Field Notes on Healthcare Strategy

Field Notes on Healthcare Strategy: Stop Asking People to Work Harder

Pablo Castañeda, MD

Most struggling healthcare systems are not short on effort. They are drowning in it. People arrive early, stay late, answer messages they should not have to, fix scheduling problems with favors, and cover gaps with goodwill. They keep the clinic moving because patients are in front of them and saying no feels impossible. Then leadership looks at the mess and says the system needs more productivity. That is usually the wrong diagnosis.

The problem is often not that people are lazy. It is that the system has been built in a way that forces good people to compensate for bad structure. That is expensive and corrosive. Over time, it erodes trust. I have seen this pattern in different forms: busy clinics, full operating schedules, long waitlists, talented physicians, good staff, and a mission people still believe in. On the surface, the institution looks active. Underneath, no one can answer the basic questions. How much capacity do we really have? Who owns the patient? What counts as productive work? Which cases are complex? Which patients are waiting too long? Where are outcomes tracked? What work is invisible? Who is actually building the program?

That is usually where the real work begins.

The first mistake is confusing activity with capacity. A hospital counts rooms and assumes it understands what it can do. It does not. Rooms are not capacity. Rooms are walls. An operating room is useful only if it has staff, equipment, anesthesia coverage, recovery space, implants, nursing support, medical backup, and a data system to support the work safely. The same is true for clinics. A clinic room without the right physician, nurse, imaging access, casting support, scheduling logic, and a follow-up plan is not capacity. It is space with furniture.

This should be obvious, but it is missed all the time. Hospitals like physical denominators because they are easy to count. Four rooms. Ten rooms. Thirty rooms. Eight clinic templates. Five operating days. These numbers look clean on a slide, but real capacity is messier. It depends on staffed minutes, case mix, patient complexity, turnover, cancellations, recovery, late starts, support services, follow-up, quality signals, and human fatigue. The denominator that matters is safe, staffed, supported, measurable throughput. Not theoretical throughput. Real throughput.

If leaders do not define that denominator, the next move is usually bad. They set a target, push volume, extend hours, add pressure, and ask physicians to “do more.” But more what? More simple cases? More complex cases? More clinic visits? More decisions? More complications? More undocumented work? More late-day risk? Before asking for more volume, the system has to define true capacity.

Case count creates a similar problem. It feels objective, but it is often crude. A 20-minute case and a six-hour case are both “one case.” A simple follow-up and a complex new patient visit are both “one visit.” A quick procedure and a high-risk reconstruction can sit next to each other in a spreadsheet as if they mean the same thing. They do not. This is how bad metrics punish the wrong people. The clinician who takes the hardest cases may look less productive. The surgeon who manages complications, counsels families, teaches trainees, and thinks carefully may look slow. The person doing easy volume may look efficient. The spreadsheet smiles. The system gets dumber.

If a system wants fair productivity, it needs to measure work in ways that respect clinical reality. What was done? How long did it take? How complex was it? What risk did it carry? What resources did it use? Was teaching involved? Was coordination involved? What outcome followed? Did the patient complete the pathway? That is a different conversation. It is also a better one. Volume matters. Access matters. Throughput matters. Patients should not wait forever because doctors dislike measurement. But volume without context is not performance. It is just counting.

Another touchy issue is presence. Healthcare organizations often drift toward presence-based control when trust starts to fall. More sign-ins, more attendance rules, more monitoring, more reports, more proof that people were physically there. I understand why it happens. Leaders need accountability. Some physicians abuse flexibility. Some systems are too loose. Some people hide behind autonomy, while others carry the work. But a blunt tool can make the culture worse.

A physician’s value is not measured only by time in the building. It is measured by judgment, clinical output, quality, access, teaching, leadership, problem-solving, and ownership of patient outcomes. Presence is easy to track. Contribution is harder. That does not mean we should avoid measuring contribution. It means we should do the harder work. A real contribution model should include clinical work, procedural work, complexity, quality, teaching, research, leadership, supervision, program building, care coordination, and institutional citizenship. Some of that can be counted. Some of it needs judgment. That is fine. Healthcare is full of judgment. The lazy answer is to monitor time and call it accountability. The better answer is to define the work that actually matters.

Quality has to come before productivity. This should not be controversial, but it often is. When a system is under pressure, quality becomes the paragraph after productivity. It should be the first line. If volume rises and complications rise with it, the system did not improve. If access improves but follow-up collapses, the system did not improve. If more patients move through the clinic but no one owns the plan, the system did not improve. If surgery expands into hours where the support system is weaker, the system may be creating risk and calling it efficiency.

Volume is only valuable within a quality boundary, and that boundary must be measured. Complications, readmissions, reoperations, cancellations, delays, adverse events, return visits, follow-up completion, patient experience, and service-specific outcomes all matter. Not everything needs to be perfect on day one, but the system needs to start. A quality dashboard is not a punishment tool. At least it should not be. It is a mirror. In many hospitals, the mirror is missing. People tell stories instead. “Our outcomes are good.” “We are efficient.” “Patients are happy.” “The team is strong.” Maybe. Show me. Not because I distrust the people, but because good people still need feedback. Surgeons need to know their outcomes. Clinicians need to see patterns. Leaders need to know when the system is drifting. You cannot improve what you do not see.

Continuity is another place where systems quietly fail. A patient is seen by one person, scheduled by another, treated by another, and followed by whoever is available. Then a complication appears, and the system cannot clearly trace the loop. Who owns this? No one and everyone. That is bad design. Team-based care is necessary. Trainees matter. Advanced practice providers matter. Cross-coverage matters. No one person can do everything. But responsibility cannot become so diluted that learning disappears.

The clinician who makes the decision should remain connected to the result. The person who performs the procedure should know the follow-up. The team should know when the plan failed. The system should know where the handoff broke. Continuity is how professionals learn. Without it, complications become isolated events. Follow-up becomes clerical. The system loses memory. Good care needs teams. Great care needs ownership.

Healthcare also spends too much energy on what happens after the visit starts and not enough on what happens before. The front door determines everything downstream. How does the patient enter the system? Who decides where they go? What information is gathered first? Is imaging needed? Is the problem urgent? Is the patient in the right clinic? Could the issue be handled differently? Is this a specialist problem at all? A weak front door creates waste. Patients go to the wrong place. Specialists see problems that should have been triaged earlier. Urgent cases hide inside routine volume. Families wait. Staff improvise. Clinicians spend time sorting chaos instead of using judgment.

This is one of the places where healthcare still behaves as if demand should simply arrive and be absorbed. It should not. Demand has to be shaped. Structured intake matters. Pre-visit review matters. Triage matters. Clear referral rules matter. Remote review matters. Eventually, AI will matter here too. Not as a magic doctor, but as a sorting layer. A good AI-supported front door could collect history, identify red flags, organize documents, suggest routing, reduce out-of-scope visits, and prepare the clinician to use time well. That is not science fiction. It is workflow hygiene. The front door is not administrative. It is clinical.

Most healthcare systems have data, but that does not mean they know anything. They have records, dashboards, scheduling exports, billing fields, quality reports, spreadsheets, committee minutes, and monthly summaries. Then someone asks one practical question, and everyone pauses. How many staffed OR minutes did we actually use? Which service has the longest wait? Which cases are delayed by missing implants? Which patients are being seen by the wrong pathway? Which physician is doing the most complex work? Which outcomes are worsening? Which clinic rooms are actually available? Which support service is limiting throughput? Which work is unpaid, unseen, or uncredited?

Often, no one knows. Or five people know five different versions. That is not a data problem. That is a definition problem. Data only helps when it is defined, trusted, timely, clinically meaningful, and visible to the people doing the work. A dashboard that clinicians distrust is wallpaper. A metric that ignores complexity is noise. A report that arrives three months late is history, not management. Healthcare needs less decorative data and more usable truth.

Incentives always win. People talk about culture as if it floats above the organization. It does not. Culture is shaped by what the system rewards, ignores, punishes, and tolerates. Reward presence, and people optimize for presence. Reward raw volume, and people chase raw volume. Ignore complexity, and complex work becomes a tax. Ignore teaching, and teaching becomes charity. Ignore leadership, and leadership becomes unpaid emotional labor. Ignore quality, and quality becomes a slogan. Underpay commitment, and people commit elsewhere.

This is not a moral flaw. It is predictable. If a healthcare system wants full commitment, it has to build a model that recognizes full contribution. That does not always mean paying more for everything. It does mean being honest about what the institution expects and what it rewards. Mission cannot carry the whole load. At some point, structure has to match the mission.

The hardest part is sequence. Healthcare systems rarely have one problem. They have stacked problems: access, morale, productivity, quality, compensation, data, governance, recruitment, scheduling, communication, follow-up, and technology. All real. All connected. But not all first. This is where many transformation efforts fail. They try to move everything at once. Or they pick the most visible issue rather than the first structural one. Or they install a tool before defining the workflow. Or they change compensation before defining contribution. Or they demand quality without building measurement.

Sequence matters. First, define the current state. Then define the true denominator. Then build trusted metrics. Then clarify ownership. Then redesign the operating model. Then align incentives. Then pilot. Then scale. Boring? Maybe. But it works better than announcing transformation and hoping the slide deck becomes reality.

Here is the lesson that may irritate people. Healthcare systems often protect themselves from the truth by praising the mission. The mission may be real. The people may be good. The patients may be grateful. The history may matter. None of that proves the operating model works. A noble mission can still sit on top of a weak structure. Good people can still work inside a bad system. A busy hospital can still be poorly designed. A beloved program can still be underdeveloped. A high-volume service can still lack real accountability.

Saying this is not an attack. It is the beginning of repair. You cannot fix what you are too polite to name.

Good healthcare strategy is not abstract. It answers practical questions. What are we trying to build? What is the true capacity? Which work matters? Who owns the patient? What should we measure? Where is the bottleneck? What should stop? What should start? Who decides? Who is accountable? What changes in 30 days? What changes in 90 days? What will we measure to know if it worked?

That is the difference between a review and a transformation plan. A review describes. A transformation plan assigns work: owners, timelines, metrics, decisions. Without that, the report is just a document.

Healthcare does not need more speeches about working harder. Most people are tired already. It needs a better structure. Better front doors. Better denominators. Better measures. Better incentives. Better dashboards. Better handoffs. Better ownership. Better alignment between what leaders say matters and what the system actually rewards.

This is the work. Not glamorous. Not easy. Often uncomfortable. But necessary.

A good healthcare system does not ask committed people to keep compensating for poor design. It builds a model worthy of their effort.