The Cath Lab Is Empty at 2 AM

Last Friday at 7 AM, I sat in on an educational meeting at a community health system in the Pacific Northwest. Three clinical service lines presented to the governing board: cardiology, musculoskeletal, and gastroenterology. Each brought data. Each brought sharp leadership. Each delivered the same message.

We need more space.

Cardiology said it first and said it plainest. Demand is growing. The cath lab is booked solid during the day. Procedure rooms are full. Offices are packed. If they want to serve more patients, they need to build.

MSK said it. Gastro said it. Three departments, three presentations, one conclusion: the walls are the problem.

Then one of the commissioners, an ER physician, asked a question. What happens in those rooms after hours?

The cardiology director gave an honest answer. The rooms are available. Staffing them outside normal hours is the real problem.

That exchange lasted maybe ninety seconds. It deserved ninety minutes. Instead, the meeting moved on.

What Nobody Said

The cath lab is empty at 2 AM. It is empty at 10 PM. It is empty most of Saturday and all of Sunday. The same is true for the endoscopy suites and the orthopedic procedure rooms.

This is not unusual. Published data says it is the norm.

The OR Benchmarks Collaborative studied 134 U.S. facilities and found median prime-time utilization of 75.3 percent.¹ But prime time itself is only about 40 to 50 hours of a 168-hour week. Run the math and operating rooms are actively in use roughly 18 percent of available hours. Plante Moran, a perioperative consulting firm, reported that typical utilization in well-performing organizations runs 50 to 60 percent of prime time², which drops actual use to 12 to 15 percent of the week.

Cath labs are similar. MedAxiom, the ACC-affiliated benchmarking group, targets 80 to 85 percent utilization during staffed hours. A case study at Deborah Heart and Lung Center documented actual utilization of 65 percent before a major improvement effort.³ On a full-week basis, a typical community hospital cath lab is performing procedures about 17 percent of total available hours.⁴

Endoscopy suites may be worse. A study of actual room activity found that non-procedure time consumed two-thirds of the staffed day.⁵

A 2011 paper in the Journal of General Internal Medicine said it directly: hospitals suffer from inefficient use of capital investments during nights and weekends, with procedural spaces at or above capacity during the week but underutilized on weekends.⁶

These are multimillion-dollar clinical spaces sitting dark for roughly three-quarters of every week. That is the fact. Three service lines are asking for tens of millions in new construction to solve a problem that might be addressed, at least in part, by using what they already have.

Why the Meeting Moved On

I want to be clear about something. I am not describing a failure. The people in that room are accomplished, dedicated, and sharp. The leadership at this health system is strong. The commissioners are engaged. The clinical teams are excellent. Nobody made a mistake.

What happened is something more interesting than a mistake. It is a pattern I have seen in every organization I have worked with in thirty years of systems consulting, and I think it has deep roots in how human beings are built.

The commissioner asked the right question. The director gave an honest answer. And then the room faced a choice that nobody explicitly made. They could follow that thread, into staffing models, shift structures, compensation, union agreements, nursing availability, physician preferences, patient expectations, or they could return to the original framing and keep moving through the agenda.

They returned to the original framing. Every group I have ever watched does the same thing at the same moment.

Here is why I think that happens.

Tribes

Years ago I read a book called Great Boss, Dead Boss by Ray Immelman. It changed how I see organizations in a way that was comparable to what Eli Goldratt’s The Goal did for how I see systems. Immelman’s argument is that organizations are tribal structures. Not metaphorically. Literally. Human beings form tribes, and organizations are layered hierarchies of tribes.

A hospital has many tribes. The cardiologists are a tribe. The nurses are a tribe. The OR staff, the facilities team, the finance department, the board of commissioners, each one is a tribe with its own shared assumptions, its own norms, its own sense of what is settled and what is open for discussion.

Tribes are functional. They are how human beings organize to get things done. The cardiologist does not re-derive the Monday-to-Friday staffing model every morning. Within her tribe, that is settled. She can focus her energy on patients because a thousand background assumptions are maintained by the group. That is the whole point of a tribe.

But here is the problem. The question the commissioner asked, what happens in those rooms after hours, does not live inside any single tribe. The answer involves nursing, HR, finance, the union, the medical staff office, facilities, and probably others. It crosses tribal boundaries. And when a question crosses tribal boundaries, something predictable happens.

Each tribe instinctively protects its own assumptions. Not out of selfishness. Not out of politics. Out of the same instinct that makes the tribe functional in the first place. The assumptions are load-bearing. If you start questioning whether Monday-to-Friday daytime staffing is the right model, you are pulling on threads that run through the entire fabric of how that tribe operates. People feel that, even if they cannot articulate it. And they pull back.

So the group converges on the assumption that feels safe to all tribes: we need more space. Space is concrete. Space is nobody’s fault. Space does not require any tribe to reexamine its own norms. A building project is complicated, but it is a kind of complicated that every tribe knows how to manage.

What I Am Calling Assumption Space

I have been thinking about this pattern and I want to give it a name. I am calling it Assumption Space.

In any complex problem, there is a set of assumptions that people are working from. Some are explicit. Most are not. In a meeting, a group can comfortably examine maybe one or two assumptions at a time. If someone tries to open three or four at once, the conversation gets overwhelming fast. People lose the thread. Energy drops. Someone suggests tabling the discussion.

This is not a character flaw. It is how we are wired. Our brains run a cost-benefit calculation on open questions that we are not even conscious of. When a line of inquiry branches into six sub-questions, each of which branches into six more, something in us says: this path is expensive and the payoff is uncertain. We close it down and return to familiar ground. On an evolutionary basis, this makes perfect sense. We do not waste cognitive energy chasing every thread to its end.

The result is that there is a depth of inquiry that human groups reliably reach and then stop. Not because they choose to stop. Not because they lack intelligence or courage. Because they hit a structural limit on how many open assumptions a roomful of people can hold at the same time.

I think this explains something that has puzzled me for years. I work with good organizations. Smart people, strong leadership, genuine commitment to doing the right thing. And yet they get stuck on problems that, from the outside, seem like they should be solvable. The space utilization issue is a perfect example. The data is not hidden. The commissioner saw it in real time. The director confirmed it out loud. The math is not complicated. And yet nothing changes, because the path from seeing the problem to solving it runs through territory that the meeting format and human cognitive limits cannot reach.

An Honest Question

I am a systems consultant. I have spent thirty years working on problems like this, in medical devices, in embedded systems, in healthcare operations. I learned the Theory of Constraints from Eli Goldratt’s conferences and his published works. That training gave me a way of seeing systems that I have never been able to unsee.

But I am also aware that I could be wrong about this. One of Eli’s final recommendations was to “Never say ‘I know.’” So I don’t. I am one person sitting in a meeting, watching a pattern, and trying to make sense of it.

So here is what I am asking.

If you work in a hospital, a health system, or any complex organization: does this match what you see? Do you recognize the moment where the right question gets asked, an honest answer comes back, and then the meeting moves on? Do you see the tribal dynamics, not as politics, but as the natural behavior of groups protecting their shared assumptions? Do you feel the limit I am describing, where the inquiry gets to a certain depth and then stops?

I think there are things that can be done about this. I am not guessing. I am working on it. But before I go further, I want to know if the problem I am describing is real for you, or if I am seeing something that is not there.

I welcome the pushback as much as the agreement. Both help.

You can reach me at john@common-sense.com.

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Footnotes

1. OR Manager, “OR Benchmarks Collaborative” (2012). Data from 134 U.S. facilities. PDF ↩

2. Plante Moran, “Key Metrics to Improve Your Operating Room Utilization” (2019). Link ↩

3. Cleveland Clinic ConsultQD, “Collaborative Alliance Yields Cath Lab Efficiencies for a New Jersey Hospital” (2022). Link ↩

4. Calculated from typical staffed hours of 45/week at 65% utilization = ~29 hours, or 17.4% of 168 total weekly hours. ↩

5. Yang et al., “A Patient Flow Analysis: Identification of Process Inefficiencies and Workflow Metrics at an Ambulatory Endoscopy Unit,” Endoscopy International Open (2016). PubMed Central ↩

6. Wong and Morra, “Excellent Hospital Care for All: Open and Operating 24/7,” Journal of General Internal Medicine (2011). PubMed Central ↩