The instinct, when value leaks, is to buy another initiative. More tooling. Another model. The evidence points the other way. The next increment of value will not come from the twenty-sixth initiative. It will come from the first honest ranking of the twenty-five already competing for the same team.

A leadership team is reviewing six strategic priorities: One promises growth. One promises cost savings. One promises better access. One promises stronger clinician efficiency. One carries political visibility. One has a particularly persuasive sponsor.

Most health systems do not struggle to generate ideas. They struggle to get the right ideas funded. That distinction matters more than most strategy conversations admit. In many organizations, the strategy itself sounds convincing. The ambition is clear. The narrative is strong. Leaders can see the opportunity. Everyone agrees the initiative is aligned with the future of the system. And then the conversation shifts. The capital committee starts asking harder questions. What is the ROI? What...