Contributors: Peggy Loughery, MSN, RN, and Melissa A. Fitzpatrick, MSN, RN, FAAN
To learn more about Peggy and Melissa, click here.
In boardrooms across the country, a quiet but consequential shift is underway. Health systems are making fewer leaders responsible for more: more markets, more service lines, and more complexity than ever before. Recent industry analyses, including work from Deloitte on health system transformation, suggest that many organizations are reducing layers of management while expanding executive scope. Some senior leaders now oversee portfolios that are 2–3 times larger than they were just a decade ago, yet through the same period of time, executive titles haven’t changed dramatically. So, what has changed?
Expectations.
A chief operating officer who once oversaw a single hospital may now be accountable for performance across an entire region. A clinical executive who previously managed one service line may now influence system-wide strategy spanning multiple geographies. The scope has expanded, but the underlying leadership models often have not. And this is where the risk - and the opportunity - emerges.
The transformations we’re seeing in healthcare leadership are increasingly structural rather than incremental. Organizations are flattening while the executive span of control is expanding and rising to enterprise levels. As a result, what it means to lead is fundamentally changing.
Crucially, this change doesn’t mirror the rapid changes we saw over half a decade ago during the COVID-19 pandemic; the evolving leadership structures we’re seeing more and more of aren’t responses to margin pressures, workforce disruptions, or other external forces. Rather, they reflect a wholesale redesign of leadership itself, and it’s a change that’s going to shape how healthcare organizations perform for the next decade. And at the center of this shift is a fact so simple it becomes a stumbling block:
Leading at scale doesn’t require leaders with more experience. It needs leaders with different judgement.
Here, we’ll break down what you should know about this shift, what it means for leaders, and how your organization can get prepared.
Leading At Scale Demands A New Type Of Leader
For decades, healthcare executives were evaluated based on their ability to deliver results within a defined operational scope, typically a single hospital, campus, or service line. Success depended on direct oversight, deep functional expertise, and clear vertical authority.
That model is rapidly giving way to a new paradigm.
Enterprise leaders today are accountable for performance across multiple facilities, markets, and service lines. Their effectiveness depends less on direct control and more on their ability to align stakeholders, integrate operations, and drive outcomes across complex, matrixed environments. Leadership expectations have shifted from hands-on operational management to enterprise-wide prioritization, coordination, and influence.
This shift introduces a fundamental tension: leaders are responsible for broader outcomes while operating at greater distance from execution.
In practice, leaders need to operate with a different posture.
- Leaders must be influencers, not executors: Executives’ scope at the enterprise scale is too large to exert direct oversight without losing focus. They increasingly need to take on a director’s role and help create alignment within the organization, rather than being immediately involved themselves.
- Leaders must be politically savvy: As much as healthcare organizations try to eschew the politics that can envelop executive leadership, it’s often a reality that can't be avoided. Modern leaders at the enterprise level need to work with and through those informal and ambiguous blocs to effectively influence multiple regions and functions, regardless of their formal authority.
Decades ago, there was a perception that the best ICU nurses would naturally excel as nurse managers. As the healthcare sector learned through experience, that notion didn’t meet its expectations. The reality today is that larger spans of control often expose leadership gaps that were previously papered over by proximity and hands-on engagement, be that for a nurse in the ICU or a hospital COO. At the end of the day, the competencies that drive success locally might not get you over the finish line at the enterprise level.
Many Organizations Aren’t Prepared For Leadership At Scale
Much of the current focus in healthcare leadership centers on identifying individuals capable of operating at scale. However, a more fundamental issue often goes unaddressed, and that’s whether the organization itself is prepared to support scaled leadership.
This gap between leadership expectations and organizational design is one of the most significant risks facing health systems today. So, before expanding roles or appointing leaders to enterprise positions, organizations need to address foundational questions like the following:
- Are decision rights clearly defined across system and site levels? Things can go downhill quickly if a hierarchy is unclear between system- and hospital-level executives.
- Are success metrics aligned across markets and functions? Without a shared north star, your organization will experience a lot of waste and frustration.
- Is accountability structured in a way that incentivizes all-round performance? Just like in leadership triads, enterprise-scale accountability must be designed to support the system’s end goal without compromising a department, market, or site’s success.
Without clarity in these areas, even highly capable leaders are placed in untenable positions.
At scale, ambiguity is a risk not worth taking. It creates competing priorities, inconsistent execution, and delays decision-making. Leaders will find themselves navigating overlapping authorities, unclear escalation pathways, and misaligned incentives between system strategy and local operations. Over time, this drags performance down and increases the likelihood of executive burnout, not to mention any downstream impacts.
The implication is clear: scaling leadership to the enterprise level can’t succeed without redesigning your organizational structure. Structural clarity must precede role expansion.
New Leadership Models Demand New Leadership Competencies
As leadership roles scale and evolve, so too must the criteria used to assess and develop executives. Traditional markers of readiness like tenure, operational performance, and functional expertise aren’t adequate indicators of success at scale. As we mentioned at the outset, it’s no longer a question of experience or skill alone (although they naturally remain factors), but rather one of judgement. Organizations must prioritize leaders with the capabilities that reflect the realities of enterprise-scale healthcare organizations, such as:
- Enterprise thinking: Leaders need to be able to balance local optimization with system-wide performance.
- Pattern recognition: Leaders need to excel at identifying trends across markets and translating those insights into enterprise-wide strategy.
- Influence without authority: Leaders need to show themselves to be capable of aligning stakeholders across geographies and reporting structures, despite ambiguous hierarchies and relationships.
- Comfort with ambiguity and responsibility: Leaders need to be comfortable and confident making decisions in dynamic, evolving environments.
- Clinical fluency: Despite the fact leaders at the enterprise scale aren’t involved in the day-to-day operations of sites, developing or maintaining clinical fluency is essential for boosting their credibility in increasingly interdisciplinary leadership teams.
These capabilities signal a shift from execution to orchestration. Leaders are no longer defined by the scope they directly control, but by how effectively they enable performance across the system. This distinction is critical. Organizations that continue to evaluate leaders using site-based criteria risk promoting individuals into something that they’re not fully prepared for, despite their strong prior performance.
Strategic Recruitment in a High-Stakes Environment
As leadership roles expand in scope and impact, the consequences of misalignment increase rapidly. The disruption of a mis-hire at the enterprise level isn’t just limited to an isolated department, unit, or even an entire hospital. It can and will lead to major disruptions across entire systems and markets. Simply put, a mis-hire at the enterprise level can put your organization in dire straits.
To be certain your organization is bringing in the right leadership, recruitment needs to evolve from a transactional process focused on filling vacancies to a strategic function that shapes organizational performance. The most effective approaches to this way of recruiting integrate role design, competency assessments, and market intelligence into a cohesive strategy. That ultimately accomplishes the following:
- Defining enterprise-specific success criteria before the search begins: This is not a ship you want to build as it sails. Getting crystal clear on your leadership must-haves early will save countless headaches and innumerable dollars down the line.
- Assessing candidates against capabilities required for scaled leadership: Remember, you aren’t looking solely for doers. You need leaders who can influence effectively without getting bogged down in execution. This isn’t about hiring a do-nothing project manager; it's about hiring an architect who will create effective systems that guide teams to the finish line.
- Benchmarking leadership talent across systems and markets: Enterprise-level leaders are responsible for conducting an orchestra of leaders. Before bringing in a leader at the scaled level, you need to develop a keen understanding of whether leaders across your clinical, administrative, and financial departments are willing and able to play in harmony.
Crucially, your organization also needs to recognize when its internal processes are insufficient for high-impact roles. Positions involving enterprise scope, transformation mandates, or cross-market accountability often require specialized expertise to assure alignment between the role, the candidate, and the organization.
Check Your Blind Spots When Promoting From Within
Just as your top ICU nurses won’t necessarily make excellent nurse managers, your best hospital executives might not be the right choice for enterprise-scale leadership roles. Assuming they can create a blind spot by confusing their operational excellence (doing) with system leadership (influencing). It’s not that operational excellence and system leadership are mutually exclusive, but rather that one doesn’t guarantee the other. And at scale, it’s less about what a leader does and more about what they influence.
Everyone loves to promote from within. It can make the search process easier, keep familiar faces around, and build a helpful recruitment narrative. However, when it comes to enterprise-level roles, internal promotions come with the added risk that everyone ends up worse off than before. Leaders who were excelling in more narrowly-defined roles can find themselves frustrated and confused, downstream impacts start building up, and executives grow frustrated with results.
So, if your organization is considering promoting a successful leader to an enterprise-level role, take a deeper look at whether they’ve shown themselves to be capable of influencing leaders who don’t report to them, whether they can get results in different contexts, and if they can balance competing incentives. If they can’t, then you need to fill the role externally.
Know the Early Signs of Leadership Strain
As we mentioned earlier, your organizational structures need to change before your leadership can be scaled. However, there comes a point where it needs to be wear tested. If your organization transitioned to a scaled leadership model, indicators that your structures may be under strain include:
- Slowed decision-making at the executive level: When decisions start taking longer, it often means the leaders are either over-inserting themselves into issues that should be delegated or struggling to align a broader, more complex stakeholder set. At scale, that hesitation compounds quickly, signaling the leader hasn’t yet built the structures or trust needed to move at enterprise speed.
- Increased reliance on informal escalation pathways: When issues routinely bypass formal channels and come up through side conversations, it’s often a sign that governance isn’t working or isn’t trusted. This could reflect either a strain on your leader’s ability to create clear accountability, or a failure of your organization's structure to distribute decision rights appropriately across the system.
- Misalignment between system strategy and local execution: If sites are interpreting your strategies differently or executing them selectively, it could indicate the leader hasn’t translated high-level priorities into actionable, locally relevant direction. Given that this ability to align and influence different sites and markets is so vital for leadership at scale, misalignment is a major red flag that needs to be addressed immediately.
- Elevated turnover or burnout among senior leaders: When experienced leaders start leaving or burning out, it’s a sign your system is suffering from sustained ambiguity, has conflicting priorities, or a lack of support from the enterprise level. This is a downstream signal that the system leader hasn’t stabilized the operating model.
These signals often reflect structural misalignment rather than individual performance issues. Addressing them requires reexamining role design, governance, and leadership models, rather than simply replacing your leaders.
Leadership Doesn’t Scale On Its Own
The shift toward expanded span of control represents more than a change in organizational charts; it’s a new paradigm of what it means to lead. As healthcare organizations scale leadership across sites, markets, and geographies, leadership isn’t just about individual capability. Instead, it’s a system-level function shaped by your organization’s structure, governance, and culture.
Organizations that succeed in this new leadership environment will be those that align leadership roles with enterprise strategy and structure, invest in developing leaders who can operate across complexity rather than specialized roles, build governance models that support clarity, speed, and accountability, and approach recruitment as a strategic lever for performance.
For boards and executive teams, the mandate is clear. Leadership must be designed with proactive intent, not as a reaction to pressure. As healthcare continues to evolve, the ability to lead effectively at scale will become a defining differentiator between organizations that adapt and those that struggle to keep pace.
Want to learn more about leading at the enterprise level? Check out ACHE’s webinar, Leading at Scale: Executive Leadership in an Era of Expanded Span of Control
Contact Peggy or Melissa at [email protected].