Working at the Top of Your License

The CEO had a name for it.
So does almost every healthcare leader we’ve ever worked with.

Every day, problems that should have been resolved “two levels down” were arriving on senior leaders' desks. Decisions were stacking up and priorities were multiplying. And despite enormous investments in new initiatives, all-hands training programs, strategic planning exercises, and executive coaching the organization wasn't converting effort into outcomes.

This is a story about why, and about what it takes to change it.

The Problem

The CEO had a word for it: "whack-a-mole."

When The Outcomes Institute began working with this health system, what we found was recognizable. In fact, it is the reality we encounter in health system after health system across the country.

At the leadership level, senior leaders were skilled, experienced, and well-intentioned - but they were operating as a collection of individuals rather than a cohesive team. Decision-making under pressure was reactive. Accountability conversations were uncomfortable and inconsistent. The culture of the team didn't yet match the ambitions of the organization.

At the organizational level, work in progress was invisible. Each executive maintained their own priority list, but these weren't shared, centralized, or aligned. Success was measured by activity - meetings held, initiatives launched, reports submitted - rather than by outcomes. A single physician spent the better part of a year cycling through committees seeking approval for a sensible, necessary initiative, only to return to the starting point with no resolution and no clarity.

Authority sat at the top. Decisions that belonged closer to the point of care kept traveling upward, creating bottlenecks that exhausted leaders and frustrated the people waiting on them. 

"I knew we were working hard," the CEO reflected. "What I wasn't sure about was whether we were working on the right things - and whether any of it was actually moving us forward."

The leadership team had begun investing in executive coaching. A training initiative targeting mid-level leaders was in the early stages of development. These were the right instincts. But they weren't going to be enough on their own - and everyone, if they were honest, knew it.

The Insight

There is a concept in clinical practice that most healthcare leaders know intuitively: practicing at the top of your license. It means deploying your training, your expertise, your judgment at the level it was built for - not getting pulled down into work that belongs somewhere else.

We believe the same principle applies to leadership.

When the systems underneath a leadership team are broken - when decisions travel upward unnecessarily, when priorities are invisible, when there is no shared language for progress - even the most talented leaders can't practice at the top of their licenses. They're too busy managing what the system should be managing for them.

A longtime colleague who lived this exact reality at his own organization put it plainly when we described what we were building here: "What you're describing is the reality for 90% of healthcare organizations in this country."

This is why leadership development alone, as essential as it is, rarely delivers its full promise in health systems. Coaching can change how leaders think and relate to one another. It cannot, on its own, redesign how decisions get made or how work gets done. For that, you need an operating system.

And you need both working together.

The Solution: Two Tracks, One Transformation

The Outcomes Institute brought two parallel workstreams to this engagement.

Track One: Leadership Team Health

We began with the team itself. Using behavioral analytics and structured one-on-one and team coaching, we helped the senior leadership team develop a clearer, more honest picture of how they were actually functioning - not how they hoped they were functioning.

The work surfaced what the data almost always surfaces in high-pressure leadership teams: the patterns that emerge under stress, the default behaviors that short-circuit real dialogue, the unspoken agreements that protect comfort at the expense of accountability.

Over time, the team built new norms. Harder conversations became more possible. Accountability became less personal and more structural. The CEO, a physician by training, began approaching leadership with the same rigor he brought to clinical decision-making.

"I've been in enough leadership programs to be skeptical," one senior leader said. "This was different. We weren't talking about leadership in the abstract or as an academic concept. We were working on how we actually lead - with each other, in real time."

Track Two: Operating System Design and Build

In parallel, we began the slower, more structural work of designing and building an operating system for the organization.

An operating system, in the way we use the term, is the set of structures, rhythms, and disciplines that govern how a leadership team makes decisions, selects and manages its work, tracks progress, and communicates what matters. It is the difference between a team that works hard and a team that works aligned.

For this health system, that meant four things.

Portfolio management. Before this work, every executive kept their own list. There was no shared, centralized view of what the organization was actually working on - which meant no real ability to make informed choices about where to focus. We built one. For the first time, the leadership team could see their collective workload, identify redundancy, and decide together what to pursue and what to set down.

Decision architecture. Approval loops that had slowed execution for months were eliminated or restructured. Authority was moved closer to the point of work. A committee landscape bloated with redundancy was streamlined. Decisions that had been traveling upward by default started landing where they belonged.

A shift from activity to outcomes. New accountability metrics, built around results rather than effort. Leaders who had been measuring success by what was launched began measuring it by what had changed. Executive communications were redesigned so leaders could speak with confidence about what was working, what wasn't, and what came next.

A new operating rhythm. A disciplined meeting cadence - weekly, monthly, quarterly - gave the leadership team a mechanism to assess, adjust, and realign rather than simply push harder. For an organization accustomed to urgency as a default setting, the quarterly strategic review became something genuinely new: a protected space to ask whether the direction was still right.

The Outcome

The work is not finished. Operating system builds take time - they require iteration, trust, and a leadership team willing to hold the discomfort of changing how they've always done things.

But the early signals are clear.

Decisions that previously stalled for months are moving. Leaders who previously operated in silos are working from a shared picture of organizational priorities. The CEO, who once described his organization as playing whack-a-mole, is beginning to see what it looks like when the moles stop multiplying.

More importantly, the leadership team is building something that belongs to them - not a framework that lives in a consultant's slide deck, but a way of working that will outlast the engagement.

"What's different now is that we have a language for it," the CNO noted. "When something isn't working, we can name why - and we know what to do about it."