For most of their institutional histories, health systems have been focused on the hospital is where the critical work happens, and governance structures should reflect that. Accountability lived in the acute setting and performance was measured at the facility level. Decision rights flowed from the building.
A growing number of health system executives say that model is breaking down under the weight of problems the hospital cannot solve on its own.
“We are evolving from structures organized largely around the hospital to an enterprise model that manages performance across the full continuum of care,” Asa Oxner, MD, vice president and associate chief medical and quality officer of ambulatory at Tampa General Hospital in Tampa, Fla.
That transition is taking shape across three parallel moves at Tampa General:
- Redesigning service-line governance so ambulatory leaders and measures sit alongside inpatient leaders and measures in the same accountability structure;
- Expanding the quality domain model so inpatient and ambulatory priorities are managed through common governance, metrics and escalation pathways rather than parallel structures; and
- Establishing enterprise care coordination governance with explicit executive accountability and cross-functional operating and technology workgroups to standardize roles, handoffs, workflows, and performance measures.
“A large academic health system cannot solve capacity, throughput, quality, or affordability within hospital walls alone,” Dr. Oxner said. “Avoidable acute-care utilization, revisits, delayed follow-up, and inpatient work that could be delivered safely in lower-cost settings are all continuum problems.”
These problems have always existed at the intersection of inpatient and ambulatory care. What’s changed is the degree to which health systems are being asked to manage them by payers, regulators, and patients, rather than accept them as a natural consequence of an episodic care model.
Becker’s reporting in 2026 found similar structural moves underway across the industry, with health systems elevating ambulatory and care continuum roles to the senior executive level.
David Burmeister, DO, president of Jefferson Medical Group and associate chief physician executive of Jefferson Health in Philadelphia, described a parallel transformation at a multi-state system.
“Rather than operating as a collection of individual entities, we are building an integrated health system that leverages scale, shared expertise, and standardized processes while preserving local engagement, transformation, and innovation,” Dr. Burmeister said.
The structural mechanism Jefferson is using is a regional physician and operational dyad leadership model for local clinical accountability paired with centralized leadership support that is designed to maintain integration across the medical group without flattening the local relationships that drive clinical performance.
The tension between integration and local autonomy is one executives across system types are navigating, and there is no settled answer on where the line belongs. Zachary Yoder, RN, president of three OSF HealthCare hospitals in the Peoria, Ill., market, described an evolution toward an integrated model that enables the hospitals to operate as a coordinated network rather than three individual facilities, while maintaining distinct local leadership at each.
“We will strengthen market-level leadership and accountability while maintaining strong local leadership at each hospital to ensure decisions remain close to the communities we serve,” Mr. Yoder said.
The structural challenge is coordinating transfers, access, ambulatory sites, primary care, specialty care, and diagnostics across a market, and the solution requires a governing layer above the individual facility but below the enterprise that can move patients across settings without requiring decisions to escalate to a central office.
Jim Andrews, president and CEO of Deborah Heart and Lung Center in Browns Mills, N.J., is pursuing a different model altogether, abandoning the traditional hierarchical structure in favor of what he calls a people-centered organization built around interconnected care rings.
“Our model revolutionizes the matrixed department/service line structures bogging down decision making and features interconnected care rings that bring clinical and operational expertise together to address all of the needs of the people we serve,” Mr. Andrews said. “These care rings reduce silos, strengthen collaboration, and create clearer accountability for outcomes across our heart and vascular and pulmonary enterprises.”
Accountability structures that stop at the hospital’s walls will be increasingly inadequate for the performance expectations health systems are now operating under.
“The how is to align decision rights, shared metrics, standardized workflows, and technology across inpatient, ambulatory, service-line, population-health, and care-transition teams, creating one operating model that can move patients reliably to the right care setting, scale what works, and sustain performance through 2030,” Dr. Oxner said.
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