Internal Alignment

What, Why, How

Note: Examples in this piece are real and fictionalized versions of my work, modified to protect confidentiality.

When I run, I pay attention to alignment. 

I’m in alignment when I move with ease and power. My core, hips, and shoulders stack. My breathing drives my effort. I move confidently.  

Organizations are the same. When aligned, they operate with ease and impact. When misaligned, there is friction: operational, cultural, interpersonal.

How to Spot Misalignment

The ED Governance Swirl

It's Tuesday morning. There are patients backed up in the ED because there are no appropriate beds. The Service Chief demands hospitalist admissions. The hospitalists push back; these patients don't meet medical necessity criteria.

Patients don’t move. The ED remains congested. Providers are frustrated.

The Five-Dollar Budget Item

A pediatric clinic uses M&Ms as a reward. For kids with sensory sensitivities, M&Ms are the “currency of cooperation.” They allow a child to sit still for a blood pressure cuff. Without them, visits take longer and vitals are inaccurate.

The clinic runs out. The provider requisitions two more bags. Eight dollars total.

The request gets routed to an operational leader trained in adult medicine. He denies it. "Standardization and cost containment," he says.

The provider is frustrated and eventually stops asking. Every month, they now buy M&Ms with personal funds.

The Real Problem: Decision rights are muddled. It's unclear who has the authority and confidence to say yes or no. The impact: frustration and compromised patient care.

What Happens When You Ignore Misalignment

A hospitalist identifies a safety risk. They raise the risk, but the Service Chief and Medical Director give conflicting instructions. Because decision rights are muddled, nobody has authority to mandate a fix. The provider stops escalating. The safety concern disappears, but a preventable error occurs a month later. 

Six months later, hospital quality scores decline. The physician starts to think about looking for another place to work. Turnover accelerates. Financial pressure increases.

Why Measuring and Managing Alignment Matters

It's easy to have a general sense of your problems, but it's harder to pinpoint which specific elements of your organization design and operations are contributing to the problems. In complex systems, multiple factors are usually at play. If you don't diagnose which elements are causing misalignment, you risk making low impact changes that don't fix the root causes. This has financial, cultural and clinical implications.  

How to Understand and Diagnose Alignment

When I assess organizational effectiveness and alignment, I look at four elements:

Element

The Question 

Strategy

How well do you have clarity on what you're trying to do and why?

Structure

How well does your organizational design, decision rights, and incentives support your strategy?

Processes

How well do your critical workflows execute what you've committed to doing?

Skills

How well do your capabilities match your processes and strategy?

Each element either enables or constrains the others. The pattern of misalignment reveals what to fix first.

Example #1: Strategy 

Let's look at strategy to illustrate how you can understand how well your strategy is formulated and how well it’s implemented.  

Where do you stand?

Score

What This Looks Like

1: Vague

You have a mission statement, but people interpret it differently: a frontline nurse, a physician, and an administrator would give you different answers. They are confused. Are we focused on growing primary care patients or strengthening our specialty referral center? We aren’t clear.

2: Somewhat clear

Leadership understands the strategy, some staff could articulate it but many couldn't. There are different theories about what matters most. Strategy is set, but doesn't cascade

3: Clear

Everyone understands what problem the organization is focused on solving and for whom. Trade-offs are explicit. A nurse, a physician, and an administrator give you similar answers. “We are committed too…because…” Resources decisions are clear and linked to your priorities.

Quick Assessment:

• How well can anyone articulate your mission? Can they say it in one clear sentence? 

• Do you know which opportunities you've decided NOT to pursue?

• How clear are your annual priorities? Have you force-ranked them or is everything equally important?

What Your Score Tells You

• Score of 1: Strategic formulation is your primary constraint. Fix this first.   

• Score of 2: Strategy could be clearer. This is causing confusion that is limiting execution.

• Score of 3: Problems are likely structural or process-related.

Example #2: Structure  

Let's use the M&M story. Here's how you'd use a diagnosis of decision rights to begin to understand the strength of organizational structure.  

Where do you stand?

Score

What This Looks Like

1 = Muddled

When a conflict arises, people feel like virtually everyone can say "no." Infrequently does someone quickly say "yes." Decisions get escalated often. Staff have started to work around the system. Concerns don't get escalated.

2 = Somewhat Clear

Most decisions have an owner, but many gray areas persist. Some things move; some things stall. Staff feel frustrated regularly.

3 = Clear

Decision rights are explicit and decisions are made quickly. People know who decides what. A five-dollar decision gets made in minutes.  

Quick Assessment:

• In general, how quickly do decisions get made?

• When a staff needs approval for a decision, how clear is it who gives approval?

• When leaders disagree, how clear is the defined escalation path?

What Your Score Tells You:

• Score of 1: You probably have structural challenges. Take a deeper dive of how well your teams, reporting relationships and performance measurement and incentive systems are working. 

• Score of 2: This might be a constraint. Worth investigating structural elements further.

• Score of 3: Decision rights are working. Structure is probably working.Problems are probably in processes or skills.

Example #3: Skills  

Let's look at whether you have the skills and knowledge to execute well.

Where do you stand?

Score

What This Looks Like

1 = Major Gaps

When you promote talent to leadership roles they are often overwhelmed. They don't know how to navigate key systems. They don't have mentors. Your There are few cross functional initiatives, signaling the teams don’t work together to achieve goals.  

2 = Some Gaps

You have strong individual expertise in key roles, but some gaps in how to work together to achieve shared goals. Some people thrive in new roles; others struggle. You have some talent development programs, but it's inconsistent.

3 = Well Aligned

When you promote someone to a critical role, you create development plans to support them. In general, all staff know how to navigate organizational systems.  .

Quick Assessment:

• When you promote talented clinicians to leadership, do you invest in developing them  with mentors, coaches, talent development programs and appropriate review systems?

• Do people know where to find critical information? 

• How confident are they navigating your systems and relationships?

What Your Score Tells You:

• Score of 1: You have a skills base problem limiting performance.  

• Score of 2: Your skills are adequate, but strength would help.

• Score of 3: You have the people and capability to execute. Challenges lie in structure or processes.  

If you assess all four elements (strategy, structure, processes, and skills), the pattern of low scores tells you where to focus. Each constraint requires different work. That's why diagnosis matters.

The Cost of Misalignment

Every time an employee has to work around the system instead of through it or stops trying, they have a suboptimal experience and start to believe the organization isn't working for them. The compromises culture, care delivery, and financial performance. The M&Ms will still show up in the clinic. As a leader, it's your job to ensure they're budgeted for and the team understands why they matter.

If You're Interested in More

The next time you experience a cluster of problems, resist ignoring them or jumping to solutions you've tried before. Instead, ask: How could alignment be contributing to this? Which of the four elements is actually misaligned?

• Strategy: Are people unclear on what you're trying to do?

• Structure: How well are reporting relationships and cross-functional teams working? How clear are decision rights? How might performance measurement and incentive systems be contributing?

• Processes: How strong is the productivity, reliability, and quality of your core processes?

• Skills: How well do people have the expertise and knowledge they need?

I use a diagnostic framework to assess organizational alignment across strategy, structure, processes, and skills. It includes focused questions, rating scales, and pattern identification to help you understand exactly what's broken and what to prioritize.

If you want to explore this further, reach out. I can walk you through the framework and we can discuss what alignment challenges you're facing.

Onwards!