By Lawrence Rosenberg, MD, CM, MSc, PhD, MEng, FRCPSC, FACS, FCAHS
President & CEO, Integrated Health & Social Services University Network for West-Central Montreal
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Every health system I know names innovation as a priority. Then it builds the machinery that quietly selects against it. The strategy says innovate, but the uniform mandates, identical structures and steady pressure to make every institution interchangeable say something else entirely: do not be different. We should not be surprised when the future arrives slowly, or somewhere else.
I am a surgeon, and I have spent my career inside some of the most standardized parts of medicine. So let me say plainly what standardization is good for, because the argument I want to make depends on the distinction. The surgical checklist, sepsis protocol and evidence-based pathway are among the great achievements of modern care. They take what we have proven and make it reliable, so that a patient’s outcome does not depend on which day or which team they happened to draw. Standardizing proven practice saves lives. No serious person, and certainly no surgeon, would argue otherwise.
But there is a second kind of standardization that does the opposite of what its champions intend. It is the standardization not of proven practice but of institutions themselves – their structure, their latitude, their permission to be distinctive. It treats the organization that is breaking new ground and the one coasting on the average as though they were the same thing, to be managed identically, held to the same ceiling and allowed the same narrow room to act. This is the instinct that freezes the frontier. And the frontier is precisely where the future is made.
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Here is the rule I would offer any health care leader: standardize the floor, never the ceiling. Make proven practice universal. Leave the unproven, the emerging, the not yet figured out free to be explored, and explored differently in different places. A system that standardizes its floor gets reliability. A system that standardizes its ceiling gets uniformity, and uniformity is not excellence. It is the average, formalized.
It helps to remember where the floor came from. Every standard we now rely on was once a deviation; the checklist, the pathway, the protocol each began as one team’s unusual practice, tried in one place, proven and only then made universal. Today’s ceiling becomes tomorrow’s floor and the exceptional, once proven, becomes the expected. Freeze the ceiling and you do not merely slow today’s innovation; you cut off the supply of tomorrow’s standards, and a system that does that begins to consume its own seed corn.
Why does this matter so much for innovation? Because innovation is not a budget line or a department you can stand up by decree. It is downstream of culture. What an institution tries, what it tolerates, what it admits when something fails and whether a better idea can survive contact with the hierarchy are cultural facts. They live inside particular organizations with particular ambitions. You cannot mandate that culture from the center, you can only create the conditions in which it forms or destroy them. An institution stripped of the latitude to be different has been stripped of the soil in which innovation grows.
Culture, in turn, is something an institution builds deliberately. It is built through whom it chooses to bring in, what it chooses to reward and which behaviors it celebrates or quietly discourages. An institution composes its own character over years. That is institutional meritocracy as I mean it: organizations earning their standing through demonstrated value, rather than being assigned an identical place regardless of what they achieve.
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The concept that follows from this is contestability: the willingness to let a better method win, to be measured against the best rather than the average, to reward institutions that demonstrably create more value for the people they serve. This is not competition for patients or care reduced to a market. It is competition of standards, not of access. A system that refuses even that kind of comparison is not protecting fairness. It is protecting the average from the excellent.
This is the part most often misunderstood. Treating every institution the same is presented as equity – It is not. Real fairness is not sameness. A system arranged so that no institution can pull ahead is, by definition, a system optimized to its own mean, and the people who pay for that are the patients who would have benefited from what the leading institution learned first.
None of this licenses unaccountable variation. An institution earns its latitude the way it earns anything: by showing results, better outcomes, lower total cost and value its peers can measure and trust. Distinctiveness without that discipline is not excellence; it is idiosyncrasy.
Which brings me to the obligation, because institutional meritocracy without it would be mere privilege. An institution that earns latitude earns, with it, a duty. The point of letting a strong institution innovate is not to create an island of excellence that hoards its advantage. It is to create a learning engine for the whole system: a place that discovers what works and then carries that knowledge to everyone else. Merit earns responsibility, not entitlement. The strong are meant to lift, not to hoard.
So, the choice in front of every leader, and every system, is not about structures or org charts. It is about what kind of future we are willing to build. We can assemble a network of interchangeable parts, each tuned to the average, each forbidden to be remarkable, and call the resulting flatness fair. Or we can let institutions strive to be the best version of themselves, earn the room to lead and lift the rest as they go. The future of health care will not be administered into existence. It will be built, in particular places, by institutions wise enough to let it become different.
This is, at its core, an argument about landscape architecture. High-performing systems do not manage their institutions toward a common mean. They design the conditions — the incentives, the information flows, the accountability structures — that allow excellence to emerge and then propagate. The science of how that architecture works, and how leaders can build it deliberately rather than by accident, is one of the most important and least discussed questions in health care today. It is the question this column will continue to explore.
You cannot standardize your way to the future. You can only design the conditions in which it arrives.
Lawrence Rosenberg is a member of the Newsweek CEO Circle, an invite-only executive community of subscribers.
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