with 40 lives saved and $9 million in financial benefit. If each of the roughly 6,000 U.S. hospitals saved even 10% of that number, the result would be approximately 24,000 lives saved every year.
The intervention also addresses one of the most contentious issues in health care today: nurse staffing. Nurses across the country have protested unsafe staffing conditions, including recent high-profile protests in New York hospitals and within Kaiser Permanente. Legislators have unsuccessfully attempted to address the issue through mandated nurse-to-patient ratios.
There is a fundamental operational reality often overlooked in these debates: Safe staffing cannot exist when workload fluctuates wildly. If the number of patients in the ICU swings dramatically from day to day, hospitals cannot maintain consistent staffing ratios regardless of legislation. One day a unit might have five patients, the next day 10, which leads to patients are not being able to receive the ICU level of care they need. It is impossible to staff chaos.
Smoothing elective admissions stabilizes patient demand, making staffing needs predictable. Hospitals can then determine how many nurses, physicians, and beds are actually required. Without stabilizing demand, these calculations are nearly impossible. Legislating staffing ratios without addressing demand variability is similar to attempting to legislate that every American drive a Lamborghini. Good intentions alone cannot overcome operational realities.
When patient demand is stabilized, nurse workload becomes more predictable and sustainable. Hospitals that implement smoothing elective admissions have reported significant reductions in nurse turnover, which also reduces the costly reliance on traveling nurses.
In short, this intervention improves patient safety, clinician well-being, and hospital finances simultaneously — a rare alignment of incentives in health care.
The concept is not obscure. It has been the focus of two patient flow books from the Joint Commission. It has been endorsed by the National Academy of Medicine and recommended by the National Academies of Sciences, Engineering, and Medicine as a way to reduce the tragic waste of donated organs that cannot be transplanted due to operating room and ICU bottlenecks. After implementing this intervention, Toronto General Hospital “improved the predictability of resource availability for both scheduled surgical and organ transplant cases, resulting in a higher proportion of cases being performed within the target time with significantly fewer scheduled case cancellations. The development and implementation of the UHN-IHO system were associated with important quality improvements”. The intervention is also described in the book “Hospital Heal Thyself,” based on interviews with hospital CEOs, surgeons, emergency physicians, nurses, and patient advocates — all of whom support it.
Remarkably, in more than two decades since the concept was introduced, there has not been a single publication presenting evidence that the intervention is ineffective or harmful.
Yet despite overwhelming evidence and broad professional support, nationwide implementation has not occurred.
Why?
One explanation may be that many hospitals remain unfamiliar with the approach. Another possibility is that hospitals understand the concept but lack the technical expertise required for implementation.
If that is the case, federal leadership should help close the gap. The Centers for Medicare and Medicaid Services could support technical assistance programs or pilot implementations, beginning within the Department of Veterans Affairs or the Department of Defense hospital systems. In collaboration with the American Hospital Association, they can also choose some volunteering hospitals that are dedicated to implementing this intervention and provide the support for technical expertise to achieve this goal.
Absent such action, the alternative is familiar: continued national debate about overcrowded emergency departments, unsafe staffing levels, clinician burnout, rising health care costs, and fragile hospital finances — while a proven solution remains largely unused.
In the analogy at the beginning, the patient refuses to change behavior while wondering why their health does not improve. Our health care system is doing something similar.
Eugene Litvak is president of the nonprofit Institute for Healthcare Optimization and an adjunct professor at the Harvard T. H. Chan School of Public Health.
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