Traditionally, the prevailing wisdom in health care leadership has been that growth is the primary antidote to financial pressure. The logic goes, if margins are thin, one must expand — build a new ambulatory center, acquire a smaller physician group, or increase bed capacity to capture more volume. But in the current climate, chasing growth on top of a fragile foundation is not a strategy; it’s a risk multiplier. 

The Pacific Northwest is a microcosm of a national shift. Three main pressures — financial, labor, and technology — are impacting the foundations of the health care industry here.

We have moved past a "rough patch" of temporary postpandemic correction and have entered into a permanently higher-complexity operating environment. In this new reality, success no longer depends on how fast an organization can grow, but on its organizational architecture — the internal governance, operating rhythms, and human dynamics designed to withstand external volatility.

Redesigning the operating rhythm

The traditional revenue cycle — once a reliable safety net for regional health systems — is fraying.  

Due to surging insurance payment denials and significant cuts to Medicaid and Medicare reimbursements, the baseline revenue needed to operate as a health care provider has been significantly weakened. When major systems across the Pacific Northwest are forced toward litigation simply to receive payment for services already rendered, it’s a signal that the engine of health care finance is stalling.

To navigate this frayed financial system, leadership must close the gap between clinical decisions and financial reality in real time.  

The era of "autopsy-style" management, where executives review financial performance 30 to 45 days after the fact, is no longer sustainable. The phrase “autopsy-style” is deliberately stark: by the time a monthly report shows a margin dip, the financial damage is already done and the opportunity for course correction has passed.

Strategic resilience requires a live operating rhythm. In the health care system, this means building internal structures where clinical and financial data are synthesized at the point of decision, ensuring that department heads and frontline leaders understand the immediate financial weight of operational choices.

When an organization integrates these insights into its daily cadence, it gains the agility to protect its mission before it’s compromised by financial impact and consequences.

The labor paradox 

We often hear about the "nursing shortage" as if it were a seasonal storm we simply need to outlast. The data suggests otherwise. We are facing a demographic permanence: fewer people are entering the profession, a veteran workforce is exiting, and leverage has shifted decisively toward labor. 

The impulse for many boards is to "hire their way out" of the problem, pouring resources into recruitment bonuses and temporary staffing. But when the labor pool is shrinking across an entire region, recruitment cannot be the primary strategy. The focus must shift toward the design of the work itself and the preservation of the psychological contract between institution and staff.

Retention in 2026 is not fundamentally about pay; it is about protecting caregiver capacity. When systems are poorly designed, clinical staff spend more time navigating administrative friction and broken communication loops than practicing at the top of their license. That friction is the primary driver of burnout. Leaders must treat the behavioral and psychological drivers of the workforce as a strategic asset — not a human resources line item. You cannot ask a workforce to be resilient if the system they work in is inherently depleting. 

The AI productivity trap 

Health systems are purchasing artificial intelligence tools, yet many are not seeing a measurable return on total organizational capacity. This is the AI productivity trap.

New technologies such as ambient dictation, a tool that passively listens, interprets, and documents conversations between clinicians and patients in real time; clinical copilots, that function as AI-driven clinical assistant platforms; and predictive analytics are being adopted at a record pace.

The problem is rarely the technology itself; it’s the implementation gap. A tool only creates value when it’s operationalized. If a physician uses AI to save two hours on charting, but the system hasn't redesigned the surrounding workflow to capture that time, the gain evaporates into other inefficient processes, adding complexity without adding capacity. 

Leadership must move beyond adoption and toward integration. That requires hard questions about decision rights: Who owns the AI output? How do we maintain clinical judgment in an automated environment?  

Workflow redesign, privacy checks, and team recalibration are not the aftereffects of buying AI — they are the implementation itself. Without deliberate architecture to support these tools, even the most sophisticated technology becomes another layer of complexity rather than a genuine gain in capacity. 

Resilience through leadership

Financial, labor, and technological pressures are not separate crises, they are interconnected features of a new operating reality representing a fundamental shift in the invisible foundations of the health care industry. 

Navigating this complexity requires a specific kind of leadership. It’s no longer enough to have a bold vision or a charismatic presence. The leaders who will succeed are those comfortable enough with uncertainty to focus on the unglamorous work of building infrastructure — those who can look past the symptoms of a rough year and see the structural shifts underneath. 

Structural resilience isn’t a byproduct of good intentions; it’s the result of deliberate design, clear roles, rhythmic governance, and a deep respect for the human capacity that keeps the lights on. 

The future of health care in the Pacific Northwest will not be won by the biggest systems, but by the most coherent ones. It’s time to stop chasing growth as a distraction and start building foundations that can actually hold the weight of the future.

Alex Barrouk is the founding director of Spokane-based Aim & Build Consulting & Development/Listen Louder. He can be reached at [email protected]; 310.980.0989.