Good leadership can be difficult to sustain when the system rewards the wrong behavior.
Across fourteen conversations with healthcare CEOs and Chief Medical Officers, a pattern has surfaced that does not appear in dashboards or formal reporting. Leaders are asked to improve outcomes, control costs, manage operational demands, expand access, and support their teams.
In healthcare, this tension is especially visible. Leaders are asked to improve outcomes, control costs and operational demands, expand access, and support their teams. Those goals can appear straightforward, but the incentives surrounding them do not point in the same direction. What is best for the organization, what is best for the patient, and what is rewarded financially can sometimes be very different things.
This became especially clear in a conversation with Chris Blackley, CEO and Co-Founder of Prescryptive Health. His perspective focused on a fundamental challenge in healthcare: leaders are often trying to create better outcomes inside systems that were not necessarily designed to produce them. When the surrounding incentives reward cost, control, or protection of existing structures, improving the system requires more than asking leaders and teams to work harder.
That distinction matters. A leader can have a clear strategy and a capable team and still find that execution is being shaped by forces outside the strategy itself. People respond to what their environment rewards, reinforces, measures, and makes easier to do. But over time, those signals influence what receives attention and what gets deprioritized, even when no one chooses to move away from the original goal.
This is where clarity becomes more than communicating a vision. Leaders have to make the choices and tradeoffs visible, but they also have to recognize when the environment is creating pressure in the opposite direction. If the system rewards one behavior while the strategy requires another, the gap eventually shows up in execution.
The same pattern appears outside of healthcare. Organizations can spend enormous amounts of time refining strategy while leaving the decisions surrounding it largely untouched. The strategy may be sound, but the operating environment keeps pulling people toward what is familiar or immediately rewarded. Over time, that creates a different kind of leadership challenge. The question is whether the system itself is helping people get where the organization says it wants to go, rather than simply whether they understand the direction.
Changing that requires leaders to look beyond individual performance and examine the conditions in which performance is being produced. Leaders need to look at what behaviors are actually being rewarded, which outcomes receive attention, and where teams are being asked to work against the incentives built into the system. They also need to ask whether optimizing the existing structure has become a substitute for questioning whether that structure is still producing the outcomes the organization needs. Existing systems often contain important knowledge, infrastructure, and safeguards. But when the outcomes an organization wants begin to conflict with the way it actually operates, improvement can only go so far.
The leaders who navigate that tension understand that performance is not created by people alone. Rather, it is shaped by the environment in which those people make decisions every day. Sometimes the most important leadership move is to step back and ask whether the system is still designed to produce what the organization says it values.
Leadership Implication:
In organizations trying to improve performance while operating within complex or competing incentives, the challenge is not always strategy, capability, or effort. Sometimes the operating environment itself reinforces behaviors that work against the desired outcome. My work with healthcare leadership teams focuses on executive briefings and off-site sessions that examine how decision environments, competing demands, and organizational conditions shape performance, and how leaders can create greater alignment between what they value and what their systems actually reward.
Briefing Context:
This Executive Briefing synthesizes recurring patterns from my Healthcare Leadership Operating System interview series, including a conversation with Chris Blackley, CEO and Co-Founder of Prescryptive Health.
Reference: Authority Magazine interview (April 2026)
Framing the system as the thing pulling you off course is the part most people miss. We treat drift as a willpower problem, when usually it is a well-designed default quietly making the choice for us. The leaders I admire spend less energy resisting the pull and more energy redesigning the defaults, so staying on course stops depending on discipline. Good to see this land in my feed, Savio.