The Red Queen's Trap, Part 2: Leadership Alignment Is the Precondition for All Three

 The Red Queen's Trap — a 4-part series on margin in healthcare. Part 1: Why → · You're reading Part 2: Leadership Alignment. · Part 3: Where the Margin Is → · Part 4: The Ongoing Process →

Part 1 closed on three fronts where traditional physician groups and hospitals actually control their own margin: physician incentives, staffing productivity, and full revenue capture from the business already in place. Part 3 gets tactical about where all three actually live inside a practice. This part is about the leadership alignment that has to exist before any of the three can move at all.

You will not find all the margin that's actually there without an open communication model connecting leadership, physicians, managers, and staff. You will not be able to execute on what you find without that same model. And you will not keep the margin you've captured, once you stop actively looking at it, unless those communication lines stay open on an ongoing basis. Alignment isn't a nice-to-have that makes the work go more smoothly. It's the precondition for all three jobs — finding, executing, and keeping.

Three Jobs, One Requirement

Finding the margin. Opportunities don't announce themselves. The front desk staff member who knows exactly which scheduling gaps cost the clinic a full patient slot every Tuesday, the physician who knows a specific order set is duplicating work, the manager who's watched an overtime staffing line grow for six months without anyone asking why — all of that knowledge already exists inside the organization. It just doesn't surface anywhere leadership can act on it unless there's a structure built to pull it up and out. Without that structure, margin opportunities stay exactly where they are: known locally, invisible organizationally.

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Executing on what's found. This is where alignment does the work covered in Part 1's close — physicians and staff control the actual decisions that move productivity and revenue numbers. A change that's designed at the leadership level and handed down without physicians, managers, and staff having been part of shaping it gets compliance at best, and compliance doesn't hold.

Keeping what's been captured. This is the job most groups skip, and it's the one that costs the most later. Margin found once and never revisited drifts. A staffing fix relaxes back to old habits the moment attention moves elsewhere. A documentation improvement fades as new staff onboard without ever hearing why it mattered. None of that requires bad intent — it just requires nobody actively keeping the communication line open once the initial push is over.

All three jobs run through the same requirement: a durable communication model, not a one-time campaign.

What the Model Actually Has to Include

This isn't a single conversation or a physician-only initiative. It has to run across every level that touches the work:

Leadership to physicians. Physicians need visibility into the same data leadership is using to make the case for a change — and need to have been part of shaping the response, not just informed of the decision after it was made.

Leadership to managers. Managers are the ones translating strategy into daily operations. Without a direct, consistent line to leadership, they're left interpreting intent secondhand — which is exactly where staffing and productivity initiatives quietly drift off course.

Managers to staff. Staff are executing the work day to day and are often the first to see where a process isn't working. A model that only talks to physicians and leadership misses the group most likely to spot the problem early.

All of it, on a follow-through loop. Every commitment made in one of these conversations needs to be tracked and visibly closed out — not verbally promised and quietly dropped. Without this, the entire model runs on the credibility of the last thing that got promised and forgotten.

In practice, that means structured leadership rounding at every level, documented follow-up on significant conversations, and a communication cascade that runs on a schedule — not just when something has already gone wrong.

This is exactly the communication infrastructure the TACTICS Framework builds — standardized rounding, a leadership cascade, and closed-loop follow-through, engineered in rather than left to chance. Explore the TACTICS Framework →

The Two Ways This Goes Wrong

A communication model without a margin focus produces a group that talks constantly and sees no financial traction — activity without output. Leadership eventually loses patience with a process that isn't producing results, right when it was starting to build the trust that makes results possible.

A productivity or revenue push without the communication model underneath it produces short-term compliance that reverts the moment enforcement relaxes — and it burns trust for the next initiative, because physicians, managers, and staff now have a reason to believe leadership treats them as an execution risk to manage rather than a partner to work with.

Both are common. Both are avoidable — but only by building the communication model first, deliberately, before asking anyone to move on the numbers.

What's Next

With that model in place — not assumed, not declared, but actually built and running — the next question becomes tactical: where, specifically, is the margin sitting inside a practice or health system that's already leaving money on the table? Part 3 gets specific about exactly that.

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