For decades, the COO’s job was straightforward: keep the trains running on time. Ask today’s COOs how the role has changed, and a different picture emerges. Operational excellence hasn’t gone away, but it’s no longer the ceiling of the job.
Leaders across the industry describe a shift from running the business to designing the operating model itself — building the governance structures, cross-functional partnerships, and decision-making frameworks that let increasingly complex, multisite systems move quickly without losing consistency.
The COO has become less a taskmaster and more a translator, connecting clinical strategy to operational reality, and a connector, linking functions that used to operate in silos: supply chain, real estate, government affairs and technology.
As healthcare organizations grow larger and more matrixed, the executives steering them are being asked to do less managing of what already exists and more building of what comes next.
Question: How has your COO or strategic leader role evolved?
Darryl Elmouchi, MD. COO of Providence (Renton, Wash.): Historically, the role of COO has been to oversee operations and ensure we are delivering the best care possible in an efficient and effective manner. While that is still true, the role has shifted in three important ways. As organizations have become larger, the role of the COO has morphed into ensuring we have the best leaders possible and empowering them to lead in a team-of-teams fashion.
Additionally, a COO serves as a connector. Gone are the days of siloed leadership. Rather, the COO needs to effectively connect our clinical care and operations with all facets of an organization — supply chain, real estate, government affairs, etc.
Finally, I would argue a modern COO needs to skate to where the puck is going to be, not to where it has been, as Wayne Gretzky once said. In other words, we are all leading through change and the changes we make today have to fit within a long-term vision of how healthcare will be delivered in the future.
Kelli Ferry. Executive Vice President and Chief Legal Officer of Novant Health (Winston-Salem, N.C.): The chief legal officer role has evolved from being primarily a legal advisor and risk manager to serving as a strategic business partner. Today, legal is involved at the beginning of important conversations, helping shape growth and transformation initiatives, enable innovation and navigate complex challenges. The role has become much more proactive, with legal leaders expected to anticipate issues before they become problems while fostering transparency and trust across the organization.
My goal is not to tell the organization what it can’t do, but to help identify the safest and most effective path to achieve what we want to accomplish for our patients, team members and the communities we serve. When legal is embedded in strategy from the beginning, it helps organizations innovate responsibly, make better decisions and move forward with confidence.
Patrick Tuer. Executive Vice President and COO of Encompass Health (Birmingham, Ala.): Traditionally, the COO role has been viewed as primarily operational, focused on metrics, efficiency and financial performance. While those responsibilities remain critically important, I have seen the role evolve into one that requires a much broader balance of operational excellence, people leadership and strategic partnership.
At Encompass Health, we know that our ability to deliver exceptional patient outcomes begins with our people. As a result, my role extends beyond reviewing performance data and operational results. It is equally important to understand the challenges, opportunities and successes occurring at the hospital level and to ensure our leaders have the support they need to thrive.
I make it a priority to spend as much time as possible in our hospitals, building relationships with leadership teams across the country and staying connected to the realities of patient care and daily operations. Those conversations often uncover opportunities to remove barriers, share best practices and better support our teams in delivering high-quality rehabilitation care.
Hope Waltenbaugh. Vice President of System Nursing Operations and Practice for Allegheny Health Network (Pittsburgh): Since 2020, my leadership focus has evolved from ensuring operational stability — having the right nursing workforce, capacity, and safety protocols in place to care for patients during unprecedented disruption — to strategically transforming the future of nursing and healthcare. As we moved beyond the immediate crisis, my role expanded to embrace innovation, particularly artificial intelligence, as a powerful tool to support nurses, strengthen the workforce, improve decision-making, and ultimately enhance the patient experience. I believe today’s nursing leaders have a responsibility not only to navigate change, but to anticipate it, embrace emerging technologies, and ensure nursing remains at the forefront of shaping what healthcare will look like tomorrow.
Joel Fagerstrom. Executive Vice President and COO of St. Luke’s Hospital & Health Network (Bethlehem, Pa.): I’ve been in healthcare for more than 40 years and have seen the COO role evolve from primarily overseeing day-to-day operations to serving as a key enterprise strategist and change leader. Years ago, success was often measured by managing hospital operations, controlling costs, and ensuring efficient execution. While those responsibilities remain fundamental, the scope of the role has expanded significantly as health systems have become larger, more complex and increasingly integrated.
Today, the COO must connect strategy to execution across the entire continuum of care. The role requires balancing operational excellence with growth, physician alignment, workforce engagement, digital transformation, consumer expectations and financial sustainability. In many ways, the modern COO serves as the organization’s chief integrator — bringing together hospitals, ambulatory services, post-acute care, technology and clinical operations to achieve a common vision.
Another major evolution has been the increased reliance on data and technology. Decisions that were once driven largely by experience and intuition are now informed by real-time analytics, predictive modeling, artificial intelligence and sophisticated operational metrics. The COO is expected not only to improve performance today but also to anticipate future challenges and position the organization for long-term success. Perhaps most importantly, leadership itself has changed.
The COO role is less about directing and controlling and more about building high-performing teams, developing future leaders, fostering collaboration, and creating a culture that can adapt to constant change. In healthcare, where workforce shortages, reimbursement pressures, and consumer expectations continue to intensify, the ability to lead through complexity has become just as important as operational expertise. For me, the role has evolved from being responsible for operations to being responsible for helping shape the future of St. Luke’s University Health Network while ensuring we continue to deliver exceptional care every day.
Jon Reuter. Chief of Operations for Keck Hospital, Keck Medicine of USC (Los Angeles): People leadership and matrixed influence matter more.
My role has limited ability to command and direct change; I focus my efforts on building trust across clinical leaders, functional executives, and my health system COO colleagues to lead through influence rather than positional authority. This approach is especially critical in matrixed organizations like AMCs where authority is dispersed.
Lyndon Edwards. COO of Loma Linda University Health Hospitals (Loma Linda, Calif.): The COO role has evolved into a much more strategic position over time. While operational excellence remains a core responsibility, many of our most significant strategic priorities are shaped by the operational and financial challenges and opportunities we encounter daily. As the connection between the C-suite and our operational and clinical teams, the role requires aligning people, strategy, and culture while leading effectively through ongoing change.
Sabi Singh. COO of Moffitt Cancer Center (Tampa, Fla.): The COO role has shifted from running the business to designing the operating model. Throughput and cost per case have given way to how we scale ambulatory surgery, integrate the hospital and medical group, and decide what belongs on the core academic campus versus in the community. Margin, technology and talent are now core COO territory: payer strategy, Disproportionate Share Hospital and 340B eligibility and Prospective Payment System-exempt requirements sit alongside transformational system implementations and AI clinical-safety governance.
Building the next generation of operating leaders has become how a COO scales the enterprise. Protecting and expanding access to clinical trials — the defining commitment of an academic cancer center — has to be designed into that operating model, not treated as a byproduct of it. The role has also turned outward — meaningful time with the board, payers, community and academic partners, and increasingly patients directly — as community-based cancer care and multisite growth have made the COO visibly external in a way it was not a decade ago.
The Bottom Line
The COO has moved from keeping the operation running to redesigning the operating model, with talent, technology, payer strategy and patient experience as the levers, and multi-site, mission-integrated growth as the outcome. In cancer care, that redesign work is not optional; it is the job.
Robert Wiehe. Senior Vice President and COO of UC Health (Cincinnati): The job used to be mostly about running today well — throughput, staffing, keeping the budget in line. That’s still table stakes, but the bigger shift is that COOs are now expected to build the governance and decision-making structures that let a complex health system move fast and stay consistent across service lines and sites of care. You’re spending as much time on organizational design as you are on traditional operations. The best ones in this seat now act as the translator between clinical strategy and operational reality.
Kurt MacDonald. Vice President of Operations for University of Michigan Health-West (Wyoming, Mich.): During my time as an operations executive, it has been encouraging to see greater recognition that every service, including ancillary and support functions, plays a critical role in the care delivery system. The pandemic underscored the importance of teamwork, innovation and cross-functional partnerships as essential services such as laboratory, supply chain and environmental services faced unprecedented constraints.
What stood out was how organizations rallied together to ensure caregivers and patients had what they needed during the crisis and recovery. As a result, the role of the operations leader has evolved beyond managing day-to-day operations to helping shape strategic growth, develop scalable programs and leverage capabilities across increasingly integrated health systems.
Services such as radiology, laboratory and pharmacy are no longer viewed solely as support functions. They are strategic platforms that can improve access, enhance patient experience, and strengthen partnerships with primary care and specialty networks. It is an exciting time in healthcare because organizations increasingly recognize that operational excellence and support services are fundamental enablers of high-quality patient care.
Brian Evans. COO for Optim Health System (Savannah, Ga.): The COO role has shifted from a focus on operations, ancillary and support functions, to supporting strategy growth and development, clinical and quality initiatives, labor management, and cost saving opportunities. As organizations restructure, we’re frequently seeing executives begin to assume roles and responsibilities outside of their traditional scope. I look at it as an opportunity to continue my development and expand my knowledge into other areas of healthcare operations.
Cindy Russo. COO of Knox Community Hospital (Mount Vernon, Ohio): Over time, I have seen the COO role evolve from an internally focused operational position into more of a strategic role. Today’s COO must balance operational excellence with innovation, efficiency and effectiveness. They must ensure the organization’s competitive advantage and organizational readiness. The COO must be a broad enterprise thinker with leadership skills that helps shape the organization’s culture, drives key areas of needed transformation and integrates both clinical and business performance.
The COO responsibilities have shifted from day-to-day operations to strategy, process management to project development and execution and performance management to culture development, employee engagement, provider alignment and leadership growth.
This expansion of the COO’s responsibilities allows for the leaders in this role to have an even greater impact on the success of the organization they are helping to lead.
Bonnie Thompson, COO of Forest Family Dentistry (Austin, Texas): The role has shifted beyond making sound financial decisions and creating processes. Today, it’s about weighing the right technology and AI investments and more importantly, building harmony across a workforce that’s become a blend of in-person teams, remote staff, offshore support and now AI tools all working side by side. Strategic leadership now means integrating all of that without losing the culture that makes an organization work.
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