Rethinking governance for an ambulatory-first health system

Many health systems remain governed as if inpatient care is still the center of gravity. Capital planning, leadership structures, quality frameworks and decision rights continue to be designed around hospitals, even as growth, access demand and consumer expectations move decisively toward ambulatory care. The result is a widening mismatch between strategy and structure with real consequences.

Health systems can often calculate inpatient cost and margin with precision yet struggle to do the same for office-based procedures. They define inpatient quality in detail but lack a shared definition of ambulatory quality or success. Capital flows more easily to new towers than to ambulatory surgery centers, wound care clinics or digital health platforms. Over time, this hospital-first governance model constrains growth, slows access improvement and weakens competitive position.

Many organizations say they want to become more ambulatory focused, but fewer have redesigned governance to make that possible. As care continues to shift outward, hospital-centric structures increasingly limit the performance of the ambulatory enterprise.

Across the country, health systems are responding. They are rethinking scope, redesigning leadership models, centralizing access functions and elevating ambulatory decision making. There is no one-size-fits-all solution. History, market dynamics and physician enterprise structure all matter. But common patterns are emerging that point toward more effective ambulatory governance.

In 2025, members of the new Vizient Ambulatory Executives Network convened to compare how their organizations structure and govern ambulatory care. What follows is a synthesis of those discussions, focused on these core fundamentals: clarifying ambulatory scope, aligning strategic and operational leadership, and establishing enterprise-level accountability for access.

Clarify the scope of ambulatory

You cannot govern what you cannot define. Yet ambulatory scope remains one of the most persistent sources of ambiguity in health systems.

In many organizations, ambulatory leaders oversee clinics and physician practices. Beyond that, the portfolio can vary widely. Some include ASCs, infusion clinics, imaging, pathology, sleep labs, virtual care, post-acute services, or even real estate and construction. In other systems, these same areas sit elsewhere in the enterprise. There is no consistent industry standard.

Scope also shifts over time. New responsibilities are added. Services that do not fit cleanly in hospital or service line structures are reassigned. While this kind of organizational churn is common, it makes it difficult for ambulatory leaders to build stable operating models.

Several health systems are taking a more deliberate approach. One organization centralized all ambulatory operations under a single dyad-based structure and removed service line and hospital management of practices. This kind of clarity is more than organizational choice. It’s a governance decision that aligns structure with ambitions for ambulatory performance.

Align operational and strategic leadership

Even with clear scope, ambulatory governance falters when strategy and operations operate in parallel rather than in partnership. When oversight is fragmented, priorities stall and accountability fades.

More organizations are addressing this through dyad and triad leadership models that pair operational, medical and nursing leaders. These structures are designed to ensure that decisions about access, staffing, quality and growth reflect both strategic intent and day-to-day-realities. One system uses a triad model with shared accountability across medical, nursing and operations leaders for the ambulatory enterprise. Another aligned service line strategy and clinic operations under a unified leadership structure to ensure specialty growth plans translate into operational performance.

These models protect executives from being pulled too far into daily operations. One system described a leader with more than 100 direct clinician reports, leaving little room to focus on long-term strategic planning. By adding director-level roles and rebalancing reporting relationships, the organization restored manageability and focus.

The specific structure matters less than the principle behind it. Ambulatory leaders need the bandwidth and alignment to think strategically and execute consistently.

Own access as a unified enterprise

Access is consistently the top strategic priority for health system leaders, and ambulatory care is where access is largely won or lost. Still ownership of access is often fragmented.

Some organizations have created dedicated leaders for access transformation. Others have centralized scheduling, built hybrid access centers or consolidated ambulatory capacity management under a unified ambulatory structure. These moves aim to reduce variation, standardize appointment workflows and improve the patient experience.

Health systems are also broadening how they define access. One cancer center measures conversion and retention separately, recognizing that not all leakage reflects failure. This more nuanced view allows leaders to focus improvement efforts where they matter most.

Measurement remains the biggest challenge. Many leaders struggle to obtain reliable access metrics from the EHR without manual validation. Shared definitions, standardized dashboards and better benchmarking are persistent needs.

The takeaway is straightforward. Access should be owned at the enterprise level—but ambulatory leaders need the authority, structure and data to lead much of the work.

As care continues to move out of the hospital, governance must move with it. While specific models may differ, the principles of high-performing ambulatory structure are the same—clarity of scope, aligned leadership, reliable data and a seat at the enterprise table. Health systems that redesign governance to support ambulatory care with these principles in mind position themselves to grow, compete and deliver access at the level patients increasingly expect. Those that do not risk being structurally misaligned with the future they say they want to build.