ACUITY

You are the chief executive of Orrington Memorial Hospital, a nonprofit community hospital with 500 licensed beds, a 1.8 percent margin, and 142 days of cash. Every quarter you decide who gets the next operating room hour, the next staffed bed, and the next nurse. The economics point to one patient, clinical urgency to another, and the mission to a third.

Orrington serves a catchment of 410,000 people and holds 24 percent of a regional market, second of four. Prentiss University Medical Center takes the complex cases you cannot staff, and the earnings per hour leave with them. Bellwether Health, a for-profit chain, runs at a cost index of 0.87 and publishes it. Tolliver County Hospital, the public safety net, takes what nobody else will until it runs out of room. In the third quarter Fulcrum Orthopedic and Spine Institute opens, takes the commercially insured elective work, and leaves you the obligation.

Each quarter you set nine inputs: operating room block hours across six service lines, how to fill the nursing gap with hires, agency staff, or overtime, a hiring plan that arrives eleven weeks later, the income level at which care is written off, and one improvement program. Once a year you take a payer contract stance and one portfolio move. The behavioral health unit can be reduced or closed, and most players decide that in year one and meet the consequence in quarter three, because three of the six service lines carry the institution and three are carried, and closing a carried line frees beds and nurses rather than operating room hours.

A scheduling assistant offers to allocate block time to maximize contribution per hour. It works, and it fills the rooms with insured orthopedic cases while it starves the emergency reserve and the behavioral unit, because nobody gave it a mission constraint. Four executives hold facts that you get only by asking, and you have two conversations a quarter. No score appears during play. The board review opens with a resident of the catchment and then shows four dimensions and a named end state, and a two-year epilogue shows the cost of every decision that looked free during play.