POINT OF VIEW · 10 MIN READ
Value Creation Isn't an Execution Problem
Execution is a capability. It has to exist before anyone can demand it.
Every value-creation plan arrives with the same instruction attached: execute. The thesis is underwritten, the levers are named, the model says the returns are there. What is left, the reasoning goes, is to go and do it.
That instruction assumes a machine that can carry it. Most platforms do not have that machine. They have something that moves and has carried them a long way: contracts with the largest payers, patients who keep coming back, and an impressive founder who has built it himself since the beginning.
It works, and it works on effort. The way a bicycle works, on the rider's own legs. But the plan developed is for a haul that needs an engine, and telling the platform to "just execute" it is telling a strong cyclist to just drive.
Every deal puts the same two questions to its platform, months apart. The deal team asks the first at underwriting, forced to build a model that shows a 2.5x MOIC: What is the company worth if the levers get pulled?
The answer is a sized prize: continued same-store growth, a 10% lift from payer rates the founder never renegotiated, tuck-ins bought below the platform's own multiple, and margin from using technology to standardize work the company does a dozen different ways. Formalize the plan, name an owner for every lever, hit the dates. Simple.
The CEO asks the second after the close, from inside: What can the company actually run? The answer is less than the plan assumes. Much less.
The plan's ambition outpaces the way the business is run: the real work lives in a few people's heads, no two leaders manage from the same set of numbers, ownership is assumed rather than assigned, and the process is whoever has been there longest, because none of it is written down.
One answer assumes the machine. The other says the machine is not there. Both are right. And the distance between them is the capability the platform is short.
The plan gets disputed to death. The capacity to run it never comes up.
The two answers finally meet three and a half years into the hold, in the numbers. The payer rates are still unrenegotiated, the tuck-ins are bought but not absorbed, and the work is still done a dozen different ways. The plan is still mostly plan, just with later dates.
Now the board has a question of its own: Why is nothing landing? The usual answer is people: the plan is sound, execution is stalling, so the platform must need stronger leaders to run it. But that skips a step. Before a better leader is the answer, the thing they would be brought in to run has to exist.
The seam no one owns
Suppose the room gets its wish. The new leaders are everything the spec asked for: a CFO who has taken two platforms like this one through to exit, a chief medical officer clinicians follow and the board trusts with a P&L, a growth leader who doubled same-store volume at a platform twice this size. The org chart has never looked better. The numbers have not noticed.
What the plan needs is different. The builds that carry a platform to the next level do not sit inside any one function. Absorbing a tuck-in, standing up a risk contract, entering a new market: each one runs across finance and clinical and operations and growth at once, and belongs to none of them.
And each seat is at capacity building its own function: the CFO pulling finance off QuickBooks, the clinical leader pulling credentialing out of spreadsheets, the operations leader pulling scheduling out of text threads, the growth leader prying referral relationships out of one rep's phone. There is a seat for every function, and no seat above them but the CEO's. So the work between the seats has no owner and no volunteer. It defaults to the one person sitting over all of them. Who already has a job.
The failure is hard to see for what it is, which is why it persists. On a factory floor, a bottleneck announces itself: unfinished parts piling up in front of one machine. Here there is no pile. The failure mode is absence, nothing happening where something should be.
Absence does not show up on a dashboard. A dashboard catches a number moving the wrong way. It has no row for the build that is not happening. The tuck-in is never absorbed, the risk contract is never stood up, the new market is never entered, and nothing anywhere turns red. Nothing broke. Nothing happened.
What absence finally throws off is heat. The growth leader and the operations leader go at each other in the monthly review, in front of everyone, over a tuck-in neither of them owns. The CEO referees, because the dispute has nowhere else to go. The rest of the company watches, and draws its own conclusions.
No leader's numbers get worse. Every function is technically fine. And the fight is its own tell: nobody in that room is angry that the tuck-in never got absorbed. Nobody is invested enough to be. The heat is over whose problem it is not.
The one visible symptom is a fight, and a fight reads as a people problem. That is where the board's answer comes from.
The coordinated how
Most executive leaders want full autonomy over how the work gets done. When every leader chooses a different how, the business cannot execute in a coordinated, aligned, and visible way. Each has accepted or built one, and the hows rarely reconcile on their own.
The reconciliation has terms. The functional leaders keep authority over the what, the why, and the when. What they hold loosely, for the sake of the whole, is the how across functions, the seam between them.
Terms like these are easy to agree to. They hold only with something underneath them.
It has a concrete shape. One source of truth the whole team plans from, so leaders stop managing from competing numbers. A cadence the business runs on, turning those numbers into decisions and decisions into accountability. A scorecard the leadership team answers to together, that none of them owns alone.
The three are the coordinated how: a horizontal operating system running underneath the verticals.
An operator walking into a company like this builds the source of truth first, because no one can coordinate what they cannot see, least of all absence.
Building it takes nothing from anyone. The finance leader still owns finance and the clinical leader still owns clinical. The horizontal work owns only the space between them, the coordination none of them was ever positioned to hold.
When a leadership team has not converged on what the plan even means, six leaders carry six definitions of it. The instruction to execute points at nothing they share.
The machine no one built
Two things explain why the machine is missing. Both are structural. Neither is anyone's failing.
The first is that it was never needed. Most of these companies scaled effort, not systems. For years the founder was the operating system: he held the context, carried the threads, made the calls the system should have made on its own. That works, until the scale outgrows the person, or a plan arrives that demands a pace one person cannot keep.
That inflection is often the moment the founder sells. So the firm inherits a business that ran on a person and hands it a plan that needs a machine. The value-creation plan assumes the company can scale differently. That infrastructure does not exist yet.
The second is that the seat that would build it does not exist. On the org chart of any platform in this market, every seat below the CEO's is a vertical. A seat whose whole job is the horizontal is not in the template these companies are built from.
A few firms have begun to carve one. It is not yet standard practice. So when the plan stalls, the board reaches for the seats the template offers: a stronger CFO, a new COO. Nobody hires for a role they have never seen.
When a firm does carve the seat, the company does not know what to make of it. Every other leader owns a function. This one owns none.
The questions start: What is this person accountable for? How do they work with the functional leaders? What are they actually doing? The mental model of the business runs person to function, and the new seat fits nowhere in it.
The seat gets built the only way the template can absorb it: accountable for everything that crosses the functions, with command over none of them. Every functional leader defends their own how, and the seat that would reconcile them is stripped of that authority, as the price of peace.
The build that comes first
That is the work the plan skips: building the capability it assumes is already there. The machine that holds the threads the founder used to hold does not arrive with the plan. Execution matters. It is also something a platform has to be built to do, and most are not built for it yet.
Get the plan right, hand it to a business that cannot run it, and you have not set execution in motion. You have named a destination and pointed a bicycle at it.
The capability has to be built first. The instruction was never wrong. There was nothing underneath it to carry the load.
McKinsey Quarterly, "The Chief Transformation Officer in the Consumer C-Suite" (2022); Barton Partnership, "The Role of the Chief Transformation Officer in Private Equity Portfolios"; and HBR, "Leading After the Founder" (2026).
MARTEL CAMPBELL
Replies welcome: martel@martelhealth.com
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