Although most hospital patients are admitted at night or on the weekend, they’re much more likely to die, experience surgical complications or suffer from medical errors than patients admitted during the day. Which is what led David Shulkin, the CEO of Beth Israel Hospital in New York, to begin prowling the corridors of his institution at midnight in hopes of better understanding — and correcting — what he calls the “stark discrepancy” between daytime and nighttime medical care.

Writing in the New England Journal of Medicine, Shulkin first blames stinginess by Medicare and private insurers:

Shrinking reimbursements from government programs and third-party payers make it economically prohibitive for many hospitals to fully staff their facilities 24 hours a day. (And that’s before one takes into account the millions of dollars in uncompensated care that hospitals provide.) Instituting longer hours for care providers is not a reasonable solution to the problem, since medical professionals who work for too long at a stretch become fatigued and make more errors. Another major obstacle is the nursing shortage. More-experienced nurses understandably choose desirable day shifts. As a result, night and weekend shifts are filled with a greater percentage of temporary or agency nursing staff, many of whom have less training and less familiarity with the hospital.

Of course, Shulkin can’t help working in the obligatory reminder that hospitals also spend a lot to cover the uninsured — for which, by the way, elite medical centers like Beth Israel are handsomely compensated by their nonprofit tax breaks.

Shulkin goes on to note a variety of measures that have improved matters somewhat:

Some teaching hospitals have mandated 24-hour coverage by attending physicians in key clinical areas, such as intensive care units — a move that has led to improvements in the supervision of residents. And off-hour coverage by hospitalists — salaried physicians who specialize in providing inpatient care — is more common than ever. System improvements, such as the deployment of rapid-response teams, are becoming more common, making lifesaving interventions accessible throughout a hospital. In addition, technological advances have led to improved outcomes and reductions in medical errors. Electronically monitored intensive care units and other strategies for remote monitoring create safety nets and permit better medical supervision, even when attending physicians are not present. Many hospitals have begun using digital and Internet-based methods to have imaging studies read during off-hours by radiologists in different time zones, and experienced physicians can now provide their medical-imaging expertise from home.

But even these steps haven’t done a whole lot to close the gap between daytime and nighttime hospital service. Shulkin endorses pay-for-performance measures that would reward doctors, nurses and other hospital staffers for improving patient outcomes during off-hours, as well as “consumer-friendly” steps such as a recent Massachusetts program in which 80 hospitals agreed to disclose their staffing levels at all hours.

Still, the best advice Shulkin offers to his fellow hospital administrators is a simple one: Get up and walk the wards at night. “There’s still a lot to learn and accomplish, but we can do it,” he writes. “We just have to be willing to get a little less sleep once in a while.”