Capacity, Time, and the Authority to Act

An open bed does not create an open path

A network dashboard shows 24 open beds. A sending facility needs an aggregate service category before midnight. One receiving site's acceptance window ends at 21:00. Another has space but no confirmed support team. A third can accept only if transport completes two cycles before a route restriction begins.

All four statements can be true. The network still does not have a settled capacity answer.

For health-system planning, capacity is a declaration that a defined service can be supported at a facility, in a stated interval, with the required staff, equipment, ancillary services, supplies, infrastructure, acceptance, and movement path. It is also governed: different people and institutions own the facility declaration, clinical judgment, incident strategy, transport assets, and any consequential action.

This paper separates two claims. Current regulation and program sources, together with explicitly dated ASPR-hosted guidance, establish selected responsibilities and planning factors for participating hospitals, health-care coalitions, incident coordination, and the National Disaster Medical System. Grid enters only as a proposition for connecting selected aggregate facts and evaluating predefined alternatives. None of the cited institutions describes, endorses, or validates Grid.

What official sources establish—and when

The hospital-specific CMS emergency-preparedness condition of participation requires an all-hazards program based on facility- and community-based risk assessments. The plan must address the patient population, services the hospital can provide in an emergency, continuity of operations, and collaboration with emergency-preparedness officials. Its policies cover evacuation transportation, staffing strategies, subsistence and power dependencies, and arrangements with other hospitals and providers to receive patients if operations are limited or cease. Its communication plan includes reporting occupancy, needs, and ability to assist to the authority having jurisdiction, incident command center, or designee.

That is a requirement for hospitals within the regulation's scope, not a universal capacity formula. The same section permits separately certified facilities in a health system to elect a unified program only under specified conditions, including facility participation and facility-specific risk assessments. A network view therefore cannot make each facility's circumstances disappear.

ASPR's current Hospital Preparedness Program page presents FY 2024–2028 cooperative-agreement materials and describes health-care coalitions as geographic networks of public and private health-care and response organizations that prepare and collaborate. ASPR also hosts the longstanding Medical Surge Capacity and Capabilities handbook. Its foreword places that revision in an earlier National Response Plan context, so this paper uses it as dated planning guidance rather than a current requirement. The handbook distinguishes capacity for increased volume from capability for unusual or specialized needs and organizes coordination across tiers. Its longstanding coalition companion says a coalition supports but does not supplant facility and jurisdictional response activities, and does not command its members.

The 2024 NDMS Federal Coordinating Center Guide offers a concrete federal planning example. Available beds reported by participating facilities include supporting space, equipment, medical materiel, ancillary and support services, and staff. The guide separately defines 24-hour throughput across reception, off-loading, staging, assessment, transport, and admission. Ground transport, critical-care equipment, reception staffing, processing time, operating windows, reset time, personnel sustainability, and route or airfield constraints can bind even when beds are reported.

Taken within their stated dates and scopes, these sources establish the need to plan across capability, coordination, movement, support, and time. They neither prescribe the model below nor establish clinical appropriateness, legal permission, or an operational result.

A healthcare-specific companion

Coordinate Health-System Capacity Without Assigning Clinical Authority is the applied operating guide for this planning model.

Capacity Is Not a Count provides a broad public-service frame across shelters, health care, transport, and government services. The Medical Plan Must Move examines defense and NDMS medical movement and sustainment. This companion narrows the question to a civilian health network: when does a facility-declared service remain usable through an acceptance window and a supported transfer path, and which authority owns each part of that conclusion?

It does not create a regional command layer. It asks whether the represented network plan is internally consistent before the responsible organizations act.

The network planning object

The permitted planning object is aggregate and category-specific. Its units must be defined by a qualified external process; unlike categories cannot be added merely because both are called beds or capacity.

• Service capability is a facility declaration for an aggregate service category, backed by the stated staff, qualifications, space, equipment, pharmacy, laboratory, imaging, oxygen or other supply, utilities, infection-control conditions, and support services.
• Demand window is an externally supplied aggregate planning requirement with an effective interval and uncertainty. It is not a forecast generated or validated by Grid.
• Acceptance window is the interval for which the responsible facility has declared that the represented capability may be considered in network planning. An expired window is not silently extended.
• Movement path connects origin, destination, transport mode, capacity per cycle, travel and turnaround time, handoffs, route state, and the receiving window. It establishes only an aggregate represented path.
• Sustainment state records the support facts and resupply gates that keep the capability valid through the planning horizon.

Each material input should carry a source, definition, revision, observation time, effective time, valid-through time, and supplied uncertainty or quality state. A facility may revise its declaration without changing its nominal bed count. A receiving window may close while staff remains present. A route may remain open while vehicle turnaround makes the last cycle too late. These are different facts and should remain separately inspectable.

Authority is plural

A useful model makes responsibility visible without attempting to infer it. The local authority matrix should identify at least four lanes.

Facility authority owns the organization's operational declaration: which aggregate services it represents as available, for what interval, behind which support conditions, and through which approved communication process. CMS's hospital governing-body condition places legal responsibility for the conduct of the hospital with its governing body and makes the medical staff accountable to it for quality of care. This paper does not interpret those provisions or assign a specific local role.

Clinical authority remains with appropriately qualified and privileged professionals operating under applicable law, bylaws, policy, and standards. They determine diagnosis, treatment, triage, clinical priority, suitability for an individual transfer, and the appropriateness of an individual destination. The aggregate planning model does none of those things.

Incident or jurisdictional authority establishes incident goals, strategy, public resource coordination, and other actions within its actual mandate. A coalition can share information and coordinate requests without becoming incident command or taking over a member facility.

Transport and support authorities control their assets and services. A modeled vehicle, oxygen delivery, laboratory service, staffing team, or mutual-aid resource is not committed until its responsible owner acts through the authorized process.

Grid occupies none of these lanes. A software role or green status cannot grant authority. Nothing here reaches a conclusion under EMTALA or any other law, resolves licensure or payment, compels acceptance or transfer, or changes command.

The Grid proposition

Grid proposes connecting the permitted aggregate facts as versioned dependencies. Configured sources can publish facility declarations, acceptance windows, demand windows, transport cycles, route states, and support gates. Authored rules can calculate separate, composable dimensions for a named horizon: feasibility may be feasible, infeasible, or unresolved; evidence may be complete or unresolved; and activation may be satisfied or conditional. One alternative can therefore be arithmetically infeasible while also relying on unresolved evidence or a conditional activation.

When an accepted fact changes, affected conclusions recalculate and explanations identify the material source and rule revisions. Coordinated views can show a facility its own declaration, a network planner the cross-site constraints, and a decision owner the same revision's unresolved gates. This is not automatic integration: source bindings, identities, units, timing behavior, interfaces, and failure handling all require configuration and testing.

The model does not predict demand, search for an optimal distribution, recommend an individual destination, assign a bed, prioritize a person, or initiate a transfer. It does not diagnose, triage, treat, allocate, or provide clinical decision support. It stops at the bounded aggregate status and reasons. External authorities decide whether to revise, authorize, reject, or defer an action.

Unknown stays visible

Network facts will be missing, stale, and contradictory. A capacity declaration may be current while its oxygen report has expired. Two systems may use different service-category definitions. A transport status may lack a turnaround time. A receiving facility may issue a correction after a coalition snapshot. A support team may be requested but not committed.

The model should preserve those conditions, not average them into confidence. An expired acceptance window, unverified support gate, or material source conflict should produce the authored unresolved or unavailable state. Sensitivity analysis can expose which assumption consumes the margin; it cannot make a stale fact current. When evidence is insufficient, refusal to conclude is a planning result.

Fictional Exercise NETWORK-27

This exercise uses invented facilities and abstract, aggregate service units. A unit is a category-specific planning counter, not a person, patient, bed assignment, diagnosis, acuity class, or clinical recommendation.

The baseline horizon is 18:00–24:00. An external exercise source supplies demand of 24 units. North declares 10 units, Central 8, and South 6, each initially valid through 24:00. The baseline arithmetic is therefore 10 + 8 + 6 = 24, with zero modeled margin. A manual baseline packet takes 31 minutes, nine rekeying steps, and two reconciliation calls; those are fictional fixture values to be measured again, not performance claims.

At 19:00, evaluators seed four failures. Demand rises by 6, so the new aggregate requirement is 24 + 6 = 30. Central corrects its acceptance valid-through time from 24:00 to 21:00. South's six-unit declaration remains on screen, but its oxygen fact expires and a support-team confirmation is missing. Reserve has a predefined 14-unit contingency, conditional on an external facility activation and acceptance declaration, support confirmation, and a movement path completed before 21:00.

Three authored alternatives make the arithmetic and the separate model dimensions inspectable:

Authored alternative	Exact represented arithmetic	Feasibility	Evidence	Activation and limiting condition
Carry the baseline	10 + 8 + 6 = 24; short 6	Infeasible	Unresolved	Central expires at 21:00; South support is unresolved
Add Reserve without restoring South	10 + 14 = 24; short 6	Infeasible	Unresolved	Reserve remains conditional on external activation, support, and movement
North, refreshed South, and activated Reserve	10 + 6 + 14 = 30; margin 0	Feasible	Complete only after exact-revision receipts	Satisfied only after responsible facility, support, route, and transport owners act
Same path after one cycle slips	10 + 6 + 7 = 23; short 7	Infeasible	Complete for the corrected fixture	One seven-unit cycle no longer fits before 21:00

Reserve's aggregate movement requirement is 14 units; the full fixture provides two transport cycles of seven, so 2 × 7 = 14 before 21:00. The favorable row is permitted only after the facility, support, route, and transport receipts for the exact revisions are supplied. The final row makes the time boundary explicit without turning the model into a dispatch instruction.

Receipts in this exercise record that a named external source reported a declaration, authorization, confirmation, delivery, or acknowledgment against a specific revision. They do not prove the report was correct, that a resource performed, that an individual was transferred, or that care or an outcome occurred. No modeled alternative directs patient-level action. Qualified facility, clinical, incident, transport, and support authorities retain every real decision.

Evaluate the planning claim, not clinical outcomes

Run the exercise first in the current workflow and then in the configured composition. Preserve the baseline packet, input fixtures, authority matrix, expected result for each case, and the revisions used. Seed an expired acceptance window, category mismatch, stale support fact, lost transport cycle, duplicate update, conflicting facility revisions, unauthorized status change, late correction, and missing acknowledgment.

Measure only bounded behavior:

• Time and manual steps from an accepted aggregate change to a stable represented network status
• Agreement with an independently prepared fixture oracle across the separate feasibility, evidence, and activation dimensions
• Stale, missing, conflicting, and wrong-category facts surfaced before a conclusion
• Explanations identifying each binding input, rule, window, and remaining margin
• Gates that block a favorable status until the configured external evidence arrives
• Receipts bound to the correct source, model, decision, and acknowledgment revisions
• Duplicate, out-of-order, superseded, and corrected events visible in replay
• Unauthorized model-state or release attempts refused inside the tested boundary

Predefine the denominator and pass criteria. Report failures and unresolved cases, not only successful runs. Repeat the same fixtures to test determinism, then change one fact at a time to confirm that explanations and affected conclusions change as expected.

The evidence ladder prevents a fixture from becoming a larger claim. Conceptual evidence explains the architecture. Illustrative evidence supplies invented scenarios. This paper is research-grounded because official sources establish the problem boundary, not Grid performance. Product-demonstration evidence requires inspectable behavior in declared fixtures. Customer-controlled evidence requires the responsible organization to control material data, environment, operators, and acceptance criteria. Independently validated evidence requires an appropriate independent method and stated scope.

None of these exercise measures establishes clinical decision quality, patient safety, prediction accuracy, optimization, legal compliance, accreditation, deployment readiness, resource activation, cost savings, service continuity, or health outcomes. Each requires different authority and evidence.

Make the window and the decision owner explicit

The practical next step is to trace one capacity correction through From a Changed Fact to Coordinated Action, record the model and authority boundary in the decision evaluation worksheet, and compare the proposition with Grid Developers' guidance for explaining and validating a changing decision and canonical examples.

A governed network plan should say which service is represented, where, through what window and supported path, from which evidence revision, and under whose external authority. Capacity, time, and authority belong in the same planning picture. They must not be collapsed into the same decision.