Designing Governance Boundaries for Hospital Bed Management: Balancing Centralized Pooling and Local Protection

Background/Objectives: Hospital-wide bed pooling is widely used in bed-management reform to reduce ward-level mismatch and improve the use of scarce inpatient capacity. However, formally pooled beds are not automatically usable beds. Cross-ward reassignment may require coordination, placement judgment, and timely execution, especially when several wards are under pressure. This study examines hospital bed governance as a healthcare management problem of where to draw the boundary between local protection and centralized pooling. Methods: We develop an α-based governance framework that places full decentralization, bounded centralization, and full centralization within a common design space. The parameter α determines how much ward-level capacity is pooled and how much remains locally protected. The analysis first establishes a frictionless pooling benchmark, and then introduces coordination friction, stress-state pooled-allocation imperfection, and the protective value of local capacity. Scenario-based computational experiments examine the mechanism across operating conditions, alternative friction specifications, and multi-ward extensions. Results: In the frictionless benchmark, full centralization weakly dominates because it has the broadest feasible allocation set. When pooled allocation remains fully effective, full centralization is not substantively outperformed. Coordination friction can move the raw maximizing boundary inward, but this movement does not necessarily imply a meaningful improvement over full centralization. When reassignment becomes less reliable in high-pressure states, however, an interior governance boundary can become substantively attractive by preserving some locally accessible capacity. Conclusions: The findings do not reject centralized pooling. They suggest that bed reform should evaluate both the formal scope of pooling and the operational usability of pooled capacity under pressure.