This article was originally published in The Journal of Healthcare Contracting.
I have sat in a lot of executive conference rooms over the past 40 years. And I have watched the same scene play out more times than I can count. A decision that everyone in the room knows needs to be made – has needed to be made for months, sometimes longer – sits on the agenda again. The CFO has run the numbers. The analysis is complete. The market has already rendered its verdict. And still, the group decides to take another look, seek a bit more input, wait for a better moment.
The moment rarely comes.
For supply chain and contracting professionals, this pattern isn’t a governance abstraction. It shows up in your work every day. A vendor contract that’s been in negotiation for six months with no resolution. A capital request cycling through committees while equipment ages. A service line everyone privately acknowledges is unsustainable – still running, still consuming inventory and staff and management attention, because no one has been willing to force the question to a close.
The frustration is legitimate. And it isn’t going away until the underlying problem is addressed. The problem isn’t the leaders. It’s the structure.
I want to be direct about something that often gets lost in these conversations.
The health system leaders I’ve worked with are not indecisive people. They are not avoiding hard decisions because they lack the courage to make them. They are operating in governance structures that were never designed to force resolution – structures that place no real cost on keeping a decision open, that reward consensus over closure, and that have no built-in mechanism to say: this has gone on long enough, a choice must be made today.
In a publicly traded company, that mechanism exists by design. Capital markets impose consequences. Shareholdersdemand returns. Delay gets priced whether management welcomes it or not. The clock runs whether anyone winds it.
Nonprofit health systems don’t have that. Which means the clock still runs – it just runs silently. And when no one is explicitly authorized to govern time, time governs the organization instead. I’ve started calling this the absence of a forcing function. It’s the single most common governance failure I’ve observed across four decades of advisory work. And it is far more damaging than most leadership teams recognize.
What The Absence Actually Costs
There’s a phrase I’ve come to use with leadership teams: decision pace is capacity.
Most people think of capacity as beds, staff, and capital. Those matters. But in my experience, the binding constraint in most complex health systems isn’t any of those things. It’s the accumulation of unresolved decisions – services that continue without evaluation, investments that linger without commitment, contracts debated but never sequenced. Every open decision consumes meetings, management bandwidth, and leadership attention that could be going somewhere else. Slow decision cycles don’t preserve capacity. They consume it.
For the supply chain community, that consumption is not theoretical. It arrives as pricing uncertainty that vendors absorb and pass back. It arrives as inventory commitments for programs that may not exist in eighteen months. It arrives as the particular exhaustion of managing complexity that persists not because it must, but because no one has closed the loop.
Healthcare is now approaching one-fifth of U.S. GDP. Costs are rising faster than paychecks. Health insurance – once a reasonable expectation for working families – is becoming unaffordable for the communities these systems were built to serve. At that scale, slow governance is no longer just an internal management problem. It becomes a structural contributor to a cost trajectory that affects everyone.
What Actually Changes Things
I am not arguing that health systems should move fast for their own sake. Speed without judgment is its own kind of failure.
What I am arguing is that durable performance requires structure – specifically, governance mechanisms that make time visible, make tradeoffs explicit, and make accountability unavoidable. Decision rights that are clear at every level. Forums built around specific decisions, not generic updates. Timelines that compress rather than absorb. Escalation paths that actually function.
These aren’t management preferences. They are the difference between a governance system that converts intent into action and one that converts intent into another agenda item.
When those mechanisms are absent, something important happens that most leadership teams don’t see until it’s too late. Decisions stop being made by leaders. They start being made over time. And time, as I’ve told more than a few leadership teams, is not a neutral actor. It always decides in favor of the status quo.
The systems that will perform best over the next decade won’t necessarily be the largest or the best resourced. They’ll be the ones who built a forcing function – and used it.
For the supply chain and contracting professionals reading this: the governance failures upstream from you are not going to resolve themselves. But they can be designed out of the system. That work starts in the executive conference room.
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