The Cost of Taking Reservations

Why hospital leadership should eat out more often.

During college I worked at a hip local restaurant.  A staff pet peeve was when walk-in customers would respond to a long wait time by smugly pointing to an empty table and declaring “what about that, why can’t we sit there”?  We would have to resist the sarcastic response of “Oh, I failed to see that table.  Of course you can sit there.  Thank you for being so much better at my job than I am!”  What we had to say instead, very politely, was “That table is for someone with a reservation”.

This local restaurant had sales under $1 million but was doing something that many billion dollar hospitals seem to have difficulty with – setting aside resources for anticipated scheduled demand. 

Hospitals know weeks in advance about inpatient elective surgeries, yet as these patients are being wheeled out of the OR, they often have to wait for beds in the same queue as patients in the ED.  These patients are boarded in the PACU, or worse, they are boarded in the actual OR with the surgical team administering post-operative care instead of prepping the next patient.  These elective patients are not a surprise visit.

Let us be reasonable about this metaphor – hungry walk-in diners are not harmed if their wait time is increased because an empty table is set aside to honor a reservation.  Restaurants also operate in a first-come first-serve basis – they don’t triage really really really hungry people to the front of the line (but there are times this would really be nice).

But the metaphor is also instructive.  The restaurant business is extremely competitive and operates on very thin margins.  The cost of food, rent, and staff is only a sliver behind income.  Even popular crowded restaurants can lose money if not well-managed.  Therefore, it must have taken fortitude for the restaurant owner to look at that empty table on a busy night and not fill it.  Maybe the last three nights were slow?  The temptation to fill that table was very real.  What if the reservation doesn’t show?  When should the table finally be released?

Hospitals are operating in a similarly competitive environment with growing patient choice for elective surgical procedures.  A hospital has the opportunity to provide a consumer-friendly service by streamlining the care of elective patients.  This means understanding demand patterns in the ED and implementing strong management of elective OR resources.  It is impossible to eliminate edge cases where ED demand causes elective surgeries to be cancelled or EDs to be diverted.  But with proper understanding of historical demand patterns, hospitals can plan for this to happen a certain number of times each year and be ready when an elective case does have to be bumped or the ED does have to be closed. These events will happen with regularity that can be mathematically modeled and forecasted. 

Finally, we have seen client hospitals that are disciplined about setting aside ICU beds for major surgeries that will require ICU care after surgery.  These surgeries are more likely to be cancelled if an ICU bed cannot be guaranteed after surgery, and a reserved ICU bed is less likely to be opened for an ED patient.  We’re heartened to see this precedent and hope to see this behavior for all beds not just the most acute.

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