Forever: How to Lead for the Long Run
A CEO emailed me earlier this month: “We've been over capacity all week... Some inpatients doubled up, some boarded in the ED. The organization is stretched. Not easy, tiring for the team, but they're finding a way every day.”
His email was time stamped 6:01 AM on a Friday.
Healthcare leaders routinely face this tension: How do you handle today's crisis (the surge, the constraint, the unexpected emergency) while building an organization that lasts generations?
After 20 years helping organizations navigate growth and manage uncertainty, I've learned that long-term success requires the same three elements I need as a lifelong distance runner: a clear purpose that guides direction and decisions, plans that are realistic, and pacing that's grounded in a “forever pace.”
This piece shares a framework for finding your organization's "forever pace," including a 15-minute diagnostic you can use in your next leadership meeting. This framework is especially valuable for:
CEOs and boards making budget decisions under financial pressure
Operations leaders asking "are we pushing our people too hard?"
The Power of Forever
I finished hiking New Hampshire's 48 four-thousand-foot peaks this summer, inspired by my grandfather, a Polish immigrant, who completed them decades ago.
The mountains change very little, and that's comforting. Walking the same granite ledges my ancestors walked creates a powerful bridge.
I felt a similar comfort this fall visiting Gifford Hospital in Randolph, Vermont. A 20th-century stone statue of a woman holding a small child greets you outside the entrance. Inside is Vermont's oldest birthing center. You feel the legacy walking past the statue.
Permanence provides comfort. It also guides decision-making. When they set strategy and goals at Giffords, leaders are asking "How do we keep serving our community for the next generation and how do we meet our financial needs today?"
Purpose: Why You Exist
As a runner, my purpose is multidimensional: some days it’s to finish a race, other days it’s to enjoy the landscape, other times it’s to catch up with friends. The purpose of each run might change, but each run has a purpose.
In healthcare, your purpose needs the same clarity. With it, you pull your organization forward and expand what's possible.
I saw the power of purpose working as an M&A advisor for a scaling autism provider. I could articulate our purpose confidently, and it resonated with prospective partners. The clarity made my job easy.
The “Logo Test”
Here's a test I use: Cover your logo and swap it out for a competitor, then read your mission, vision and values statement (why you exist, how you operate). Could it be your competitors? If yes, it's not specific enough. This will make it harder for you to commit to the work, make decisions, align your organization, and inspire your employees.
I recently worked with a CEO whose organization's values were too general to be authentic. They couldn't pass the logo test. He knew it was hurting engagement, not helping the organization achieve its purpose.
Plan: How You'll Get There
When I help organizations build execution plans, I start with diagnostic questions about the terrain and the weather (see my previous post here):
What's the business context? What’s your margin for error? Are you in a pilot where mistakes are learning opportunities, or doing a large scale deployment where there's little room for error?
What's your capacity and your team's temperature today? What resources and bandwidth do we have? For example, do we have a dedicated team or is this work on top of existing workloads.
The answers determine what kind of plan you need. Some experiences:
Tight plan: When I worked with a behavioral health clinic piloting a new remote patient monitoring software, we needed a tight plan: detailed milestones, daily check-ins, immediate technical corrections when necessary. Every patient and provider experience mattered because we had a very thin margin for error and few extra hands to fix mistakes when they happened.
Adaptive Plan: Compare that to an autism provider I advised who was launching speech therapy services. They had capacity and expertise, but this was new territory. They needed clear success criteria but flexibility to adapt as they learned what actually worked with patients.
Directional and diagnostic plan: At UVM Health this summer, we mapped annual initiatives to see how much we were actually trying to do. An operations leader said: "Helpful to see. I knew it was a lot. Let's revisit this quarterly." Making workload visible gave us confidence to proceed—with realistic recognition of what we were asking.
Pacing: Your Effort
For success in ultra marathons, I've learned to find my "forever pace," the effort I can sustain for hours without excessive fatigue. To find this pace, I run breathing only through my nose. When I breathe only through my nose, I physically can't push too hard and am forced to stay in my low end aerobic zone. If I need to get extra air through my mouth, I'm going too fast.
Healthcare organizations need the same awareness of their “forever pace.” They need to know what effort they can sustain indefinitely, and what it feels like and for how long they can operate above that threshold.
As an M&A advisor for autism providers, I spoke with dozens of ABA clinics. We could identify which organizations had sustainable pacing by asking about staffing ratios, retention, and career development. What was the clinical supervisor to non-supervisor ratio? Did they have internal career development programs for behavior technicians to advance to BCBA roles? How many were promoted within? Were they able to retain traveling, in-home therapists who could sustain the travel demands?
The clinics with stronger retention and better internal promotions had done a better job managing their pacing and figuring out their forever pace. For clinical staff, they averaged years of retention versus quarters. Their waitlists existed, but were relatively consistent and shorter than peers because they had more reliable staffing.
A Back-of-the-Napkin Pacing Diagnostic
Here's a simple exercise to calibrate your pacing, assess whether you're asking too much, and decide whether to say yes to new initiatives:
Step 1: List your major initiatives (for the year or quarter) across the top of a sheet
Everything beyond day-to-day operations
Step 2: List your teams or functions along the left side
Step 3: For each initiative, mark the level of effort each initiative requires from each team using t-shirt sizes:
S = Minimal effort; no dedicated project management needed
M = Modest effort; requires part-time project lead
L = Significant cross-team impact; requires full-time project manager and change management support
XL = Major organizational change; requires executive sponsor and dedicated PM
Example: "Epic Update" might be:
IT: XL (Q1, Q2, Q3)
Medical and nursing leadership: L (Q2, Q3)
All staff: M (Q2, Q3)
Step 4: Look at the data and the patterns
When I did this with UVM Health, we immediately saw patterns: initiatives with multiple names creating confusion, work clustering in Q1, and the same handful of teams carrying multiple initiatives. With the previously invisible now visible, we could align more effectively: fix naming, confidently plan project management resources, give project leaders visibility into competing demands.
Red flags
Multiple "large" or "XL" initiatives hitting the same team simultaneously
Turnover or engagement problems in teams touched by the most initiatives
Progress on initiatives stalling, taking months longer to finish
Quality/safety scores staying flat or declining
What sustainable pacing looks like:
No single team carrying more than two large initiatives simultaneously
XL initiatives get dedicated project resources (not "on top of day job")
Planned celebrations and recovery periods after major implementations
Retention and quality metrics holding steady or improving
You Can’t Always Choose Your Pace
Care delivery and human reality don't allow the luxury of always working at your forever pace. But knowing your forever pace equips you to handle sprints and make better decisions under pressure.
When that CEO emailed me at 6:01 AM, he was relatively calm. He knew:
This surge and this pace was temporary
His team was stretched but not broken
What his priorities were
The organizations that burn resources less sustainably are less in tune with their forever pace:
They don't recognize when they've shifted from a sprint (a temporary "surge" pace) to a higher, less sustainable pace ("a new normal")
They say yes when resources are already thin without knowing what impact the decision will have
They lose people because they can't provide assurance about when the intensity will ease.
Knowing your forever pace doesn't mean you always operate there. But it makes you a more flexible, adaptable, human-centric organization that can handle uncertainty.
What becomes possible when you get all three right?
When you align all three elements—purpose, plans, pacing—results improve and what's possible expands.
For three years, I paced runners at the Vermont 100. I'd meet them at mile 70 when they were slowing down, then run, walk, and hike with them through the night to the finish. I paced because it was fun, it was inspiring, and because that's what was possible for me at the time.
As I volunteered at more races and saw runners achieving what seemed virtually impossible, I was encouraged to revisit my purpose, plan smarter, and improve my pacing. Seven years later, I was a finisher in the Vermont 100K.
The same change happens in organizations. When I started working with a VC-backed startup, they were planning based on revenue targets disconnected from operational reality. Staff worked overtime routinely.
I helped them build a more realistic forecast that linked revenue goals with operational capacity. We measured safety incidents to understand which teams were delivering quality at a sustainable pace and which were not. The result of this alignment: they could hire with confidence, order products based on realistic mix projections, and have more confidence that they could handle an operational surge. At one branch, overtime dropped from 10+ hours a week to a handful of hours. Safety incidents dropped from weekly to monthly occurrences. Variable costs decreased and began to align with budget.
They still face peaks and uncertainty. But they now have a more realistic plan and stronger sense of pacing to help them minimize risk.
The CEO I’m working with is still managing a crunch. This week brought another all-hands-on-deck situation: an unannounced accreditation survey. Now is the time for him to say to his team “We see you putting in the effort, again. Thank you. This is not forever.”
What's next for you:
Take the 15-minute diagnostic in your next leadership meeting. Map your initiatives, see the clustering, and get immediate clarity on your pacing.
If you see concerning patterns, or know someone who's drowning, reach out. I help healthcare leaders make "what do we stop?" decisions and find their sustainable pace.
Onwards!
